Values and Public Speaking: Examining the Efficacy of a Brief Acceptance-Based Intervention for Public Speaking Anxiety

Social anxiety Disorder (SAD), including public speaking (the most frequently endorsed social fear; Ruscio, Brown, Sareen, Stein, & Kessler, 2008), is prevalent, chronic, and can be vastly debilitating. Cognitive behavioral therapies (CBTs) have garnered substantial empirical support for the treatment of SAD (e.g., Norton & Price, 2007). Although effective in reducing social anxiety, they are not sufficient, as a significant proportion of patients, as many as 40-50%, do not respond to treatment (e.g., Hofmann & Bogels, 2006). This insufficiency may result from shortcomings in the underlying model of SAD. Specifically, CB models fail to account for the role experiential avoidance and values inaction may play in social anxiety related distress. To date, CBT for SAD has also been characterized by high drop-out rates (e.g., Davidson et al., 2004), which could in part reflect the absence of a client-centered rationale for treatment. Treatment for social anxiety might be improved with the integration of strategies aimed at increasing acceptance and engagement in valued action (i.e., Acceptance-based Behavioral Therapies; ABBTs). Clients may be more willing to stay engaged in treatment, if the rationale is focused on facilitating action in the domains of functioning personally valued by the client. Preliminary evidence for ABBTs exists (Block & Wulfert, 2000; Dalrymple & Herbert, 2007; England et al., 2012; Kocovski, Fleming, & Rector, 2009; Ossman, Wilson, Storaasli, & McNeill, 2006), although the specific contribution of values articulation is unknown. The current study had two goals: (1) to examine the relationships among academic values, experiential avoidance, public speaking, and willingness to engage in anxiety-provoking academic activities and (2) to explore the efficacy of a brief values intervention compared to a CBT and control condition in increasing willingness to engage in anxiety-provoking academic activities among students with public speaking anxiety. Findings from a sample of 117 undergraduates demonstrated that public speaking anxiety was negatively associated with a willingness to engage in academic activities such as asking and answering questions in class (r = -.44, p \u3c .01). However the degree to which participants endorsed valuing academics predicted their willingness to engage in them over and above the effects of anxiety (explaining an additional 20.5% of the variance in willingness). In a sample of 27 students with public speaking anxiety, students experienced an increase in willingness to engage in anxiety provoking classroom activities in both the values and the cognitive restructuring conditions (although the values condition demonstrated a moderate to large effect while the cognitive condition exhibited a small effect). Moreover, a significant increase in engagement in valued public speaking activities from baseline to 10 day follow-up was found in the values condition, with a large effect. Comparatively, a non-significant increase was observed in the cognitive condition (with a small effect), while no change was found in the neutral condition. Thus, overall, findings provide support for an acceptance-based model of SAD and suggest that values may play an important role in treatment refinement

RESISTING RESISTANCE TO CHANGE: A CRITICAL ANALYSIS OF THE STRUCTURE OF SURGICAL RESIDENCY TRAINING PROGRAMS

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) issued regulations affecting the structure of surgical residency training programs. These regulations placed work hour restrictions on residents. There has been significant resistance by the surgical leadership, including program directors and officers in academic organizations, to the adoption of the changes required by these regulations. The need for these changes to the structure of the resident’s work environment, and the resistance to the incorporation of these changes, provide an opportunity to examine the ethos and culture of surgical residency for a potential source of this conflict. This thesis claims that a significant element of this resistance is the recognition that the required changes will not only affect the structure of surgical residency training, but also the culture of residency training and the adoption of a traditional surgical identity by the trainees immersed in that culture. There is increasing evidence of significant ethical problems resulting from the traditional structure of surgical residency training. The norms perpetuated by the traditional approach to surgical training are antithetical to the current ethical norms expected regarding patient care and the surgeon’s personal and professional development. Critical ethical issues addressed in this thesis include those raised by both the apparent generational break between surgeons trained before and after work hour reform, and the conflict in balancing visions of surgical identity and concerns of patient and personal safety. The thesis argues that there is no well grounded reason for the resistance to incorporating the changes required by the ACGME. Instead, the development of the structure and culture of the surgical residency may have evolved in response to dysfunctional influences, rather than being built on sound pedagogical theory. The resulting surgical identity molded by this culture may then be appreciated as a potentially flawed, dysfunctional social construct. Changes prompted by the ACGME may result in both a healthier surgical work force and the ability to attract a greater diversity of applicants to the field of surgery. The reframing of what is essential to the surgical identity may allow the creation of new models of surgical training

Interval appendectomy in perforated appendicitis

The treatment of the perforated appendix remains controversial, with the optimal timing of surgical intervention unclear. Previous studies have documented an increase in both minor and major complication rates in patients undergoing appendectomy for perforated appendicitis. We sought to evaluate the nonoperative therapy of perforated appendicitis followed by interval appendectomy. The charts of all children undergoing admission for appendicitis during a 10-year period (n = 480) were reviewed. Data were abstracted regarding patient presentation, laboratory and radiologic findings, operative and pathology reports, and postoperative course in those patients with perforated appendicitis (n = 104). Comparisons were made between patients undergoing primary appendectomy for perforated appendicitis (n = 87) and those treated with IV antibiotics and hydration and then scheduled for interval appendectomy 4 to 6 weeks following the acute event (n = 17). Treatment assignment was determined by the attending pediatric surgeon in a non-randomized fashion. No significant differences were seen between these two groups in days of antibiotic treatment, nasogastric decompression, and IV hydration. Additionally, total hospital days and cost did not differ significantly between the two groups (primary = 10.3 days and $10,550; interval = 13.3 days and$13,221, P = 0.11 and 0.21, respectively). The overall complication rates, 12.6% in the primary group and 5.9% in the interval group, also did not differ significantly, while the major complication rate (wound dehiscence, abscess, and small-bowel obstruction), 10% versus 0%, was significantly higher in the primary group as compared with the interval group. Our data demonstrate no significant disadvantage, and possibly an improvement in the major complication rate, with nonoperative treatment of perforated appendicitis followed by interval appendectomy. We suggest that this treatment modality should be considered when evaluating the child with perforated appendicitis.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47148/1/383_2004_Article_BF00171160.pd

Guidelines for the Development of Comprehensive Care Centers for Congenital Adrenal Hyperplasia: Guidance from the CARES Foundation Initiative

Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH) often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA), New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC), and National Newborn Screening and Genetics Resource Center (NNSGRC) also participated. Thus, this document should serve as a “roadmap” for the development phases of comprehensive care centers (CCC) for individuals and families affected by CAH

Guidelines for the Development of Comprehensive Care Centers for Congenital Adrenal Hyperplasia: Guidance from the CARES Foundation Initiative

Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH) often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA), New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC), and National Newborn Screening and Genetics Resource Center (NNSGRC) also participated. Thus, this document should serve as a “roadmap” for the development phases of comprehensive care centers (CCC) for individuals and families affected by CAH

Guidelines for the Development of Comprehensive Care Centers for Congenital Adrenal Hyperplasia: Guidance from the CARES Foundation Initiative

Abstract Patients with rare and complex diseases such as congenital adrenal hyperplasia (CAH) often receive fragmented and inadequate care unless efforts are coordinated among providers. Translating the concepts of the medical home and comprehensive health care for individuals with CAH offers many benefits for the affected individuals and their families. This manuscript represents the recommendations of a 1.5 day meeting held in September 2009 to discuss the ideal goals for comprehensive care centers for newborns, infants, children, adolescents, and adults with CAH. Participants included pediatric endocrinologists, internal medicine and reproductive endocrinologists, pediatric urologists, pediatric surgeons, psychologists, and pediatric endocrine nurse educators. One unique aspect of this meeting was the active participation of individuals personally affected by CAH as patients or parents of patients. Representatives of Health Research and Services Administration (HRSA), New York-Mid-Atlantic Consortium for Genetics and Newborn Screening Services (NYMAC), and National Newborn Screening and Genetics Resource Center (NNSGRC) also participated. Thus, this document should serve as a "roadmap" for the development phases of comprehensive care centers (CCC) for individuals and families affected by CAH

Decreased Oxidized Glutathione with Aerosolized Cyclosporine Delivery

Cyclosporine immunosuppression remains vital for successful lung transplantation. Cyclosporine also functions as a membrane active biological response modifier and has been noted to have a variable effect on ischemia-reperfusion (I/R) injury in various tissues. Glutathione plays an important role in the endogenous antioxidant defense system; plasma oxidized glutathione (GSSG) levels are useful as a sensitive indicator of in vivo oxidant stress and I/R injury. Lung transplantation results in ischemia, followed by a period of reperfusion, potentially producing functional injury. This study was designed to evaluate the effect of cyclosporine on oxygen radical generation in a model of single-lung transplantation. Single-lung transplantation was performed in 12 mongrel puppies, with animals assigned to receive either intravenous or aerosolized cyclosporine. Arterial blood and bronchoalveolar lavage fluid (BALF) samples were obtained to determine GSSG levels via a spectrophotometric technique. Samples were obtained both prior to and following the revascularization of the transplanted lung. Whole blood and tissue cyclosporine levels were determined via an high-performance liquid chromatography technique 3 hr following the completion of the transplant. Aerosolized cyclosporine administration resulted in greatly decreased arterial plasma and BALF GSSG levels, whole blood cyclosporine levels, and equivalent tissue cyclosporine levels when compared to intravenous cyclosporine delivery. These findings support the hypothesis that the transplanted lung is a source of GSSG production and release into plasma. Additionally, these findings suggest that cyclosporine may have a direct antioxidant effect on pulmonary tissue, with this activity occuring at the epithelial surface, an area susceptible to oxidant injury.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30777/3/0000428.pd

Endoscopically guided thoracoscopic esophagectomy for stricture in a child

Purpose: Caustic ingestion is a common cause for acquired esophageal strictures in children. Thoracoscopic esophagectomy can be very useful in this setting, particularly for short segments of disease [1-4]. Thus far, the use of endoscopy to guide resection margins has not been described. Methods: A 6-year-old boy developed a tight, short esophageal stricture from a lye ingestion injury at the age of 4 years. He had a gastrostomy tube placed at the time for supplemental feedings and subsequently failed attempts at antegrade and retrograde esophageal dilatation. This video demonstrates an endoscopically guided (endoscopes simultaneously passed retrograde via the gastrostomy and antegrade through the oropharynx) thoracoscopic esophagectomy and primary anastomosis management of the stricture. Methods: In the left lateral decubitus position, four 5-mm ports were placed in the right chest in the fifth intercostal space, anterior-axillary line; sixth intercostal space, midaxillary line; fourth intercostal space, midaxillary line; and seventh intercostal space, posterior axillary line. A 5-mm 30° Storz® telescope and 4.9-mm and 9.6-mm Olympus® endoscopes were used. The area of esophageal stricture was identified using the endoscopes and thoracoscopically dissected circumferentially. The vagus nerves were identified and circumferentially freed from the strictured esophageal segment. Primary resection and anastomosis was performed using intracorporeal sutures and then tested for leak using the endoscope via the gastrostomy site. Results: Esophagram on postoperative day (POD) 7 revealed no leak and a widely patent anastomosis. He was discharged home on a soft diet on POD 8 and continues to feed orally over 1 year following his operation. Conclusion: As demonstrated by our video, endoscopy is a useful adjunct in the performance of a thoracoscopic esophagectomy for short esophageal stricture. It is particularly helpful because it provides direct visualization of the compromised lumen and allows for a more precise resection. © 2009 Springer Science+Business Media, LLC