Academic literature on the topic 'White Mountains (N. H. et Me.)'

On September 25, 2010, a wood sample was collected from an entirely decayed root ball of an alpine larch (Larix lyallii Parl.), 10 cm in diameter at breast height, recently downed, but still green. No attempts were made to determine whether the decay progressed into the stem. The discovery occurred in a stand in the Bitterroot Mountains, south of Darby, Montana (elev. 2,530 m; 45.893528° N, 114.278322° W). Several adjacent alpine larches were either dead or displayed thin crowns, and an old Heterobasidion basidiocarp was found on the decayed root ball of a neighboring dead tree, suggesting the presence of a root disease pocket. The stand is mature and composed of alpine larch, whitebark pine (Pinus albicaulis Engelm.), and a few subalpine firs (Abies lasiocarpa (Hooker) Nuttall), but only larches were symptomatic. No stumps were visible, and the site is in a designated wilderness area characterized by minimal forest management. Wood chips displaying a white rot with bleached speckles were plated on 2% malt agar, and cultures displaying the typical Heterobasidion anamorph (Spiniger meineckellus) were visible after 7 days. DNA was extracted from two distinct cultures, and the sequences of three nuclear loci, namely the internal transcribed spacer, the elongation factor 1-alpha, and the glyceraldehyde 3-phosphate dehydrogenase, were analyzed. The sequence of the mitochondrial ATPase was also sequenced. All loci were amplified using the primers indicated in Linzer et al. (2). Sequences of all three nuclear loci (GenBank Accession Nos. KF811480 to 82) unequivocally indicated both isolates to be first generation hybrids between H. irregulare (Underw.) Garbel. & Otrosina and H. occidentale Otrosina & Garbel. Cumulatively, sequences were heterozygous at over 40 positions in all three loci, and for the presence of two indels (one in ITS, one in EF 1-alpha). Polymorphisms and indels indicated alleles from both species were present in these heterokaryotic (ploidy n+n) isolates. The mitochondrial ATPase (KF811483 to 84) indicated instead the cytoplasm belonged to H. occidentale, suggesting that species was the first to be established in the infected tree and was either dikaryotized by a basidiopsore of the other species, or subject to nuclear re-assortment through di-mon mating with a genotype of H. irregulare. This is the first report of a Heterobasidion sp. in L. lyalli, and it is the second report of a natural Heterobasidion hybrid in North America (1). This finding indicates Alpine larch may be a host for both Heterobasidion species, as described for pine stumps in California (1). Thus, this conifer may have provided a substrate for the hybridization and interspecific gene introgression documented to have occurred before stumps were generated in high frequency by modern forestry practices (2). References: (1) M. Garbelotto et al. Phytopathology 86:543, 1996. (2) R. Linzer et al. Mol. Phylogenet. Evol. 46:844, 2008.

Lebanon cedar (Cedrus libani A. Rich) is an ecologically, economically, and historically important conifer species that currently mainly occurs in the Taurus Mountains in southern Turkey. In former times, extensive forests of this species were also found in Syria and Lebanon. However, because of intensive cutting, burning, and goat grazing, only small populations are left in these countries. Currently, the range of Lebanon cedar covers approximately 600,000 ha in Turkey, including extremely degraded stands and bare karstic land that was previously covered by this species (1). Therefore, efforts to protect existing forests and promote natural regeneration of this endangered tree species were undertaken in recent years. In addition, reforestations were carried out on bare karstic lands to expand the population of Lebanon cedar in Turkey. During disease surveys, carried out in October 2009 in the Mt. Dedegül Region of the western Taurus Mountains (37°36′54″N, 31°20′00″E), a dieback of lower branches and young plants of C. libani was observed at 1,700 to 1,885 m above sea level. The disease often occurred in scattered patches and was most evident near the timberline. Needles, shoots, and twigs of affected trees or entire small trees were covered or completely enmeshed in silky, shining, blackish brown mycelial felts. Symptoms resembled those of brown felt blight, also known as black snow mold, caused by Herpotrichia juniperi and Neopeckia coulteri on various other conifer species (2). For fungal isolation and identification, 18 twig samples from 14 different C. libani trees were collected. Two colonized needles from each twig were transferred to water agar (16 g liter–1 of agar and 0.1 g liter–1 of streptomycin) and incubated at 4°C for at least 8 days in the dark. Single hyphal-tip cultures were then established from only one of the developing colonies per twig and transferred to 1.5-ml microcentrifuge tubes containing 500 μl of potato dextrose broth. DNA extraction, directly from the mycelium, was performed after 20 days (3). DNA was amplified using primer pair ITS1 and ITS4 (4) and sequenced. Sequences of two representative fungal isolates from C. libani were deposited in GenBank (HM853976 and HM853977). Comparison of the 18 internal transcribed spacer sequences obtained from C. libani showed 99 to 100% nucleotide identity with those of reference strains of H. juniperi (2) from GenBank and variation among the 18 sequences was <1%, which is within the limits reported in a previous study (2). To our knowledge, this is the first report of C. libani as a new host of H. juniperi. Thus, brown felt blight is considered to have a significant impact on regeneration of C. libani as well as on the survival and growth of seedlings and young trees in the study area. References: (1) M. Boydak For. Ecol. Manag. 178:231, 2003. (2) M. Schneider et al. Mycol. Res. 113:887, 2009. (3) D. Smith and G. Stanosz. Phytopathology 85:699, 1995 (4) T. J. T. White et al. PCR Protocols: A Guide to Methods and Applications. Academic Press, New York 1990.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. 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Quinoa (Chenopodium quinoa Willd.) is a traditional food originally from the Andes Mountains in South America. It was first planted in China in 1987 and is grown in Tibet, Gansu, and Qinghai provinces. In May 2021, 40% of 2-month-old quinoa plants in the 3.4 hm² experimental base of Qinghai University (36.7262° N, 101.7487° E) were found to have leaves with grey-brown subcircular spots (about 0.4 to 0.7 cm) with black dots (acervuli). Severely infected plants exhibited symptoms such as withered and stunted growth. The diseased–healthy junctions of infected leaves (0.5 cm) were cut out, disinfected with 3% NaClO for 1.5 min, washed three times with sterile water, dried, placed on water agar, and incubated at 25°C for 48 h. After sporulation was seen on the leaf surface, spore suspensions were prepared by placing conidia in sterile water using a pipette. Next, 200 μl of each spore suspension was spread on the surface of water agar and incubated at 25°C for 12 h. Single spores were selected under a stereomicroscope and cultured on potato dextrose agar (PDA) (Qi et al. 2022). The mycelium of two representative isolates (20DLMF-5-4-1 and 20DLMF-7-4-1) was grey-black with white edges and included a fluffy aerial mycelium. Conidia were unicellular, colorless, long ellipsoid or curved moon shaped, averaging 14.3 × 1.8 to 20.2 × 2.2 μm (n=100). The light brown appressoria were ovoid, averaging 8.5 × 5.2 to 7.7 × 4.1 μm (n=20). Spherical, dark brown acervuli were observed on the leaves, averaging 160 to 200 μm (n=20), and there were dark brown spiny bristles. The ITS, partial ACT, CHS, GAPDH and TUB2 genes were amplified from genomic DNA of the two isolates (Weir et al. 2012). Sequences were deposited in GenBank (accession no. OQ871595 to OQ871602 for ACT, CHS, GAPDH, and TUB2, and OQ860235 to OQ860236 for ITS) and showed over 99% identities with the corresponding sequences of C. spinaciae CBS125347 and CBS128.57 (Vu et al. 2019; Damm et al. 2009). Both isolates clustered with the type culture of C. spinaciae (CBS125347, CBS128.57), with 100% bootstrap support in the phylogenetic tree. Thus, according to the morphological and molecular characteristics, the two isolates were identified as C. spinaciae. Pathogenicity tests were conducted on 24 healthy, tender leaves of six 1-month-old quinoa plants, with three replicates (Yang et al. 2021). The leaves were gently scratched in 3-4 areas with a sterile needle. A conidial suspension (105 conidia/ml) of the two isolates was sprayed on these wounds. The control group was unscratched and sprayed with sterile water. The plants were incubated in a greenhouse at 25°C for 24 h in the dark and 7 days in the light. Tiny grey-brown spots appeared on day 3 (about 0.4 to 0.6 cm) and continued to enlarge until perforations and ruptures developed on day 7. Subsequently, acervuli were observed on the surface of the leaves. The control leaves remained healthy. Isolates were reisolated from the symptomatic leaves and they had the same morphological and molecular characteristics as the original isolates, confirming Koch’s postulates. To our knowledge, this is the first report of C. spinaciae causing quinoa leaf anthracnose in China. C. spinaciae seriously affects the yield and quality of quinoa and has been previously reported to cause anthracnose of Vicia sativa in China (Wang et al. 2019). The results provide a basis for the study and control of quinoa leaf anthracnose.

Cardamine hupingshanensis is a selenium (Se) and cadmium (Cd) hyperaccumulator plant distributed in wetlands along the Wuling Mountains of China (Zhou et al. 2018). In March of 2020, a disease with symptoms similar to gray mold was observed on leaves of C. hupingshanensis in a nursery located in Changsha, Hunan Province, China. Almost 40% of the C. hupingshanensis (200 plants) were infected. Initially, small spots were scattered across the leaf surface or margin. As disease progressed, small spots enlarged to dark brown lesions, with green-gray, conidia containing mold layer under humid conditions. Small leaf pieces were cut from the lesion margins and were sterilized with 70% ethanol for 10 s, 2% NaOCl for 2 min, rinsed with sterilized distilled water for three times, and then placed on potato dextrose agar (PDA) medium at 22°C in the dark. Seven similar colonies were consistently isolated from seven samples and further purified by single-spore isolation. Strains cultured on PDA were initially white, forming gray-white aerial mycelia, then turned gray and produced sclerotia after incubation for 2 weeks, which were brown to blackish, irregular, 0.8 to 3.0 × 1.2 to 3.5 mm (n=50). Conidia were unicellular, globose or oval, colourless, 7.5 to 12.0 × 5.5 to 8.3 μm (n=50). Conidiophores arose singly or in group, straight or flexuous, septate, brownish to light brown, with enlarged basal cells, 12.5 to 22.1 × 120.7 to 310.3 μm. Based on their morphological characteristics in culture, the isolates were putatively identified as Botrytis cinerea (Ellis 1971). Genomic DNA of four representative isolates, HNSMJ-1 to HNSMJ-4, were extracted by CTAB method. The internal transcribed spacer region (ITS), glyceraldehyde-3-phosphate dehydrogenase gene (G3PDH), heat-shock protein 60 gene (HSP60), ATP-dependent RNA helicaseDBP7 gene (MS547) and DNA-dependent RNA polymerase subunit II gene (RPB2) were amplified and sequenced using the primers described previously (Aktaruzzaman et al. 2018) (MW820311, MW831620, MW831628, MW831623 and MW831629 for HNSMJ-1; MW314722, MW316616, MW316617, MW316618 and MW316619 for HNSMJ-2; MW820519, MW831621, MW831627, MW831624 and MW831631 for HNSMJ-3; MW820601, MW831622, MW831626, MW831625 and MW831630 for HNSMJ-4). BLAST searches showed 99.43 to 99.90% identity to the corresponding sequences of B. cinerea strains, such as HJ-5 (MF426032.1, MN448500.1, MK791187.1, MH727700.1 and KX867998.1). A combined phylogenetic tree using the ITS, G3PDH, HSP60 and RPB2 sequences was constructed by neighbor-joining method in MEGA 6. It revealed that HNSMJ-1 to HNSMJ-4 clustered in the B. cinerea clade. Pathogenicity tests were performed on healthy pot-grown C. hupingshanensis plants. Leaves were surface-sterilized and sprayed with conidial suspension (106 conidia/ mL), with sterile water served as controls. All plants were kept in growth chamber with 85% humidity at 25℃ following a 16 h day-8 h night cycle. The experiment was repeated twice, with each three replications. After 4 to 7 days, symptoms similar to those observed in the field developed on the inoculated leaves, whereas controls remained healthy. The pathogen was reisolated from symptomatic tissues and identified using molecular methods, confirming Koch’s postulates. B. cinerea has already been reported from China on C. lyrate (Zhang 2006), a different species of C. hupingshanensis. To the best of our knowledge, this is the first report of B. cinerea causing gray mold on C. hupingshanensis in China and worldwide. Based on the widespread damage in the nursery, appropriate control strategies should be adopted. This study provides a basis for studying the epidemic and management of the disease.

Introdução: A terapia fotodinâmica representa uma abordagem alternativa para a desinfecção do tecido cariado e tem apresentando resultados promissores no que diz respeito ao seu efeito deletério sobre os microrganismos envolvidos na progressão da cárie dentária. Objetivo: Investigar a produção científica brasileira sobre Terapia Fotodinâmica no manejo da Cárie dentária. Material e método: Tratou-se de uma pesquisa transversal, com abordagem quantitativa, a partir de dados secundários. Realizou-se uma análise bibliométrica dos resumos apresentados nas últimas dez Reuniões da Sociedade Brasileira de Pesquisa Odontológica. A pesquisa dos trabalhos procedeu-se através da seguinte estratégia: localização do fragmento “terapia fotodinâmica” e/ou “fotodinâmica” entre os resumos publicados nos anais do evento (1ª fase), em seguida foi realizada a busca pelo fragmento “cárie” e/ou “cardiologia” nos resumos selecionados na 1ª fase. Resultados: Foram selecionados 21 resumos, desses, 15 (71,43%) foram realizadas em universidades públicas, 13 (61,91%) receberam auxílio financeiro, 11 (52,38%) foram desenvolvidas na região Sudeste do Brasil, 9 (42,86%) eram do tipo in vitro, 6 (28,58%) utilizaram apenas o azul de toluidina como fotossensibilizante e 5 (23,81%) utilizaram apenas o LED vermelho como fonte de luz. Conclusão: Apesar dos resultados promissores da Terapia Fotodinâmica como terapia adjunta ao manejo da cárie, observou-se que poucas pesquisas abordando esse procedimento foram desenvolvidas nos últimos dez anos no Brasil.Descritores: Fotoquimioterapia; Cárie Dentária; Coleta de Dados.ReferênciasBradshaw DJ, lynch RJ. Diet and the microbial aetiology of dental caries: new paradigms. Int Dent J. 2013;63(Suppl 2):64-72.Hasan S, Singh K, Danisuddin M, Verma PK, Khan AU. Inhibition of major virulence pathways of Streptococcus mutansby quercitrin and deoxynojirimycin: a synergistic approach of infection control. 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Involuntarily celibate men (Incels) form online communities in which they “often bemoan their lack of a loving relationship with a woman while simultaneously dehumanizing women and calling for misogynistic violence” (Glace et al., 2021, p. 288). Several studies investigate this dehumanization and misogyny including (gendered) hate speech in online comments from Incels (e.g., Glace et al., 2021). However, not all online comments from Incels contain misogyny or gendered hate speech. To get a better understanding of the phenomenon of Incels, it would be better to not only focus on these problematic comments. Thus, we propose a new construct called “Online Incel speech”, which is defined as the sum of all online comments from Incels that are related to Inceldom, that is, being or becoming an Incel. In an approach to provide an extensive system of categorization, Grau Chopite (2022) synthesized codebooks from several studies on Incels (see example studies table note) and put it to an empirical test. She found that most Incel comments found online can be categorized into three subdimensions. The first two subdimensions cover framing by Incels, namely how Incels frame the subjective causes of becoming an Incel and how they frame the subjective emotional consequences of being an Incel. Both subdimensions can also be interpreted as part of a subjective theory (sensu Groeben et al., 1988) of Inceldom. In contrast to this, the third subdimension does not consist of framing, but of observable verbal behaviors, which are often linked to gendered hate speech. When trying to categorize online comments from Incels, former studies often applied the construct “Hybrid Masculinities” (e.g., Glace et al, 2021). This construct from Bridge and Pascoe (2014) suggests that “some men develop masculinities which appear to subvert, but actually reaffirm, White hegemonic masculinities” (Glace et al., 2021, p. 289). Glace et al. (2021) structure the construct into three subdimensions, namely (1) discursive distancing (claiming distance from hegemonic masculine roles without actually relinquishing masculine power), (2) strategic borrowing (appropriating the cultures of nondominant groups of men), and (3) fortifying boundaries (continually using hegemonic standards to constrain masculinity and demeaning men who fail to meet them). However, the construct only covers a part of Inceldom, which Glace et al. (2021) indirectly acknowledge by adding two inductive categories, that is, hostile sexism (shaming and degrading women) and suicidality (reporting suicidal thoughts, feelings, and intentions). Field of application/theoretical foundation: The construct “Online Incel speech” was coined by Grau Chopite (2022), and there are currently no other studies making use of it. However, there are studies (e.g., Vu & Lynn, 2020; also see the entry “Frames (Automated Content Analysis”) based on the framing theory by Entman (1991) where the subdimension “subjective causes” would correspond to Entman’s “causal interpretation frame”, while the “subjective emotional consequences” would correspond to Entman’s “problem definition frame”. The “subjective causes” also correspond to the “discursive distancing” and the “emotional consequences” to “suicidality” in the construct of Hybrid Masculinities. The third subdimension “verbal behavior” corresponds to gendered online hate speech (e.g., Döring & Mohseni, 2019), but also to “hostile sexism” and “fortifying boundaries” in the construct of Hybrid Masculinities. References/combination with other methods: The study by Grau Chopite (2022) employs a quantitative manual content analysis using a deductive approach. Studies based on the construct of Hybrid Masculinities also employ manual online content analyses or manual thematic analyses, but those are often qualitative in nature (e.g., Glace et al., 2021). Framing is also often assessed with manual content analyses (e.g., Nitsch & Lichtenstein, 2019), but newer studies try to assess it computationally (e.g., Vu & Lynn, 2020). Hate speech is often assessed with manual content analyses (e.g., Döring & Mohseni, 2019) and surveys (e.g., Oksanen et al., 2014), but some newer studies try to assess it computationally (e.g., Al-Hassan & Al-Dossari, 2019). As Online Incel Speech is related to framing and gendered hate speech, it seems plausible that manual content analyses of Online Incel Speech could be combined with computational analyses, too, to enable the investigation of large samples. However, computational analyses of subtle forms of verbal behavior can be challenging because the number of wrong categorizations increases (e.g., for sexism detection see Samory et al., 2021; for hate speech detection see Ruiter et al., 2022). Example studies: Example study Construct Dimensions Explanation Reliability Online Incel speech Grau Chopite (2022) Subjective Causes of Inceldom Race/Ethnicity having certain racial features and/or belonging to a certain ethnic κ = .55;AC1 = .80 Mental Health suffering from any mental health issue κ = .58;AC1 = .90 Employment difficulties with getting and/or maintaining employment; experiencing dissatisfaction in the workplace κ = .85;AC1 = .98 Family having family issues (e.g., an abusive family member) κ = .66;AC1 = .98 Subjective Emotional Consequences of Inceldom Hopelessness expressing hopelessness κ = .37;AC1 = .89 Sadness expressing sadness κ = .26;AC1 = .91 Suicidality expressing suicidality κ = .24;AC1 = .95 Anger expressing anger κ = .44;AC1 = .87 Hatred expressing hatred κ = .40;AC1 = .83 Verbal Behavior of Incels Using Gendered Hate Speech Against Women hostile sexism against women and misogynistic speech κ = .80;AC1 = .87 Adopting Social Justice Language claiming unfairness/ injustice of being discriminated by society or groups (e.g., other men, other races) κ = .48;AC1 = .82 Claiming Lack of Masculine Traits lacking masculine traits (e.g., muscles, a big penis) κ = .62;AC1 = .86 Shaming Other Men shaming of other men directly by calling them terms related to being “effeminate” or “unmanly” κ = .71;AC1 = .91 Claiming Lack of Female Interest being unable to attract women or being rejected by women κ = .61;AC1 = .87 Hybrid Masculinities Glace et al. (2021) Discursive Distancing Lack of Female Interest claiming a lack of ability to attract female romantic companionship and sexual interest n/a Lack of Masculine Traits claiming a lack of traditionally attractive masculine physical traits n/a Strategic Borrowing Race and Racism appropriating the culture of racial and ethnic minority men n/a Social Justice Language using the language of the marginalized to diminish one’s own position of power n/a Fortifying Boundaries Soyboys deriding non-Incel men as weak and desperate n/a Cucks deriding non-Incel men as being cheated or exploited by women n/a Hostile Sexism Women are Ugly deriding women for being unattractive n/a Slut-Shaming deriding women for having sex n/a False Rape Claims claiming that women make false rape claims (e.g., when approached by an Incel) n/a Women’s Only Value is Sex claiming that women’s only value is their sexuality n/a Women are Subhuman dehumanizing women n/a Suicidality Due to Incel Experience attributing suicidal thoughts, feelings, and intentions to Incel status n/a The “Clown World” claiming that the world is meaningless and nonsensical n/a Note: The codebook from Grau Chopite (2022) is based on the codebook and findings of Glace et al. (2021) and other studies (Baele et al., 2019; Bou-Franch & Garcés-Conejos Blitvich, 2021; Bridges & Pascoe, 2014; Cottee, 2020; Döring & Mohseni, 2019; D’Souza et al., 2018; Marwick & Caplan, 2018; Mattheis & Waltman, 2021; Maxwell et al., 2020; Rogers et al., 2015; Rouda & Siegel, 2020; Scaptura & Boyle, 2019; Williams & Arntfield, 2020; Williams et al., 2021). Gwet’s AC1 was calculated in addition to Cohen’s Kappa because some categories were rarely coded, which biases Cohen’s Kappa. The codebook is available at http://doi.org/10.23668/psycharchives.5626 References Al-Hassan, A., & Al-Dossari, Hmood (2019). Detection of hate speech in social networks: A survey on multilingual corpus. In D. Nagamalai & D. C. Wyld (Eds.), Computer Science & Information Technology. Proceedings of the 6th International Conference on Computer Science and Information Technology (pp. 83–100). AIRCC Publishing. doi:10.5121/csit.2019.90208 Baele, S. J., Brace, L., & Coan, T. G. (2019). From “Incel” to “Saint”: Analyzing the violent worldview behind the 2018 Toronto attack. Terrorism and Political Violence, 1–25. doi:10.1080/09546553.2019.1638256 Bou-Franch, P., & Garcés-Conejos Blitvich, P. (2021). Gender ideology and social identity processes in online language aggression against women. In R. M. DeKeyser (Ed.), Benjamins Current Topics: Vol. 116. Aptitude-Treatment Interaction in Second Language Learning (Vol. 86, pp. 59–81). John Benjamins Publishing Company. doi:10.1075/bct.86.03bou Bridges, T., & Pascoe, C. J. (2014). Hybrid masculinities: New directions in the sociology of men and masculinities. Sociology Compass, 8(3), 246–258. doi:10.1111/soc4.12134 Cottee, S. (2021). Incel (e)motives: Resentment, shame and revenge. Studies in Conflict & Terrorism, 44(2), 93–114. doi:10.1080/1057610X.2020.1822589 Döring, N., & Mohseni, M. R. (2018). Male dominance and sexism on YouTube: Results of three content analyses. Feminist Media Studies, 19(4), 512–524. doi:10.1080/14680777.2018.1467945 D'Souza, T., Griffin, L., Shackelton, N., & Walt, D. (2018). Harming women with words: The failure of Australian law to prohibit gendered hate speech. University of New South Wales Law Journal, 41(3), 939–976. Entman, R. M. 1991. Framing U.S. coverage of international news: contrasts in narratives of the KAL and Iran Air incidents. Journal of Communication, 41(4), 6-7. Glace, A. M., Dover, T. L., & Zatkin, J. G. (2021). Taking the black pill: An empirical analysis of the “Incel”. Psychology of Men & Masculinities, 22(2), 288–297. doi:10.1037/men0000328 Grau Chopite, J. (2022). Framing of Inceldom on incels.is: A content analysis [Master’s thesis, TU Ilmenau]. Psycharchives. doi:10.23668/psycharchives.5626 Groeben, N., Wahl, D., Schlee, J., & Scheele, B. (Eds.). (1988). Das Forschungsprogramm Subjektive Theorien: eine Einführung in die Psychologie des reflexiven Subjekts. Francke. Retrieved from https://nbn-resolving.org/urn:nbn:de:0168-ssoar-27658 Marwick, A. E., & Caplan, R. (2018). Drinking male tears: language, the manosphere, and networked harassment. Feminist Media Studies, 18(4), 543–559. doi:10.1080/14680777.2018.1450568 Mattheis, A. A., & Waltman, M. S. (2021). Gendered hate online. In K. Ross & I. Bachmann (Eds.), The Wiley Blackwell-ICA international encyclopedias of communication. The international encyclopedia of gender, media, and communication (pp. 1–5). John Wiley & Sons Inc. doi:10.1002/9781119429128.iegmc019 Maxwell, D., Robinson, S. R., Williams, J. R., & Keaton, C. (2020). “A short story of a lonely guy”: A qualitative thematic analysis of involuntary celibacy using Reddit. Sexuality & Culture, 24(6), 1852–1874. doi:10.1007/s12119-020-09724-6 Nitsch, C. & Lichtenstein, D. (2019). Satirizing international crises. The depiction of the Ukraine, Greek debt and migration crises in political satire. Studies in Communication Science (SComS), 19(1), 85-103. doi:10.24434/j.scoms.2019.01.007 Oksanen, A., Hawdon, J., Holkeri, E., Näsi, M., & Räsänen, P. (2014). Exposure to online hate among young social media users. In N. Warehime (Ed.), Soul of Society: A focus on the lives of children & youth (p. 253-273). doi:10.1108/S1537-466120140000018021 Rogers, D. L., Cervantes, E., & Espinosa, J. C. (2015). Development and validation of the belief in female sexual deceptiveness scale. Journal of Interpersonal Violence, 30(5), 744–761. doi:10.1177/0886260514536282 Rouda, B., & Siegel, A. (2020). I’d kill for a girl like that”: The black pill and the Incel uprising. International Multidisciplinary Program in the Humanities, Tel Aviv University. Retrieved from https://www.academia.edu/43663741/_Id_kill_for_a_girl_like_that_The_Black_Pill_and_the_Incel_Uprising Ruiter, D., Reiners, L., Geet D’Sa, A., Kleinbauer, Th., Fohr, D., Illina, I., Klakow. D., Schemer, Ch., & Monnier, A. (2022). Placing m-phasis on the plurality of hate. A feature-based corpus of hate online. Preprint. Retrieved from https://doi.org/10.48550/arXiv.2204.13400 Samory, M., Sen, I., Kohne, J., Flöck, F., & Wagner, C. (2021). “Call me sexist, but...”: Revisiting sexism detection using psychological scales and adversarial samples. Proceedings of the International AAAI Conference on Web and Social Media, 15(1), 573-584. Retrieved from https://ojs.aaai.org/index.php/ICWSM/article/view/18085 Scaptura, M. N., & Boyle, K. M. (2019). Masculinity threat, “Incel” traits, and violent fantasies among heterosexual men in the United States. Feminist Criminology, 15(3), 278–298. doi:10.1177/1557085119896415 Vu, H. T., & Lynn, N. (2020). When the news takes sides: Automated framing analysis of news coverage of the Rohingya crisis by the elite press from three countries. Journalism Studies. Online first publication. doi:10.1080/1461670X.2020.1745665 Williams, D. J., & Arntfield, M. (2020). Extreme sex-negativity: An examination of helplessness, hopelessness, and misattribution of blame among “Incel” multiple homicide offenders. Journal of Positive Sexuality, 6(1), 33–42. doi:10.51681/1.613 Williams, D. J., Arntfield, M., Schaal, K., & Vincent, J. (2021). Wanting sex and willing to kill: Examining demographic and cognitive characteristics of violent "involuntary celibates". Behavioral Sciences & the Law, 39(4), 386–401. doi:10.1002/bsl.2512

Introdução: Devido às altas taxas de mortalidade, a candidemia têm se tornado um grave problema de saúde na realidade pediátrica, sobretudo quando se considera o aumento de infecções e a letalidade dos casos em grupos de risco como as crianças hospitalizadas e com sistema imunológico deficiente. Ultimamente têm-se percebido um aumento de infecções fúngicas provocadas por espécies não-albicans, trazendo uma nova realidade para o combate destas infecções, especialmente por envolver espécies resistentes à terapia convencional. Já foi demonstrado que o óleo essencial de Cymbopogon winterianus possui uma vasta gama de propriedades farmacológicas, incluindo atividade antifúngica. Objetivo: Este trabalho buscou avaliar a atividade antifúngica do óleo essencial de Cymbopogon winterianus Jowitt ex Bor (Poaceae) contra isolados de Candida não-albicans de importância clínica pediátrica. Material e Método: A concentração inibitória mínima (CIM) e a concentração fungicida mínima (CFM) foram determinadas pelas técnicas de microdiluição em caldo. Resultados: Tanto a CIM50 quanto a CFM50 do óleo essencial de C. winterianus para os isolados testados foi de 128 μg/mL.Conclusão: Este produto natural apresentou potencial antifúngico in vitro contra cepas de Candida não-albicans clinicamente relevante para a pediatria médica. Contudo, mais estudos são necessários para elucidar seu mecanismo de ação.Descritores: Técnicas de Tipagem Micológica; Candida; Candidemia; Cymbopogon; Óleos; Pediatria.ReferênciasSteinbach WJ. Pediatric invasive candidiasis: epidemiology and diagnosis in children. J Fungi (Basel). 2016;2(1):5.Ruiz LS, Khouri S, Hahn RC, da Silva EG, de Oliveira VK, Gandra RF et al. Candidemia by species of the Candida parapsilosis complex in children’s hospital: prevalence, biofilm production and antifungal susceptibility. Mycopathologia. 2013;175(3-4):231-39.Oliveira VKP, Ruiz LS, Oliveira NAJ, Moreira D, Hahn RC, Melo ASA et al. Fungemia caused by candida species in a Children´s Public Hospital in the city of São Paulo, Brazil: study in the period 2007-2010. Rev Inst Med Trop Sao Paulo. 2014;56(4):301-5.Morace G, Borghi E, Iatta R, Amato G, Andreoni S, Brigante G et al. Antifungal susceptibility of invasive yeast isolates in Italy: the GISIA3 study in critically ill patients. BMC Infect Dis. 2011;11:130.Khan SMA, Malik A, Ahmad I. Anti-candidal activity of essential oils alone and in combination with amphotericin B or fluconazole against multi-drug resistant isolates of Candida albicans. Med Mycol. 2012;50(1):33-42.Svetaz L, Aguero MB, Alvarez S, Luna L, Feresin G, Derita M et al. Antifungal activity of Zuccagnia punctata Cav.: evidence for the mechanism of action. Planta Med. 2007;73(10):1074-80.Ganjewala D, Silviya S, Khan HK. Biochemical composition and antibacterial activities of Lantana Camera plants with yellow, lavender, red and white flowers. EurAsia J BioSci. 2009;3:69-77.Scazzocchio F, Garzoli S, Conti C, Leone C, Renaioli C, Pepi F et al. Properties and limits of some essential oils: chemical characterisation, antimicrobial activity, interaction with antibiotics and cytotoxicity. Nat Prod Res. 2016;30(17):1909-18.Silva MR, Ximenes RM, da Costa JG, Leal LK, de Lopes AA, Viana GS. Comparative anticonvulsant activities of the essential oils (EOs) from Cymbopogon winterianus Jowitt and Cymbopogon citratus (DC) Stapf. in mice. Naunyn Schmiedebergs Naunyn Schmiedebergs Arch Pharmacol. 2010;381(5):415-26.Silva CT, Wanderley-Teixeira V, Cunha FM, Oliveira JV, Dutra KA, Navarro DM et al. Biochemical parameters of Spodoptera frugiperda (J. E. Smith) treated with citronella oil (Cymbopogon winterianus Jowitt ex Bor) and its influence on reproduction. Acta Histochem. 2016;118(4):347-52.Oliveira WA, Pereira FO, Luna GCDG, Lima IO, Wanderley PA, Lima RB et al. Antifungal activity of Cymbopogon winterianus Jowitt ex Bor against Candida albicans. Braz J Microbiol. 2011;42(2):433-41.Eloff JN. A sensitive and quick microplate method to determine the minimal inhibitory concentration of plant extracts for bacteria. Planta Med. 1998;64(8):711-13.Hadacek F, Greger H. Testing of antifungal natural products: methodologies, comparability of results and assay choice. Phytochem Anal. 2000;11(3):137-47.CLSI. Clinical and laboratory standards institute. protocol M27-A3. Reference method for broth dilution antifungal susceptibility testing of yeasts. 3ed. Wayne, PA, USA. 2008.Espinel-Ingroff A, Chaturvedi V, Fothergill A, Rinaldi MG. Optimal testing conditions for determining MICs and minimum fungicidal concentrations of new and established antifungal agents for uncommon molds: NCCLS collaborative study. J Clin Microbiol. 2002;40(10):3776-81.Falagas ME, Roussos N, Vardakas KZ. Relative frequency of 3 albicans and the various non-albicans Candida spp among candidemia isolates from inpatients in various parts of the world: a systematic review. Int J Infect Dis. 2010;14(11):e954-66.Nucci M, Queiroz-Telles F, Alvarado-Matute T, Tiraboschi IN, Corte J, Zurita J et al. Epidemiology of candidemia in Latin America: a laboratory-based survey. Plos One. 2013;8(3):e59373.Simões ER, Santos EA, de Abreu MC, Silva JN, Nunes NM, da Costa MP et al. Biomedical properties and potentiality of Lippia microphylla Cham. and its essential oils. J Intercult Ethnopharmacol. 2015;4(3):256-63.Bilia AR, Santomauro F, Sacco C, Bergonzi MC, Donato R. Essential Oil of Artemisia annua L.: An Extraordinary Component with Numerous Antimicrobial Properties. Evid Based Complement Alternat Med. 2014; 2014:159819.Duarte MCT, Figueira G M, Sartoratto A, Rehder VLG, Delarmelina C. Anti-Candida activity of Brazilian medicinal plants. J Ethnopharmacol. 2005;97(2):305-11.Sartoratto A, Machado ALM, Delarmelina C, Figueira GM, Duarte MCT, Rehder VLG. Composition and antimicrobial activity of essential oils from aromatic plants used in Brazil. Braz J Microbiol. 2004;35(4):275-80.Morales G, Paredes A, Sierra P, Loyola LA. Antimicrobial activity of three baccharis species used in the traditional medicine of Northern Chile. Molecules. 2008;13(4):790-94.Oliveira WA, Arrua JMM, Wanderley PA, Lima RB, Lima EO. Effects of the essential oil of Cymbopogon winterianus against Candida albicans. Rev Pan-Amaz Saude. 2015;6(3):21-6.Tragiannidis A, Tsoulas C, Groll AH. Invasive candidiasis and candidaemia in neonates and children: update on current guidelines. Mycoses 2015;58(1):10-21.Hafidh RR, Abdulamir AS, Vern LS, Bakar FA, Abas F, Jahanshiri F et al. Inhibition of growth of highly resistant bacterial and fungal pathogens by a natural product. Open Microbiol J. 2011;5:96-106.Monk BC, Goffeau A. Outwitting multidrug resistance to antifungals. Sci. 2008;321(5887):367-69.

Introduction: We present a case report of posterior reversible leukoencephalopathy syndrome (PRES) following transarterial chemoembolization (TACE) of liver metastasis of an intestinal neuroendocrine tumour.Case presentation: A 62-year-old female was evaluated for progressive bilateral vision loss following transarterial chemoembolization (TACE) of hepatic metastasis of a midgut carcinoid tumour with cisplatin. Vital signs were remarkable for significant hypertension (170-210/85-110) since having undergone TACE (baseline BP 136/74), despite pre-procedure administration of octreotide. Blood pressure failed to correct with administration of amlodipine, hydralazine, captopril and labetalol infusion but responded promptly to octreotide infusion. Magnetic resonance imaging showed findings compatible with PRES. The patient’s vision gradually corrected to her baseline over 2 days. Conclusion: TACE for neuroendocrine tumours can be complicated by carcinoid crisis despite pre-administration of octreotide. Rarely, this may present as a hypertensive emergency of which PRES is a manifestation. Prompt recognition and treatment with high dose octreotide are important and can avoid permanent neurological injury in patients.RésuméIntroduction : Il s’agit d’une étude de cas de syndrome de leuco encéphalopathie réversible postérieure (SERP) consécutive à la chimioembolisation transartérielle (CETA) d’une métastase hépatique d’une tumeur neuro-endocrinine intestinale.Présentation du dossier: Une femme de 62 ans est évaluée pour une perte de vision bilatérale progressive à la suite de la chimioembolisation transartérielle (CETA) de métastases hépatiques d’une tumeur du tube digestif effectuée au moyen du cisplatine. Les signes vitaux sont remarquables malgré une hypertension importante (170-210/85-110) depuis la CETA (p.a. de base 136/74) et l’administration d’octréotide préalable à l’intervention. La pression artérielle ne s’est pas corrigée avec l’administration d’amlodipine, d’hydralazine, de captopril et de labétalol en perfusion, mais a répondu promptement à l’octréotide en perfusion. Une imagerie par résonnance magnétique a fourni des résultats compatibles avec un diagnostic de SERP. La vision de la patiente s’est graduellement corrigée pour revenir à son état habituel en deux jours.Conclusion : Dans le cas de tumeurs neuro-endocriniennes, la CETA peut être compliquée d’une crise carcinoïde malgré l’administration d’octréotide au préalable. Cette condition peut, quoique rarement, représenter une urgence hypertensive dont le SERP est une manifestation. L’identification rapide de la condition et un traitement à l’aide d’octréotide à dose élevée sont de la plus haute importance et peuvent éviter des dommages neurologiques permanents.Carcinoid syndrome is a syndrome classically consisting of diarrhea, paroxysms of cutaneous flushing with or without hypotension and bronchospasm arising most frequently in the setting of hepatic metastases originating from midgut carcinoid tumours. However, these neuroendocrine tumours can synthesize a wide variety of polypeptides, prostaglandins, and biogenic amines and hence present atypical clinical manifestations such as pellagra, abdominal pain, right-sided heart failure from valvular lesions and paroxysmal hypertension. Tumour manipulation may result in a massive influx of hormones into the systemic vasculature, potentially resulting in life threatening swings in blood pressure, cardiac arrhythmias and bronchoconstriction, even in patients without liver metastases or preoperative carcinoid syndrome.1 We present a case report of hypertensive emergency presenting as posterior reversible leukoencephalopathy syndrome (PRES) after transarterial chemoembolization (TACE) of a hepatic metastasis of carcinoid tumour.Case PresentationA 62-year-old caucasian female was evaluated on the surgical ward for progressive bilateral vision loss about 10 hours following transarterial chemoembolization (TACE) of a hepatic metastasis of a midgut carcinoid tumour (Figure 1, Figure 2) with Lipiodol and cisplatin. Premedication with octreotide 100 mcg subcutaneously and dexamethasone 8 mg IV pre-procedure was given, and post-procedure orders were given for dexamethasone 4 mg bid, ondansetron as needed and D5% NaCl 0.45% at a rate of 150 mL/h. The rest of her past medical history was unremarkable, specifically without history of hypertension, cerebrovascular disease, or clinical manifestations of carcinoid syndrome prior to admission. She had undergone two intra-abdominal surgeries without complication. Her usual medication was limited to inhaled glycopyrronium and indacaterol. Figure 1. Axial computed tomography scan of hepatic metastasis. A mass is visible in hepatic parenchyma corresponding to a metastasis of the midgut carcinoid tumour. Figure 2. Fluroscopic image of transarterial chemoembolization of hepatic metastasis. Upon evaluation, the patient was somnolent but otherwise well oriented. Eye exam confirmed bilateral 0/20 vision though pupils were 4 mm and reactive. On motor exam, the patient had diffuse hyperreflexia with upgoing plantar reflexes but without focal weakness. Chart review was remarkable for blood pressures ranging from 170-210/85-110 since TACE (pre-procedure blood pressure 136/74). A presumptive diagnosis of PRES due to cisplatin was made.Initial cerebral computed tomography scan was suspicious for a right occipital sub-cortical hypodensity of 3 cm, possibly of ischemic nature. IV fluids were discontinued (NaCl 0.9% at a rate of 250 mL/h) and anti-hypertensive agents were begun. After failure of improvement of blood pressure or symptoms despite amlodipine, hydralazine, labetalol, and captopril, a diagnosis of carcinoid crisis was suspected and octreotide 300mcg IV bolus followed by an infusion of 50 mcg/h was started. The suspected diagnosis of carcinoid crisis was later confirmed by 24h urinary 5-HIAA dosing at 141.4 umol/day (normal 0–42, previously within normal limits pre-operatively). Serum chromogranin A was also elevated at 138.2 ug/L (normal 0–82), compatible with a neuroendocrine tumour.Characteristic changes of PRES were seen on cerebral magnetic resonance imaging (MRI) (Figure 3) including predominantly sub-cortical hyperintensities in the bilateral parietal and occipital lobes on T2 and FLAIR sequences which were also hyperintense on diffusion-weighted imaging (DWI), likely from T2 shine through, and apparent diffusion coefficient (ADC) maps without restricted diffusion, hence confirming the finding of vasogenic edema compatible with PRES. Figure 3. FLAIR sequence, axial slice, cerebral magnetic resonance imaging. Subcortical hyperintensies in the bilateral occipital lobes reflecting vasogenic edema of the visual white matter tracts are seen. The patient’s blood pressure and her visual symptoms progressively normalized over 48 hours. On last follow-up 1 month after procedure, vital signs were normal (blood pressure 115/54) and vision was normal.DiscussionCarcinoid tumours are classically described as slow growing, mainly affecting the gastrointestinal (GI) tract. They are known to internists mainly for their capability to produce the carcinoid syndrome. However, only about 25% of carcinoids actually produce the mediators which produce the carcinoid syndrome and less than 10% of patients actually develop the carcinoid syndrome.2 The syndrome usually presents when midgut carcinoids metastasize to the liver, hence bypassing hepatic metabolism. Typical symptoms include secretory diarrhea (80%) and flushing of the head, neck, and upper torso (90%) which may be associated with hypotension and tachycardia. Less frequent manifestations are right heart failure due to carcinoid valve disease (30%), bronchospasm (15%) and pellagra (5%). 3 The classic triad of flushing, diarrhea and wheezing is infrequently found. Foregut (e.g., bronchial) and extra-digestive midgut (e.g., ovarian) bypass the liver and may result carcinoid syndrome without hepatic metastasis, although symptoms are usually atypical in these cases.Perioperative carcinoid crisis occurs in 10–30% of patients undergoing operative resection. Absence of preoperative carcinoid syndrome decreases the risk of carcinoid crisis, however it may still occur.1 This has led to the recommendation by some that patients be premedicated with somatostatin analogues to block bioactive peptide release and action, with or without other hormone antagonists (e.g., anti-histamines).3 However, the benefit of octreotide prophylaxis has been questioned by other studies.1 Once a carcinoid crisis has occurred, bolus doses of 25–500 mcg and intravenous infusions at rates of 50–150 mcg/h have been effective in case reports and case series, with higher doses being potentially required in patients on maintenance octreotide therapy or with carcinoid heart disease.4Despite a lack of data comparing it to surgical management, transarterial chemoembolization (TACE).5 is a frequent management strategy for patients with liver metastases, especially when patients present with hormonal symptoms and multiple metastases preclude resection. Rates of complication from TACE are difficult to estimate ranging from 0 to 100%, likely due to variable definitions and reporting. Only one study reported on the incidence of post embolization carcinoid crisis,6 with 2 of 12 patients developing the complication. Both had a history of carcinoid syndrome and had been premedicated with octreotide 200 mcg SC before procedure and q8h afterward. One group7 did report a patient who developed transient cortical blindness following TACE which possibly could have been due to PRES.PRES is a syndrome of failure of cerebral blood pressure autoregulation with acute onset elevations of blood pressure from baseline and a combination of altered level of consciousness, visual symptoms, headache and seizures.8 Blood pressure is often only moderately elevated, though significantly above the patient’s baseline. Etiologies are varied but include cytotoxic chemotherapy, eclampsia and other causes of hypertensive emergency. It was originally felt that the patient’s PRES was due to the cisplatin received during TACE with contribution from dexamethasone and iatrogenic fluid overload (NaCl 0.9% at 150 mL/h had been running for several hours) as she had no history of carcinoid syndrome, had been premedicated and had no other findings associated with the disease. However, her lack of response to standard anti-hypertensives and prompt response to octreotide suggest carcinoid crisis as the cause.Neuroimaging with MRI confirms the diagnosis. Findings are compatible with symmetrical white matter edema in the posterior cerebral hemispheres, particularly the parieto-occipital regions. The cortex, basal ganglia, brainstem, and cerebellar may also be involved though less so than the subcortical white matter, while anterior cortical involvement is seen only with the most severe cases. Importantly, the distribution is not confined to a single vascular territory. Classically lesions appear as punctate or confluent areas of hyperintensity on T2 and FLAIR sequences.9 DWI usually shows hypo or iso-intense signal (though sometimes mildly hyperintense from T2 shine through) while ADC maps show increased signal, thus distinguishing PRES from ischemic stroke. With prompt recognition and management, full recovery over a period of days to weeks can be expected. ConclusionsCarcinoid crisis is a well-known and dreaded complication of surgical manipulation of carcinoid tumours. Transarterial chemoembolization of these tumours may also result in carcinoid crisis and our report suggests that pre-procedure carcinoid syndrome is not a prerequisite for this. Presentation may be atypical, as it was in our patient, and so clinical suspicion should be high. When suspected, prompt management with octreotide and other supportive therapies should be instituted.Key Points1. Patients undergoing transarterial chemoembolization for carcinoid tumour metastases are at risk for carcinoid crisis, even if they have been premedicated with octreotide and have no history of carcinoid syndrome.2. Carcinoid crisis may present as hypertensive crisis rather than hypotension, and may give rise to PRES.References1. Condron ME, Pommier SJ, Pommier RF. Continuous infusion of octreotide combined with perioperative octreotide bolus does not prevent intraoperative carcinoid crisis. Surgery 2016;159:358–67.2. Van Der Lely AJ, Herder WWd. Carcinoid syndrome: diagnosis and medical management. Arquivos Brasileiros de Endocrinologia & Metabologia 2005;49:850–60.3. Mancuso K, Kaye AD, Boudreaux JP, et al. Carcinoid syndrome and perioperative anesthetic considerations. J Clin Anesth 2011;23:329–41.4. Seymour N, Sawh SC. Mega-dose intravenous octreotide for the treatment of carcinoid crisis: a systematic review. Can J Anesth/J can d'anesthés2013;60:492–9.5. Kennedy A, Bester L, Salem R, Sharma RA, Parks RW, Ruszniewski P. Role of hepatic intra‐arterial therapies in metastatic neuroendocrine tumours (NET): guidelines from the NET‐Liver‐Metastases Consensus Conference. HPB 2015;17:29–37.6. Maire F, Lombard-Bohas C, O’Toole D, et al. Hepatic arterial embolization versus chemoembolization in the treatment of liver metastases from well-differentiated midgut endocrine tumours: a prospective randomized study. Neuroendocrinology 2012;96:294–300.7. Gupta S, Johnson MM, Murthy R, et al. Hepatic arterial embolization and chemoembolization for the treatment of patients with metastatic neuroendocrine tumours. Cancer 2005;104:1590–602.8. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494–500.9. Pedraza R, Marik PE, Varon J. Posterior reversible encephalopathy syndrome: a review. Crit Care Shock 2009;12:135–43.

Photo by Sam McGhee on Unsplash ABSTRACT Medical education has a long history of discriminatory practices. Because of the hierarchy inherent in medical education, underrepresented-in-medicine (URiM) students are particularly vulnerable to discrimination and often feel they have limited recourse to respond without repercussions. URiM student leaders at a USA medical school needed their peers, faculty, and administration to know the institutional racism and other forms of discrimination they regularly experienced. The students wanted to share first-person narratives of their experiences; however, they feared retribution. This paper describes how the medical students partnered with a theater company that applied elements of verbatim theater to anonymously present student narratives and engage their medical school community around issues of racism and discrimination. The post-presentation survey showed the preponderance of respondents increased understanding of URiM student experiences, desired to engage in conversation about inclusion, equity, and diversity, and wanted to make the medical school more inclusive and equitable. Responses from students showed a largely positive effect from sharing stories. First-person narratives can challenge discriminatory practices and generate dialogue surrounding the experiences of URiM medical students. Authors of the first-person narratives may have a sense of empowerment and liberation from sharing their stories. The application of verbatim theater provides students the safety of anonymity, thereby mitigating fears of retribution. INTRODUCTION The field of medicine has a long history of discriminatory practices toward racial and ethnic minorities, women, and members of the LGBTQ+ community.[1] Because of the inherent hierarchy in medical education, medical students are particularly vulnerable to discriminatory practices and may feel they have limited recourse to respond to discrimination.[2] Underrepresented-in-medicine (URiM) students experience “death by a thousand cuts,” often with the perception that they are alone to shoulder and overcome injurious behavior inflicted by peers, faculty, and administrators. l. Social Impetus and Desire for Change Spring 2020 saw the confluence of three social exigencies in the United States: the disproportionate burden of the COVID-19 pandemic on people of color;[3] wide-spread awareness of racist police brutality;[4] and resurgence of demands for equity within medicine by the White Coats for Black Lives organization.[5] URiM student leaders at the Frank H. Netter MD School of Medicine at Quinnipiac University, CT, USA, felt compelled to awaken their medical school community to the bias and discrimination they faced regularly. The URiM student leaders (15 people representing Student National Medical Association, Latinx Medical Student Association, Netter Pride Alliance, Asian Pacific American Medical Student Association, Student Government Association, and White Coats for Black Lives) met regularly with the medical school dean and associate deans to address issues of culture and institutional racism. They needed their peers, faculty, and administration to know that institutional racism and other forms of discrimination were present in the school of medicine, despite vision and mission statements that prioritize equity and inclusion. To that end, in addition to advocating for policy changes, the URiM student leaders wanted to share personal stories from their classmates with the hope that the narratives had the power to instigate change for the better at the school of medicine. They wanted to be heard and seen and to have their perceptions recognized and valued; yet, they could not shake the fear of retribution if they were truly honest about their experiences. Therefore, the students concluded that anonymous storytelling was the safest approach. ll. Foundational Deliberations and Partnership To anonymizing their stories, the students first had to deliberate two foundational features: One: How to account for a plurality of opinions and make decisions? Two: How to speak about their personal experiences and maintain anonymity? The 15 URiM student leaders elected three students (GH, VS, SD) to organize the event and imbued the three organizers with decision-making capacity. The three students, named the Crossroads Organizers, arrived at decisions by consensus. With the aim of maintaining student anonymity, a faculty member (AW) suggested the students investigate using a theater company to present their stories – the premise being that the actors would provide anonymous cover for the students while speaking the students’ words. Having a script comprised exclusively of storytellers’ words is a foundational technique of verbatim theater.[6] The students decided the Crossroads Organizers would meet theater company representatives to seek assurance that their stories would be presented with respect and appropriate representation. Squeaky Wheelz Productions[7] is a theatrical production company specializing in giving voice to the stories of minoritized individuals. lll. Recruit Story Authors The Crossroads Organizers used email and social media platforms such as Facebook, GroupMe, and Instagram to invite medical students to author stories. Authors were given three weeks to submit their stories via an anonymous survey drop on Google Forms, thus assuring that no one, including the Crossroads Organizers, knew the identity of the story authors. lV. Work with the Theater Company The Crossroads Organizers met with the director of the theater company (AMW) multiple times to discuss logistics for the production. The director guided the medical students to refine their goals for the audience and authors (see Theater Company Process) and establish the timeline and task list to arrive at a finished product promptly. Initially, the Crossroads Organizers thought it would be a good idea to have the authors and actors meet to discuss their specific stories and roles. However, after further discussion, they decided that meeting would compromise the anonymity of the student authors and might discourage them from coming forward. Instead, they let the authors know they had the option of meeting their actor. In the Google Forms survey, the Crossroads Organizers provided the opportunity for authors to list specific demographic characteristics of the actor they wanted to portray their story. For example, a Latinx author could choose to have a Latinx actor portray their story. V. Theater Company Process The Squeaky Wheelz actors and director met to discuss how best to use their artistic skills to serve the students’ goals. Given that the collaboration occurred amid the COVID-19 pandemic, there were health, safety, technology, and geography parameters that informed the creative decisions. Actors were recorded individually, and then the footage was edited to create one cohesive piece. Using video meant that in addition to the artistic choices about casting, tone, pacing, and style (which are elements of an in-person event), there were also choices about editing, sound, and mise-en-scéne (“putting in the scene” or what is seen on screen). The Squeaky Wheelz director collaborated with the Crossroads Organizers about the project goals for their audience and colleagues. For example, the theater company encouraged the Crossroads Organizers to consider questions such as: Do they want to tell the viewer what to feel? If a student author identified their race or ethnicity in their story, should casting reflect that as well? Is there anything they would like the audience to know in a disclaimer, or should the stories stand on their own? Consequent to the discussions, the theater company made the decision to not include music or sound (often used in film to dictate emotion), to cast actors of the same race or ethnicity if the author included such identifiers, and to create an introduction for the piece. The introduction stated: “The stories you are about to hear are the true, lived experiences of students in this program, read by actors. Students submitted these words anonymously. We, the actors, ask you to listen.” The Crossroads Organizers expressed their goal was to share the stories authentically and to be clear that these were real experiences, not fictional accounts performed by actors. To serve these goals artistically in the mise-en-scéne, each actor was filmed in front of a plain white wall, in a medium-close-up, and holding a piece of white paper in the bottom corner of the frame from which they read the story. The actors looked straight to the camera for most of their reading, occasionally looking down to the paper to indicate that these words belonged to someone else visually. Actors were directed to “read the words,” not “perform the story” – to communicate the words simply and clearly rather than projecting an assumed emotionality behind the story. This choice was made for two reasons: One, the stories were submitted anonymously, and an assumed emotion may have been inaccurate to the author’s intention; two, without projecting assumed emotionality, the audience has permission to feel and think for themselves in response. All the actors worked independently to prepare for their virtual shoot dates. They also were available if any student authors wanted to meet about their personal stories. [One author chose to meet with their actor.] The final production, comprised of 16 student stories, was entitled Netter Crossroads: A Discourse on Race, Gender, Sexuality, and Class. Vl. Finding the Audience Knowing the unique features and importance of the video as a tool to increase awareness of institutional racism and discrimination within the school community, the Crossroads Organizers aimed to secure as large a viewing audience as possible. To that end, they sought and obtained approval from the dean of the school of medicine to show the video during the Annual State of the School Address, which historically is delivered on the first day of classes and attracts a sizable cross-section of students, faculty, and staff. The Crossroads Organizers asked the dean and associate deans to make event attendance mandatory to engage as many students and faculty as possible in active reflection about discrimination, racial inequality, and social injustice within the medical education community. The deans agreed to make attendance mandatory for first-year medical students and to strongly encourage all other students, faculty, and staff to attend. The Annual State of the School Address is typically an in-person event. Because of the COVID-19 pandemic, all university events had to be hosted virtually on Zoom. The Crossroads Organizers valued the real-time shared experience of viewing the video as a community, so they decided to divide the video into four short segments. The shorter length increased the likelihood that the video’s audio and visual quality was not affected. Between the video segments, the Crossroads Organizers presented national data about underrepresentation in medicine. Vll. Attendee Feedback The 2020 State of the School event had 279 attendees who watched the video, Netter Crossroads: A Discourse on Race, Gender, Sexuality, and Class, in real-time. The audience was comprised of medical students, medical school faculty, staff, and administrators, and university administrators. A four-question Likert-scale survey and open-response field disseminated after the event indicated the vast preponderance of attendees were favorably impressed by the Crossroads video (see Table 1). Approximately 84 percent (67/80) of respondents strongly agreed or agreed with the statement that their understanding of URiM student experiences had increased based on the presentation. Approximately 82 percent (66/80) of respondents strongly agreed or agreed with the statement that the Crossroads presentation effectively conveyed the challenges of URiM students. Seventy percent of respondents (56/80) strongly agreed or agreed with the statement that they were more inclined to engage in conversation about inclusion, equity, and diversity since seeing the Crossroads presentation. Approximately 77 percent (62/80) of respondents strongly agreed or agreed that since seeing the Crossroads presentation, they wanted to learn more about how to help make the medical school more inclusive and equitable. Table 1. Likert-scale survey results after viewing Crossroads video (N=80). The open-response field attracted 24 commentators who largely made favorable comments. Representative favorable comments included: “That was a great presentation. I wish I could hear more from students like that.” “A big thank you to the students who conveyed their stories to the actors – that was a heavy lift.” “Hearing the stories of people at Netter made this presentation hit close to home.” “The Crossroads presentation was outstanding and really opened my eyes to things that I had no idea were happening or that I had never even thought about.” “Definitely we need to hear more of these voices. Very powerful and moving session!” “It was powerful to hear real students’ experiences, played by actors…It communicated to me that Netter is…really committed to improving diversity and inclusion.” Representative unfavorable comments include: “I found this style confrontational instead of conversant/dialogue, and that may have been what the students were going for…but dialogue might have been just as, if not more, effective…” “I fear that welcoming new students virtually to our school by sharing stories of bias, racism, and sexism at our own institution may have left them feeling even more isolated and insecure.” “We need less of these presentations.” Vlll. Student Author Survey After the assembly, the Crossroads Organizers posted announcements on their social media sites inviting the student authors to respond to two queries about their experiences of sharing their stories. Since the student authors were anonymous and unknown to the Crossroads Organizers, they could not directly query the student authors. Instead, the posted announcement asked for open responses to the following questions: a. How did writing and sharing your personal experience at Netter make you feel? b. How did viewing your story portrayed by actors during the state of the school address make you feel? Six of the sixteen student authors put their responses anonymously in a Google Forms survey drop. The authors indicated a range of feelings about writing and sharing their personal experiences. Several authors expressed appreciation for the process and the psychotherapeutic effects. “I feel as though it was an opportunity for my voice to be heard in an anonymous way.” [student author #3] “Empowered to get that frustration out.” [student author #4] “It helped me process some thoughts and emotions that were bothering me subconsciously. I was allowing things like microaggressions affect me without actually addressing the issues.” [student author #6] Others focused on the value of having an audience for their experience. “I feel as though at school, I am never in safe spaces to be able to share my concerns, and that my voice is never heard. I just appreciated being able to vent to someone else about my experiences other than my friends.” [student author #3] “Before this presentation, I had only shared my feelings about being viewed as a minority at school privately with my close friends. Hearing someone else’s stories normalized my feelings of isolation (unfortunately).” [student author #5] Two authors expressed concern about how their stories would be received. “A little worried about the reaction.” [student author #1] “Vulnerable, scared, apprehensive.” [student author #2] The authors also had a range of responses about their experience of seeing their stories portrayed by actors. For some, there was a sense of exuberance and activation. “Really empowered!” [student author #1] “The actors were excellent and really funneled our voices. Viewing both my story and the other students’ [stories] made me realize there is so much work that needs to be done in predominantly white medical schools.” [student author #5] Others conveyed hopefulness. “Heard…like attempts were made to at least take my experience seriously.” [student author #2] Some students experienced conflicting and even negative emotions. “It made me feel sad, but also proud…” [student author #3] “The negative stress racism and discrimination that plays on underrepresented medical students is traumatizing and completely unfair. We are all trying to succeed as future physicians and none of us should carry the burden of feeling targeted based on our skin color or physical features. Viewing the other stories made me feel angry that these micro/macro-aggressions are tolerated every single day.” [student author #5] “It made me feel vulnerable that my experience was on display for the community to see.” [student author #6] And finally, there was mention of the psychodynamic processing that took place from seeing their experiences. “I felt that it was relatively therapeutic.” [student author #3] “It also helped me work through the emotions that I had been suppressing.” [student author #6] CONCLUSION Discriminatory practices often go unnoticed or unmentioned in the medical education setting. Failure to address discriminatory practices leads to isolation, stress, and disempowerment. To mitigate these harms, the medical school curriculum should enable conversations and events about racism and other forms of discrimination. URiM student narratives can aid faculty and student development. After viewing the stories, facilitated conversations could address questions such as the following: a. What could you do to prevent this scenario from ever even occurring? b. Now that it has occurred, how will you support this student? c. What structural changes and/or policies need to be in place for corrective action to be effective? d. If the scenario in the video happened to you, what would you do next? e. Why would you make that choice? f. Alternatively, if you witnessed this happen to a student or faculty member, what would you do? g. Why would you make that choice? h. What are the potential personal and professional consequences of your choice? In alignment with the published literature, our small sample of student author respondents experienced positive therapeutic effects from the process of writing and sharing their stories.[8] At the same time, seeing other authors’ stories of discrimination portrayed by actors ignited anger and sadness for some of our students as they recognized the depth of trauma within the community. Partnership with a theater company provides students the safety of anonymity when telling their stories, thereby allaying their fears of retribution. While some student authors maintained a sense of vulnerability despite the anonymity, they also expressed a sense of empowerment, hopefulness, and pride. Medical educators and administrators must take bold steps to address institutional racism in a meaningful way. Health humanities, including theater, can help the medical education community recognize and overcome the harms imposed on URiM students by institutional racism and other forms of discrimination and awaken capacity for compassionate, respectful, relationship-based education. [1] Hess, Leona, Palermo, Ann-Gel, and David Muller. 2020. “Addressing and Undoing Racism and Bias in the Medical School Learning and Working Environment” Academic Medicine, 95, no. 12 (December): S44-S50. https://pubmed.ncbi.nlm.nih.gov/32889933/ [2] Naif Fnais et al., “Harassment and Discrimination in Medical Training: A Systematic Review and Meta-analysis,” Academic Medicine 89, no. 5 (2014): 817-827, https://doi.org/10.1097/ACM.0000000000000200; Melody P. Chung et al., “Exploring Medical Students’ Barriers to Reporting Mistreatment During Clerkships: A Qualitative Study,” Medical Education Online 23, no. 1 (December 2018): 1478170, https://doi.org/10.1080/10872981.2018.1478170 [3] “Racial Data Transparency,” Coronavirus Resource Center, Johns Hopkins University & Medicine, accessed July 15, 2021, https://coronavirus.jhu.edu/data/racial-data-transparency [4] Radley Balko, “There’s Overwhelming Evidence that the Criminal Justice System is Racist. Here’s the Proof,” Washington Post, June 10, 2020, https://www.washingtonpost.com/graphics/2020/opinions/systemic-racism-police-evidence-criminal-justice-system/. [5] “WC4BL,” White Coats for Black Lives, accessed May 15, 2021, www.whitecoats4blacklives.org. [6] Will Hammond and Dan Steward, eds., Verbatim: Contemporary Documentary Theatre (London: Oberon Books, 2012). [7] “Our Vision,” Squeaky Wheelz Productions, accessed June 30, 2021, www.squeakywheelzproductions.com/. [8] James Pennebaker and Joshua Smyth, Opening Up by Writing It Down: How Expressive Writing Improves Health and Eases Emotional Pain, 3rd ed (New York, London: The Guilford Press, 2016).