IMPROVing communication about diversity, equity, and inclusion in health professions education

There has never been a stronger call for authenticity in health professions education than this moment in time. The health inequities laid bare by the COVID-19 syndemic (a concept that describes the clustering of SARS-CoV-2 infection and disease by political, social, and economic factors) compels health professions educators to learn how to best engage in, sustain, and deepen conversations on diversity, equity, and inclusion (DEI) within our learning environments. Health professions curricula should address such concerns through explicit faculty training programs in dialogue models of communication. In this commentary, I propose that medical improv can help refocus health professions training to the humanistic values of empathy for others and respect for multiple viewpoints. Medical improv refers to teaching methods that adapt improvisation principles and exercises to enhance professional competencies in the health professions, such as communication. I describe a training series implemented at one institution to prepare faculty facilitators to engage in conversations about DEI in a discussion-based core course on the social determinants of health for first year medical students called "Humanity in Medicine." Key elements of dialogue training, including examinations of identity and positionality, caretaking and team-making, and conversations with a skeptic, are viewed through the lens of improv exercises as a pedagogy in communication. I report on facilitator and medical students' positive response to facilitator training and the Humanity in Medicine course. Potential next steps towards a formal evaluation of the method, and outcomes assessments of the use of improv in health professions training are discussed.

Congenital Cytomegalovirus Knowledge, Practices, and Beliefs Among Primary Care Physicians and Newborn Hospitalists

BACKGROUND

Congenital cytomegalovirus (cCMV) affects 1 in every 200 United States infants, at present there are 9 states which mandate newborn cCMV screening. With more infants being diagnosed, more children will need continuing care from providers who are knowledgeable about cCMV.

OBJECTIVES

To examine pediatric provider knowledge, practices, and beliefs around cCMV.

METHODS

Primary care and newborn hospitalist pediatricians (N = 103) from Michigan, who "regularly care for infants" were invited to participate in a survey about their cCMV-related knowledge, clinical practices, and beliefs.

RESULTS

Respondents had low knowledge of typical cCMV presentation and sequelae, with mixed knowledge of screening and testing standards. Most (68%) reported rarely/never screening for cCMV, though 71% strongly agreed/agreed that primary care providers should test for cCMV. Most (90%) strongly agreed/agreed that infants who fail/refer on their newborn hearing screen should be tested for cCMV, yet 81% expressed not being comfortable diagnosing and managing cCMV. Most (72%) felt that cCMV was not sufficiently covered in their medical training; almost all respondents endorsed interest in learning more.

CONCLUSIONS

Primary care and newborn hospitalists in this study expressed mixed knowledge about, infrequent practice of and low comfort with screening and caring for children with cCMV. This may present a prime opportunity for education and clinician support by professional organizations.

Teasing Apart Impacts of Human Activity and Regional Drought on Madagascar’s Large Vertebrate Fauna: Insights From New Excavations at Tsimanampesotse and Antsirafaly

Madagascar experienced a major faunal turnover near the end of the first millenium CE that particularly affected terrestrial, large-bodied vertebrate species. Teasing apart the relative impacts of people and climate on this event requires a focus on regional records with good chronological control. These records may document coeval changes in rainfall, faunal composition, and human activities. Here we present new paleontological and paleoclimatological data from southwestern Madagascar, the driest part of the island today. We collected over 1500 subfossil bones from deposits at a coastal site called Antsirafaly and from both flooded and dry cave deposits at Tsimanampesotse National Park. We built a chronology of Late Holocene changes in faunal assemblages based on 65 radiocarbon-dated specimens and subfossil associations. We collected stalagmites primarily within Tsimanampesotse but also at two additional locations in southern Madagascar. These provided information regarding hydroclimate variability over the past 120,000 years. Prior research has supported a primary role for drought (rather than humans) in triggering faunal turnover at Tsimanampesotse. This is based on evidence of: (1) a large freshwater ecosystem west of what is now the hypersaline Lake Tsimanampesotse, which supported freshwater mollusks and waterfowl (including animals that could not survive on resources offered by the hypersaline lake today); (2) abundant now-extinct terrestrial vertebrates; (3) regional decline or disappearance of certain tree species; and (4) scant local human presence. Our new data allow us to document the hydroclimate of the subarid southwest during the Holocene, as well as shifts in faunal composition (including local extirpations, large-vertebrate population collapse, and the appearance of introduced species). These records affirm that climate alone cannot have produced the observed vertebrate turnover in the southwest. Human activity, including the introduction of cattle, as well as associated changes in habitat exploitation, also played an important role.

Evolutionary and phylogenetic insights from a nuclear genome sequence of the extinct, giant, "subfossil" koala lemur Megaladapis edwardsi

No endemic Madagascar animal with body mass >10 kg survived a relatively recent wave of extinction on the island. From morphological and isotopic analyses of skeletal "subfossil" remains we can reconstruct some of the biology and behavioral ecology of giant lemurs (primates; up to ∼160 kg) and other extraordinary Malagasy megafauna that survived into the past millennium. Yet, much about the evolutionary biology of these now-extinct species remains unknown, along with persistent phylogenetic uncertainty in some cases. Thankfully, despite the challenges of DNA preservation in tropical and subtropical environments, technical advances have enabled the recovery of ancient DNA from some Malagasy subfossil specimens. Here, we present a nuclear genome sequence (∼2× coverage) for one of the largest extinct lemurs, the koala lemur Megaladapis edwardsi (∼85 kg). To support the testing of key phylogenetic and evolutionary hypotheses, we also generated high-coverage nuclear genomes for two extant lemurs, Eulemur rufifrons and Lepilemur mustelinus, and we aligned these sequences with previously published genomes for three other extant lemurs and 47 nonlemur vertebrates. Our phylogenetic results confirm that Megaladapis is most closely related to the extant Lemuridae (typified in our analysis by E. rufifrons) to the exclusion of L. mustelinus, which contradicts morphology-based phylogenies. Our evolutionary analyses identified significant convergent evolution between M. edwardsi and an extant folivore (a colobine monkey) and an herbivore (horse) in genes encoding proteins that function in plant toxin biodegradation and nutrient absorption. These results suggest that koala lemurs were highly adapted to a leaf-based diet, which may also explain their convergent craniodental morphology with the small-bodied folivore Lepilemur.

A Cross-Sectional Survey Evaluating Awareness of Congenital Cytomegalovirus Among Audiologists and Speech-Language Pathologists

Purpose Congenital cytomegalovirus (cCMV) is the most common congenital infection worldwide and a leading environmental cause of pediatric hearing loss (HL). The objective of this study was to evaluate audiologists and speech-language pathologists (SLPs) on awareness and knowledge of cCMV. Method A multiple-choice survey assessing awareness, knowledge, and practice patterns was sent electronically to audiologists and SLPs of the American Speech-Language-Hearing Association. Results were compared between audiologists and SLPs and within stratified groups of audiologists. Data were collected, and descriptive analysis was performed. Results Ninety-four audiologists and 317 SLPs responded. Most audiologists were somewhat or very familiar with cCMV (85.9%), while only 26% of SLPs responded that they were at least somewhat familiar with cCMV (p < .0001). When comparing audiologists' and SLPs' knowledge of symptoms, transmission, and diagnostic age for cCMV, audiologists had higher scores in all categories (p < .0001). Audiologists were then stratified into subgroups to evaluate the association of the given subgroup with their overall knowledge. The more advanced audiology training, the more knowledgeable the respondent was regarding HL progression (p = .002). Audiologists who were more familiar with cCMV scored better in most categories compared to those reporting somewhat or less familiar; these findings were only significant for knowledge of symptoms (p < .0001). Audiologists who were sometimes or frequently evaluating children less than 5 years of age had a better understanding of HL presentation among cCMV patients than those who rarely saw this patient population. Those who were in practice for < 20 years frequently knew the time-sensitive age of diagnosis than respondents in practice longer. Conclusions As a leading environmental cause of pediatric HL, cCMV is frequently encountered by audiologists and SLPs. This study highlights knowledge gaps and areas where targeted education is needed for both groups.

SARS-CoV-2: Is it the newest spark in the TORCH?

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The SARS-CoV-2 pandemic poses under-appreciated risks during pregnancy, and perinatal infections endanger newborn outcomes.

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SARS-CoV-2 virus is transmitted in utero, although the clinical manifestations of neonatal infection are not understood.

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While the route of infection is uncertain, infection control measures should be developed to protect the newborn infant.

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Breast milk acquisition of COVID-19 is not described, and breast-feeding remains the preferred source of infant nutrition.

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The study of SARS-CoV-2 vaccines should target not only protection of the pregnant patient, but also the newborn infant.

Amid the rapidly evolving global coronavirus disease 2019 (COVID-19) pandemic that has already had profound effects on public health and medical infrastructure globally, many questions remain about its impact on child health. The unique needs of neonates and children, and their role in the spread of the virus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) should be included in preparedness and response plans. Fetuses and newborn infants may be uniquely vulnerable to the damaging consequences of congenitally- or perinatally-acquired SARS-CoV-2 infection, but data are limited about outcomes of COVID-19 disease during pregnancy. Therefore, information on illnesses associated with other highly pathogenic coronaviruses (i.e., severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome [MERS]), as well as comparisons to common congenital infections, such as cytomegalovirus (CMV), are warranted. Research regarding the potential routes of acquisition of SARS-CoV-2 infection in the prenatal and perinatal setting is of a high public health priority. Vaccines targeting women of reproductive age, and in particular pregnant patients, should be evaluated in clinical trials and should include the endpoints of neonatal infection and disease.

Knowledge of congenital cytomegalovirus (cCMV) among physical and occupational therapists in the United States

Congenital cytomegalovirus (cCMV) infections cause more children to have permanent disabilities than Down Syndrome, Fetal Alcohol Syndrome, Spina Bifida, and pediatric HIV/AIDS combined. The risk of infection during pregnancy can be significantly decreased using universal precautions, such as thorough handwashing and cleansing of surfaces and objects that have come into contact with infected body fluids. Children under 3 years of age are commonly asymptomatic excretors of CMV, with the highest viral loads present in saliva. Pediatric therapists have regular close contact with young children, and are thus likely at elevated occupational risk of acquiring CMV. Our objective was to evaluate therapist knowledge of cCMV and its transmission. We recruited American Occupational Therapy Association (AOTA) and American Physical Therapy Association (APTA) members via electronic newsletters and printed flyers from April to September 2015. Participants completed an online, anonymous 24-question survey using Survey Monkey. We compared responses between groups and previously published CMV awareness data using binomial tests of difference of proportions and multiple logistic regression. Our study identified both a low level of therapist awareness and poor demonstrated understanding of cCMV. Self-reported cCMV awareness amongst therapists was greater than awareness in the general population, and equivalent to awareness amongst health care professionals. Whereas 52% of participants self-reported awareness of cCMV, only 18% demonstrated understanding of the behavioral modes of CMV transmission. Fewer therapists reported awareness of cCMV than other, less prevalent conditions. Higher levels of health risk knowledge were associated with greater contact with children. Most participants reported learning about cCMV from the workplace. The knowledge gaps between self-reported awareness of cCMV and demonstrated understanding of modes of transmission described by our results emphasize the need for additional training of therapists. cCMV is preventable, and accurate knowledge of modes of transmission is crucial for the health of practitioners and clients.

What did Hadropithecus eat, and why should paleoanthropologists care?

Over 40 years ago, Clifford Jolly noted different ways in which Hadropithecus stenognathus converged in its craniodental anatomy with basal hominins and with geladas. The Malagasy subfossil lemur Hadropithecus departs from its sister taxon, Archaeolemur, in that it displays comparatively large molars, reduced incisors and canines, a shortened rostrum, and thickened mandibular corpus. Its molars, however, look nothing like those of basal hominins; rather, they much more closely resemble molars of grazers such as Theropithecus. A number of tools have been used to interpret these traits, including dental microwear and texture analysis, molar internal and external morphology, and finite element analysis of crania. These tools, however, have failed to provide support for a simple dietary interpretation; whereas there is some consistency in the inferences they support, dietary inferences (e.g., that it was graminivorous, or that it specialized on hard objects) have been downright contradictory. Cranial shape may correlate poorly with diet. But a fundamental question remains unresolved: why do the various cranial and dental convergences exemplified by Hadropithecus, basal hominins, and Theropithecus exist? In this paper we review prior hypotheses regarding the diet of Hadropithecus. We then use stable carbon and nitrogen isotope data to elucidate this species' diet, summarizing earlier stable isotope analyses and presenting new data for lemurs from the central highlands of Madagascar, where Hadropithecus exhibits an isotopic signature strikingly different from that seen in other parts of the island. We offer a dietary explanation for these differences. Hadropithecus likely specialized neither on grasses nor hard objects; its staples were probably the succulent leaves of CAM plants. Nevertheless, aspects of prior hypotheses regarding the ecological significance of its morphology can be supported. Am. J. Primatol. 78:1098-1112, 2016. © 2015 Wiley Periodicals, Inc.

Primates as Predictors of Mammal Community Diversity in the Forest Ecosystems of Madagascar

The geographic distribution of species is the typical metric for identifying priority areas for conservation. Since most biodiversity remains poorly studied, a subset of charismatic species, such as primates, often stand as surrogates for total biodiversity. A central question is therefore, how effectively do primates predict the pooled species richness of other mammalian taxa? We used lemurs as indicator species to predict total non-primate mammal community richness in the forest ecosystems of Madagascar. We combine environmental and species occurrence data to ascertain the extent to which primate diversity can predict (1) non-primate mammal α-diversity (species richness), (2) non-primate complementarity, and (3) non-primate β-diversity (species turnover). Our results indicate that primates are effective predictors of non-primate mammal community diversity in the forest ecosystems of Madagascar after controlling for habitat. When individual orders of mammals are considered, lemurs effectively predict the species richness of carnivorans and rodents (but not afrosoricids), complementarity of rodents (but not carnivorans or afrosoricids), and all individual components of β-diversity. We conclude that lemurs effectively predict total non-primate community richness. However, surrogate species alone cannot achieve complete representation of biodiversity.

Testing Bergmann's rule and the resource seasonality hypothesis in Malagasy primates using GIS-based climate data

We tested four major hypotheses on the ecological aspects of body mass variation in extant Malagasy strepsirrhines: thermoregulation, resource seasonality/scarcity, resource quality, and primary productivity. These biogeographic hypotheses focus on the ecological aspects of body mass variation, largely ignoring the role of phylogeny for explaining body mass variation within lineages. We tested the independent effects of climate and resource-related variables on variation in body mass among Malagasy primates using recently developed comparative methods that account for phylogenetic history and spatial autocorrelation. We extracted data on lemur body mass and climate variables for a total of 43 species from 39 sites. Climatic data were obtained from the WorldClim database, which is based on climate data from weather stations compiled around the world. Using generalized linear models that incorporate parameters to account for phylogenetic and spatial autocorrelation, we found that diet and climate variables were weak predictors of lemur body mass. Moreover, there was a strong phylogenetic effect relative to the effects of space on lemur body mass in all models. Thus, we failed to find support for any of the four hypotheses on patterns of geography and body mass in extant strepsirrhines. Our results indicate that body mass has been conserved since early in the evolutionary history of each genus, while species diversified into different environmental niches. Our findings are in contrast to some previous studies that have suggested resource and climate related effects on body mass, though these studies have examined this question at different taxonomic and/or geographic scales.

Evidence for dietary niche separation based on infraorbital foramen size variation among subfossil lemurs

The size of the infraorbital foramen (IOF) has been used in drawing both phylogenetic and ecological inferences regarding fossil taxa. Within the order Primates, frugivores have relatively larger IOFs than folivores or insectivores. This study uses relative IOF size in lemurs to test prior trophic inferences for subfossil lemurs and to explore the pattern of variation within and across lemur families. The IOFs of individuals belonging to 12 extinct lemur species were measured and compared to those of extant Malagasy strepsirhines. Observations matched expectations drawn from more traditional approaches (e.g. dental morphology and microwear, stable isotope analysis) remarkably well. We confirm that extinct lemurs belonging to the families Megaladapidae and Palaeopropithecidae were predominantly folivorous and that species belonging to the genus Pachylemur (Lemuridae) were frugivores. Very high values for relative IOF area in Archaeolemur support frugivory but are also consistent with omnivory, as certain omnivores use facial touch cues while feeding. These results provide additional evidence that the IOF can be used as an informative osteological feature in both phylogenetic and paleoecological interpretations of the fossil record.

The climatic niche diversity of malagasy primates: a phylogenetic perspective

BACKGROUND

Numerous researchers have posited that there should be a strong negative relationship between the evolutionary distance among species and their ecological similarity. Alternative evidence suggests that members of adaptive radiations should display no relationship between divergence time and ecological similarity because rapid evolution results in near-simultaneous speciation early in the clade's history. In this paper, we performed the first investigation of ecological diversity in a phylogenetic context using a mammalian adaptive radiation, the Malagasy primates.

METHODOLOGY/PRINCIPAL FINDINGS

We collected data for 43 extant species including: 1) 1064 species by locality samples, 2) GIS climate data for each sampling locality, and 3) the phylogenetic relationships of the species. We calculated the niche space of each species by summarizing the climatic variation at localities of known occurrence. Climate data from all species occurrences at all sites were entered into a principal components analysis. We calculated the mean value of the first two PCA axes, representing rainfall and temperature diversity, for each species. We calculated the K statistic using the Physig program for Matlab to examine how well the climatic niche space of species was correlated with phylogeny.

CONCLUSIONS/SIGNIFICANCE

We found that there was little relationship between the phylogenetic distance of Malagasy primates and their rainfall and temperature niche space, i.e., closely related species tend to occupy different climatic niches. Furthermore, several species from different genera converged on a similar climatic niche. These results have important implications for the evolution of ecological diversity, and the long-term survival of these endangered species.

Ecogeographic size variation in small-bodied subfossil primates from Ankilitelo, Southwestern Madagascar

Variation in body size is well documented for both extant and extinct Malagasy primates, and appears to be correlated with geographic patterns of resource seasonality. Less attention has been paid to extant lemurs in subfossil collections, although it has been suggested that subfossil forms of extant species are characterized by greater size than their modern counterpart. This trend of phyletic size change has been related to climate change, habitat fragmentation, or human hunting. However, space- and time-averaging in the subfossil samples of previous studies may have obscured more general ecogeographic patterns underlying these size differences. Our objective is to examine size variation in subfossil still-extant primates within a regional comparative context to determine if subfossil and living forms conform to similar ecogeographic patterns. We report on the subfossil still-extant primate assemblage from Ankilitelo, southwestern Madagascar (approximately 500 yr BP) to test this hypothesis. The Ankilitelo primates were compared with museum specimens of known locality. Extant taxa were assigned to one of five distinct ecogeographic regions, including spiny thicket, dry deciduous forest, succulent woodland, lowland and subhumid rainforest. Comparisons of tooth size in extant lemurs reveal significant geographical patterns of variation within genera. In general, the primates from Ankilitelo are indeed larger than their modern counterpart. However, these differences fit an ecoregional model of size variation, whereby Ankilitelo species are comparable in size to living forms inhabiting ecoregions present near the cave today. This suggests that Malagasy primates have been subjected to similar patterns of resource seasonality for at least 500 years.

Omomyid primates (Tarsiiformes) from the Early Middle Eocene at South Pass, Greater Green River Basin, Wyoming

Recent fieldwork in the Gardnerbuttean (earliest Bridgerian) sediments along the northeastern edge of the Green River Basin at South Pass, Wyoming, has yielded a large and diverse sample of omomyid (tarsiiform) primates. This assemblage includes two species each of Artimonius gen. nov., Washakius, and Omomys, one species of Anaptomorphus, Trogolemur and Uintanius, and a new, primitive species of the rare omomyine genus,Utahia. Utahia is known elsewhere only from its type locality in the Uinta Basin and its phylogenetic position is poorly understood. Utahia carina sp. nov. allows for re-evaluation of the affinities of this genus relative to other omomyines. In most characters, such as a lesser degree of molar trigonid compression, more widely open talonid notches, and a lack of molar talonid crenulation, the new species is more primitive than U. kayi. The dental anatomy of U. carina also indicates that Utahia is morphologically intermediate between washakiins and omomyins, although the balance of anatomical features places Utahia as the sister taxon to a broadly defined "Ourayini" clade. Morphological similarity between U. carina, Loveina zephyri, and primitive Washakius suggests that while the omomyin and washakiin clades may have diverged by the middle Wasatchian, substantial morphological distinctions are first evidenced only in the early Bridgerian. This may be due either to a lack of appropriate faunal samples from older sediments, or, more likely, because ecological circumstances in the early Bridgerian favored omomyine diversification and subsequent replacement of previously occurring taxa. This hypothesis is further supported by the stratigraphic co-occurrence of U. carina, W. izetti, and a primitive variant of W. insignis at South Pass, a marginal area. Basin margins have been hypothesized to provide heterogeneous habitats conducive to the production of evolutionary innovation. Basin margin samples have also been cited as evidence that anaptomorphines were relegated to upland refugia as omomyine taxa began to appear in the later part of the early Eocene. Another possible explanation for the unusual co-occurrence of species at South Pass relates to fluctuating lake levels in the Green River Basin, which intermittently would have made lowland environments inhospitable for arboreal fauna. This would have created a situation whereby species which would normally be allopatric become sympatric at South Pass.