Vermont Medicine Magazine

Khadija Moussadek
Health Care Provider Education: Preventing Suicide in Adolescents
In 2019, Khadija Moussadek lost a close friend to suicide. “The day she died, I went to her family’s house, and her mother told me my friend had just seen the pediatrician. The pediatrician said, ‘How did I miss this?’” said Moussadek, recalling a statistic she had seen that one-third of those who died by suicide had seen a physician in the month immediately preceding their death. “That stuck with me. I thought, ‘we have to do better.’”

Moussadek’s project aims to help physicians prevent suicide by identifying and intervening in patients’ self-harming behavior, which is an upstream risk for later suicide attempts. Self-harming behaviors can include intentional self-poisoning, cutting, and burning. While mental health professionals are typically trained to identify these behaviors, other health care professionals may not be prepared, Moussadek said.

To address these deficits, Moussadek developed a learning module with a screening tool providers can use to identify self-harming behaviors among their patients and a script for broaching a potentially difficult conversation with a patient suspected of expressing self-harming behaviors. It also includes clinical scenarios that model patients who are self-harming and instructional quizzes that assess providers’ preparedness for recognizing suicidal ideation. After piloting the toolkit with local primary care providers, Moussadek devised a dissemination plan for statewide distribution.

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Avery Campbell
Hepatocyte Growth Factor and Cognitive Impairment Risk
Growing up in North Carolina, Avery Campbell knew people affected by stroke and cognitive impairment. The southeastern U.S. is known as the “stroke belt” because of the high incidence stroke, related cardiovascular disease and cognitive impairment. For Campbell, this is personal: His maternal grandmother suffered a stroke, and both paternal grandparents had severe dementia.

“It was devastating to our family,” Campbell said, “and stories like mine will only become more common. The prevalence of cognitive impairment is expected to balloon with increasing life expectancy, and it disproportionately affects minoritized communities.”

For his project, Campbell investigated cognitive impairment among Black versus White adults, among pre- versus postmenopausal women, and among men younger than versus older than age 55. He focused on the biomarker hepatocyte growth factor (HGF), which plays a role in organ and vascular repair after injury. HGF level correlates with inflammatory conditions like vascular disease, and higher HGF levels are associated with stroke risk.

Campbell examined data from an ongoing national study, Reasons for Geographic and Racial Differences in Stroke (REGARDS), which follows more than 30,000 Americans to understand why Black Americans and southerners have higher rates of cardiovascular diseases affecting brain health. Campbell used HGF measurements in a nested case-control study of 1000 REGARDS participants, half with cognitive impairments and half without. He hypothesized that the association of HGF with cognitive impairment is greater in Black than White adults, greater among younger than older men, and greater in premenopausal than postmenopausal women. Using the REGARDS data, he created regression models to test each hypothesis.

“Identifying and characterizing the relationship between HGF and cognitive impairment is the first step towards exploring its utility in prevention, prognostication, and treatment,” Campbell said.

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Tyler Hastings
Perspectives on Mental Health Emergency Care in Pre-Hospital Settings
Before attending medical school, Tyler Hastings worked as an advanced emergency medical technician in Utah. It disturbed him that so many patients he transported to the hospital were experiencing mental illness events that could have been resolved on-site, rather than in the emergency department (ED).

“Mental illness is on the rise everywhere, among all age groups,” Hastings said. “People see a family member or friend experiencing an episode and they don’t know what to do, so they call 9-1-1. The ambulance can’t just leave the person there, so we taxi them to the ED. It’s straining for the patient, the family, and the ED staff who may have seen the same patient previously for the same thing.” The costs of ambulance transport and ED care create additional burdens for patients and families.

To help change this pattern, Hastings evaluated training of emergency medical technicians (EMTs) and paramedics in Vermont for encounters involving patients with mental illness and resources for treating those patients on-site. Hastings worked with Vermont Emergency Medical Services (EMS) Office to recruit EMTs and paramedics for interviews. He developed questions to assess whether they feel their training prepared them to care for patients with psychological conditions. He looked for gaps in scope and ability of EMS providers, and presented his findings to the Vermont EMS Office.

His goal is to catalyze change locally, and spark interest nationally. “Advancements have been made in other areas of emergency care—cardiac arrest, stroke, bleeding—but mental health is a gray area,” Hastings said. “With recent uptrends in mentally ill patients, I’m hoping to see that EMTs are wellequipped to treat them.”

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Muhammad Haaris Zeb
Supporting Culturally Appropriate Assessment and Response to Mental Health Challenges in Afghanistan Refugee Populations in Vermont
Mental health and suicide are difficult topics for many people, but in certain cultures, these subjects are taboo. Within many central Asian cultures, talking about suicidal feelings is frowned upon, so individuals who need help typically hide their feelings.

Muhammad Zeb understands this well. His uncle committed suicide, and his family, who are Pakistani, avoided talking about what happened. “It was a big lesson for me. This problem can happen to anyone, and we must not push it under the rug,” Zeb said.

At UVM, Zeb has an opportunity to examine this issue among Afghan refugees. An increasing number of individuals forced to flee their homelands are resettling in Vermont. Post-traumatic stress, social isolation, racism, unemployment, and language barriers elevate refugees’ risk for depression and suicidal ideation. Afghani and Pakistani cultures parallel, and Zeb can support health care providers in understanding their Afghani patients’ cultural norms.

“A lot of refugees aren’t literate, so existing screening methods done in the primary care office are useless,” Zeb said. “The language on screening forms may not be familiar, or the patient may be scared to check boxes because they fear it creates an issue for their staying in the U.S.”

Zeb assessed gaps in mental health resources and identified cultural barriers among Afghanistan refugees, via literature reviews and interviews with experts in the field of refugee care. With this information, Zeb designed an interactive, web-based, educational module on mental health for providers working with Afghan refugees.

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Wendy Memishian
Cerebral Blood Flow Autoregulation in Adult Offspring from Preeclamptic Mothers and Effects of Sevoflurane
Wendy Memishian feels at home in a laboratory working with instruments and animals. While an undergraduate biology major at Bates College, Memishian investigated the physiology of respiration in embryonic quail, measuring changes in their breath while she adjusted oxygen levels inside egg-infusing respirators. Post-graduation, she conducted cancer research with mice. Now, she wants to know more about brains and cardiovascular systems.

For her project, Memishian investigated cerebral blood flow autoregulation—the ability of brain blood vessels to maintain blood flow over a range of blood pressures—during surgery under a commonly used anesthetic called sevoflurane.

Preeclampsia is a serious hypertensive disorder of pregnancy with long-term cardiovascular effects for mothers and offspring across their lifespan, including organ damage and increased risk of stroke. Preeclampsia pregnancies affect one in seven hospital deliveries, representing 16 percent of human births. It is known that sevoflurane affects cerebral blood flow autoregulation. In most people this is easy to control, but in adults born from preeclamptic mothers, sevoflurane can cause cerebrovascular dysfunction that persists into adulthood. The impacts are poorly understood.

To examine the impacts, Memishian performed surgery on adult rats born from preeclamptic mothers. She used sevoflurane anesthesia and provided ventilation to maintain a normal oxygen input and carbon dioxide output. As she administered a drug to increase blood pressure, she monitored blood pressure and oxygen levels.

Memishian wrapped up her project by comparing brain blood flow between preeclamptic and non-preeclamptic offspring, writing a report, and preparing a poster for a presentation. She’s working toward getting her research published and presenting at a national conference.

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Susanna Schuler
Connectional Silence in Telemedicine-Facilitated Palliative Care Conversations
Susanna Schuler investigated palliative care conversations between clinicians and patients receiving dialysis treatments for kidney failure. Palliative care conversations take place when patients have serious illness, to help them think through important decisions and focus on what matters most to them.

“It’s not so common to have these conversations with patients with kidney disease. Dialysis is like a limbo stage, keeping them alive,” Schuler said, adding that the three- to five-hour process occurs up to four times weekly and can leave patients feeling exhausted and powerless.

Schuler’s research followed prior studies that identified “connectional silence” within palliative care conversations and concluded that silent moments in conversations were associated with the patient feeling heard and understood, which is associated with better outcomes. Schuler’s project was novel, in that the conversations occurred during telemedicine visits, rather than in person. Her project aimed to provide insight into how serious illness conversations via telemedicine may be different, how patients receiving dialysis engage with palliative care, and how clinicians can support patients feeling heard and understood.

She examined videos in which palliative care clinicians spoke with the patients while they received dialysis. She listened for pauses in their conversations and looked for gestures including smiling, leaning, nodding, and eye contact, which can facilitate connection and empathy. Schuler concluded that patients enjoyed having meaningful conversations during dialysis treatment, and they felt heard and understood.

“They seemed excited to have someone to talk to while getting dialysis,” she said, noting that the conversations touched on the patients’ thoughts about ending dialysis, which will lead to death. “For someone who has been on dialysis for many years, it is powerful for them to be able to make informed decisions for themselves.” VM

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Summer research fellowships are supported by the Larner College of Medicine Fund, Cardiovascular Research Institute, UVM Cancer Center, and Four Pines Fellowship in Suicide and Self-Harm Prevention.