Previous work shows that emergency medicine attending physicians have higher-than-average rates of burnout. Preliminary data suggest that emergency medicine residents are also at risk for burnout. ...The objective of this study was to conduct the first national survey assessment of US emergency medicine residents to determine the prevalence of burnout.
This prospective 2017 National Emergency Medicine Resident Wellness Survey study was conducted through the Wellness Think Tank, whereby emergency medicine residents from 247 residencies across the United States were invited to participate in a national survey. The primary measure of burnout was the Maslach Burnout Inventory–Human Services Survey. In accordance with others' work, "burnout" was defined as a dichotomous variable represented by high levels of emotional exhaustion or depersonalization. Because of interpretative variability with the survey tool, we also calculated burnout rates by using a more restrictive definition and a more inclusive definition that have been reported in the literature.
Surveys were completed by 1,522 residents (21.1% of all US emergency medicine residents), representing 193 of 247 US emergency medicine residency programs (78.1%). Within this sample, the prevalence of burnout was 76.1% (95% confidence interval 74.0% to 78.3%). With alternative definitions applied, burnout prevalence rates for this same sample were 18.2% (95% confidence interval 16.3% to 20.1%) with the more restrictive definition and 80.9% (95% confidence interval 78.9% to 82.9%) with the more inclusive definition.
The majority of US emergency medicine residents responding to this survey reported symptoms consistent with burnout, highlighting that physician burnout in the emergency medicine profession seems to begin as early as residency training. These findings may provide a baseline against which future work can be compared.
Abstract Psychedelics have experienced renewed interest following positive clinical effects, however the neurobiological mechanisms underlying effects remain unclear. The paraventricular nucleus of ...the hypothalamus (PVN) plays an integral role in stress response, autonomic function, social behavior, and other affective processes. We investigated the effect of psilocin, the psychoactive metabolite of psilocybin, on PVN reactivity in Sprague Dawley rats. Psilocin increased stimulus-independent PVN activity as measured by c-Fos expression in male and female rats. Psilocin increased PVN reactivity to an aversive air-puff stimulus in males but not females. Reactivity was restored at 2- and 7-days post-injection with no group differences. Additionally, prior psilocin injection did not affect PVN reactivity following acute restraint stress. Experimental groups sub-classified by baseline threat responding indicate that increased male PVN reactivity is driven by active threat responders. These findings identify the PVN as a significant site of psychedelic drug action with implications for threat responding behavior.
Background
Completion axillary lymph node dissection (cALND) was standard treatment for breast cancer with positive sentinel lymph nodes (SLNs) until 2011, when data from the Z11 and AMAROS trials ...challenged its survival benefit in early stage breast cancer. We assessed the contribution of patient, tumor, and facility factors on cALND use in patients undergoing mastectomy and SLN biopsy.
Patients and Methods
Using the National Cancer Database, patients diagnosed from 2012 to 2017 who underwent upfront mastectomy and SLN biopsy with at least one positive SLN were included. A multivariable mixed effects logistic regression model was used to determine the effect of patient, tumor, and facility variables on cALND use. Reference effect measures (REM) were used to compare the contribution of general contextual effects (GCE) to variation in cALND use.
Results
From 2012 to 2017, the overall use of cALND decreased from 81.3% to 68.0%. Overall, younger patients, larger tumors, higher grade tumors, and tumors with lymphovascular invasion were more likely to undergo cALND. Facility variables, including higher surgical volume and facility location in the Midwest, were associated with increased use of cALND. However, REM results showed that the contribution of GCE to the variation in cALND use exceeded that of the measured patient, tumor, facility, and time variables.
Conclusions
There was a decrease in cALND use during the study period. However, cALND was frequently performed in women after mastectomy found to have a positive SLN. There is high variability in cALND use, mainly driven by interfacility practice variation rather than specific high-risk patient and/or tumor characteristics.
Patient reported outcome measures (PROMs) are important for patient-centered, value-based care; however, implementation into surgical practice remains limited. We aimed to demonstrate feasibility of ...measuring PROMs in an academic breast cancer clinic.
We conducted a pilot study implementing the patient-reported outcome measure BREAST-Q among patients with Stage 0-III breast cancer at a single institution from 06/2019-03/2023 using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Barriers and facilitators were characterized. Survey completion was assessed pre-operatively and up to 12 months post-operatively.
Barriers included limited time and lack of incorporation into the electronic medical record. Facilitators included utilizing trained team members and an automated workflow. Among eligible patients, 74% completed BREAST-Q at 2-weeks post-operatively and 55% at 12 months post-operatively.
We describe the implementation of a PROM using the RE-AIM framework, highlighting facilitators and barriers that may assist others in collecting patient-reported outcome data.
•Patient-reported outcome data were collected in a breast cancer clinic.•A number of facilitators and barriers impacted implementation.•Work remains to incorporate patient-reported outcome data into clinical care.
Repeated exposure to social stress is a common risk factor for anxiety disorders. Women are twice as likely as men to suffer from anxiety. However, the mechanisms behind this increased risk remain ...unclear, which limits targeted therapeutic options. Interestingly, this increased susceptibility in females is confined between the onset of puberty and the end of menopause, suggesting that ovarian hormones may contribute to this disproportionate risk of stress‐related disorders. We have previously shown that witness stress (WS), a model of social stress in which a female rat is subjected to witnessing an aggressive social defeat encounter between a male intruder and a novel male resident, produces lasting anxiety‐like behaviors selectively in intact, cycling female rats. Ovariectomized (OVX) females are largely resistant to WS‐evoked behaviors, but estradiol replacement reinstates these anxiety‐like behaviors. Moreover, intact females, but not OVX, exposed to WS exhibit a distinct and long‐lasting increase in corticotropin releasing factor (CRF) expression in the central amygdala (CeA), a stress sensitive brain region. The current study seeks to understand specific 17‐β estradiol (17‐βE)‐induced neural regulation that may contribute to the heightened susceptibility to social stress among females to identify a druggable target to promote stress resilience. Following recovery from OVX or sham surgery, adult female rats were treated with either 17‐βE (10μg/rat, s.c.) or vehicle (0μg/rat, s.c.) and one hour later, were exposed to WS or control handling. WS/control episodes were video recorded to measure burying, freezing, and rearing behaviors, and blood samples were collected one hour after WS/control to assess corticosterone (CORT) levels. Brains were collected two hours after WS/control. To quantify activity of CRF neurons, immunohistochemistry was used to double label for CRF and cFos in various stress sensitive regions. Behavioral responses were shown to be regulated by 17‐βE; WS‐evoked burying evident in intact females was decreased by OVX and reinstated by 17‐βE. However, there was no effect of WS or 17‐βE on freezing or rearing behaviors. Additionally, 17‐βE increased WS‐induced plasma CORT levels. cFos positive CRF expression in the CeA was robustly enhanced by 17‐βE during WS, but not control. This effect was not globally observed as there was no effect of WS or 17‐βE on cFos expression in CRF positive neurons within the paraventricular nucleus of the hypothalamus and the hippocampus. Analysis of stress‐ and CRF‐sensitive brain regions including the locus coeruleus are ongoing. Taken together, these findings suggest that an interaction between 17‐βE and CRF is paramount in facilitating the anxiety‐like responses to WS. Given the controversial impact of CRF1 receptor antagonists to date, this study provides evidence of conditions under which anxiety‐like behaviors are associated with enhanced CRF responses and may serve as a personalized viable target to treat increased sensitivity to stress‐related disorders in females.
•Intra-LC LPS augments behavioral and physiological responses to social stress.•Mannosylated liposomal clodronate site-specifically reduces microglial expression.•Microglia within the locus coeruleus ...regulate stress-evoked behavior in female rats.
Women are at increased risk for psychosocial stress-related anxiety disorders, yet mechanisms regulating this risk are unknown. Psychosocial stressors activate microglia, and the resulting neuroimmune responses that females exhibit heightened sensitivity to may serve as an etiological factor in their elevated risk. However, studies examining the role of microglia during stress in females are lacking.
Microglia were manipulated in the stress-sensitive locus coeruleus (LC) of female rats in the context of social stress in two ways. First, intra-LC lipopolysaccharide (LPS; 0 or 3 μg/side, n = 5–6/group), a potent TLR4 agonist and microglial activator, was administered. One hour later, rats were exposed to control or an aggressive social defeat encounter between two males (WS, 15-min). In a separate study, females were treated with intra-LC or intra-central amygdala mannosylated liposomes containing clodronate (m-CLD; 0 or 25 μg/side, n = 13–14/group), a compound toxic to microglia. WS-evoked burying, cardiovascular responses, and sucrose preference were measured. Brain and plasma cytokines were quantified, and cardiovascular telemetry assessed autonomic balance.
Intra-LC LPS augmented the WS-induced burying response and increased plasma corticosterone and interleukin-1β (IL-1β). Further, the efficacy and selectivity of microinjected m-CLD was fully characterized. In the context of WS, intra-LC m-CLD attenuated the hypervigilant burying response during WS as well as the accumulation of intra-LC IL-1β. Intra-central amygdala m-CLD had no effect on WS-evoked behavior.
These studies highlight an innovative method for depleting microglia in a brain region specific manner and indicate that microglia in the LC differentially regulate hypervigilant WS-evoked behavioral and autonomic responses.
Chelonid alphaherpesviruses 5 and 6 (ChHV5 and ChHV6) are viruses that affect wild sea turtle populations. ChHV5 is associated with the neoplastic disease fibropapillomatosis (FP), which affects ...green turtles (
) in panzootic proportions. ChHV6 infection is associated with lung-eye-trachea disease (LETD), which has only been observed in maricultured sea turtles, although antibodies to ChHV6 have been detected in free-ranging turtles. To better understand herpesvirus prevalence and host immunity in various green turtle foraging aggregations in Florida, USA, our objectives were to compare measures of innate and adaptive immune function in relation to (1) FP tumor presence and severity, and (2) ChHV5 and ChHV6 infection status. Free-ranging, juvenile green turtles (
= 45) were captured and examined for external FP tumors in Florida's Big Bend, Indian River Lagoon, and Lake Worth Lagoon. Blood samples were collected upon capture and analyzed for ChHV5 and ChHV6 DNA, antibodies to ChHV5 and ChHV6, in vitro lymphocyte proliferation using a T-cell mitogen (concanavalin A), and natural killer cell activity. Despite an overall high FP prevalence (56%), ChHV5 DNA was only observed in one individual, whereas 20% of turtles tested positive for antibodies to ChHV5. ChHV6 DNA was not observed in any animals and only one turtle tested positive for ChHV6 antibodies. T-cell proliferation was not significantly related to FP presence, tumor burden, or ChHV5 seroprevalence; however, lymphocyte proliferation in response to concanavalin A was decreased in turtles with severe FP (
= 3). Lastly, green turtles with FP (
= 9) had significantly lower natural killer cell activity compared to FP-free turtles (
= 5). These results increase our understanding of immune system effects related to FP and provide evidence that immunosuppression occurs after the onset of FP disease.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The COVID-19 pandemic restricted in-person gatherings, including residency conferences. The pressure to quickly reorganize educational conferences and convert content to a remote format overwhelmed ...many programs. This article describes the pilot event of a large-scale, interactive, virtual educational conference modeled, designed, and implemented by Academic Life in Emergency Medicine (ALiEM), called ALiEM Connect.
The pilot ALiEM Connect event was conceptualized and implemented within a 2-week period in March 2020. The pilot was livestreamed via a combination of Zoom and YouTube and was archived by YouTube. Slack was used as a backchannel to allow interaction with other participants and engagement with the speakers (via moderators who posed questions from the backchannel to the speakers live during the videoconference).
The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was used for program evaluation, showing that 64 U.S. Accreditation Council for Graduate Medical Education-accredited emergency medicine residency programs participated in the pilot event, with 1,178 unique users during the event (reach). For effectiveness, 93% (139/149) of trainees reported the pilot as enjoyable and 85% (126/149) reported it was equivalent to or better than their usual academic proceedings. Adoption for ALiEM Connect was fairly good with 64/237 (27%) of invited residency programs registering and participating in the pilot event. Implementation was demonstrated by nearly half of the livestream viewers (47%, 553/1,178) interacting in the backchannel discussion, sending a total of 4,128 messages in the first 4 hours.
The final component of the RE-AIM framework, maintenance, will take more time to evaluate. Further study is required to measure the educational impact of events like the ALiEM Connect pilot. The ALiEM Connect model could potentially be used to replace educational conferences that have been canceled or to implement and/or augment a large-scale, shared curriculum among residency programs in the future.
Assessing the linkage between breeding and non-breeding areas has important implications for understanding the fundamental biology of and conserving animal species. This is a challenging task for ...marine species, and in sea turtles a combination of stable isotope analysis (SIA) and satellite telemetry has been increasingly used. The Northwest Atlantic (NWA) loggerhead (
Caretta caretta
) Regional Management Unit, one of the largest sea turtle populations in the world, provides an excellent opportunity to investigate key biological patterns as well as methodological aspects related to the use of stable isotopes to infer spatial distribution of turtles in foraging areas. We provide the first comprehensive assessment of the annual distribution of NWA adult female loggerheads among foraging areas and investigate the efficacy of various analytical approaches as well as the effect of sample size in these types of studies. A total of 5168 individual females were sampled from seven Management Units (MUs) between 2013-2018. We provide the first estimate of the proportion of females originating from each MU that uses each foraging area and show how this proportion varies over time. We also estimate the relative importance (in terms of number of turtles) of each foraging area to the overall loggerhead breeding aggregation nesting in Florida and in the NWA for each year of the study. The foraging area used by reproductively active females differs considerably across MUs. One of these, the Subtropical NWA, is by far the most important foraging area in terms of both number of individuals and genetic diversity, and therefore this region may be considered as a conservation priority. Through simulations, we show that limited sizes of sample groups (unknowns; training; priors) may result in false geographic differentiation and consequently mislead interpretations. We provide thresholds and methodological recommendations for future studies. This study establishes a fundamental baseline for monitoring the annual contribution of foraging area to a terrestrial-based breeding aggregation of a marine animal in a cost-effective way. This type of monitoring allows for early detection of changes in foraging distributions—a possible effect of climate change on marine ecosystems or of area-specific anthropogenic threats.
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