ABSTRACT
Introduction &Objective: Burnout continues to increase in the healthcare field, particularly amongst our trainees, yet there is no 'gold standard' for preventing burnout or promoting wellness. Given reports on the impact of the COVID-19 pandemic on mental health combined with increased calls by institutional leadership to prevent burnout amongst healthcare workers, our objective was to assess wellness initiatives and burnout levels amongst trainees at the start and two years into the pandemic. Method(s): This was a prospective survey distributed to medical students and residents at two timepoints: (1) Peak onset of the COVID-10 pandemic (April-May 2020, N = 121) and two years later following vaccine availability and reductions in social distancing precautions (March 2022, N = 77). Trainees provided demographic information and described wellness or burnout prevention initiatives currently available to them. They also took two standardized assessments (Maslach Burnout Inventory, Perceived Stress Scale). Result(s): Satisfaction with burnout mitigation education appears in Figure 1. Trainees were only slightly satisfied with their current ability to reduce wellness and mitigate burnout, as well as with the education or training currently provided to them (ps <0.05). Over the two-year pandemic, trainees reported that the amount of wellness education provided by their program formally had increased (p < 0.01) but remained very low (p < 0.001). Trainees also reported less ability to fulfil work requirements without compromising their own health and wellness (p < 0.001). Although levels of burnout (MBI) and stress (PSS) did not differ across training level (p > 0.1), scores on the MBI were significantly related to perceived need for additional wellness education and training (ps <0.05). Conclusion(s): Even following calls from leadership to increase burnout mitigation for healthcare workers, trainees are still not satisfied with the amount of education and training related to burnout mitigation and think more is needed to succeed in their current and post-graduation careers, with those experiencing higher burnout reporting this more strongly. These results suggest the need for formalized wellness and burnout mitigation education.
ABSTRACT
Introduction:Acquired tracheo-esophageal fistula (TEF) is a dreaded complication of lithium button battery (LBB) ingestion in the pediatric population. Traditionally acquired TEFs are managed with surgical interventions. Very few case reports have described successful closure of a TEF secondary to LBB with conservative management. There is no reported literature on the use fibrin glue or laser therapy to enhance closure. Here we describe successful conversative management of TEF secondary to LBB and for the first time, attempted trial of fibrin glue and argon laser therapy. Case presentation: 13-month-old female presented to the emergency department with a 3-day history of croupy cough. Neck X ray demonstrated a radio-opaque foreign body suggestive of a button battery. Patient urgently underwent rigid esophagoscopy and found to have a 20 mm lithium battery in the proximal esophagus. The negative pole was facing anteriorly. Battery was retrieved and inspection revealed a Zagar 2 B grade mucosal injury. Site was washed with 0.25% acetic acid. Direct laryngoscopy and bronchoscopy noted significant posterior tracheal wall edema. Patient was kept NPO overnight and an esophagram obtained next day was reassuring. Therefore, diet was advanced as tolerated and patient discharged next day with plan to repeat esophagram in 2 weeks and endoscopy in 4 weeks. Patient presented 3 days later with drooling, coughing, nasal congestion. She tested positive for SARS Covid 19 PCR on admission. Esophagram at admission noted irregularity and distension of the proximal esophagus with persistent focal outpouching. Patient was kept strict NPO and a repeat esophagram 24 hours later showed large volume aspiration associated with excessive coughing. A nasogastric tube was placed, and tube feedings initiated. Esophogastroduodenoscopy (EGD) was delayed by 1 week due to COVID positive status and upper respiratory symptoms. Initial EGD demonstrated purulent exudates in proximal esophagus and a 6 mm fistulous opening surrounded by ulcerated margins. Bronchoscopy confirmed tracheal end of fistula in addition to posterior tracheal wall ulceration. A fiber-optic scope was used to advance the endotracheal tube so that its distal end was positioned beyond the inflamed mucosa. Patient was kept intubated and sedated, on IV antibiotics and PPI, and on NG tube feeds in the ICU. Repeat scope 7 days post TEF diagnosis showed a 4 mm fistula with healing of the ulcerated mucosa. Fibrin glue was injected into the fistula from the tracheal side in an attempt to close the TEF, but this was unsuccessful and lead to dislodgment of fibrin glue into airway creating a foreign body which necessitated endoscopic retrieval. EGD, 14 days after diagnosis of TEF demonstrated a fistula now ~ 3 mm wide. Argon plasma coagulation (APC) probe (Beamer unit flow of 0.5 L/min,15 W) was directed at the mucosa lining the esophageal end of the fistula with an aim to promote healing by secondary intention. At 21 days post TEF diagnosis complete closure of the fistula was demonstrated on EGD and bronchoscopy and the per-operative esophogram was reported as normal. Patient was discharged 5 days later tolerating an age-appropriate diet. A follow-up esophogram 2 weeks later was reassuring. Patient was asymptomatic on clinical follow up visit 4 weeks from discharge. Discussion(s): Acquired TEF secondary to LBB ingestion is traditionally managened through endoscopic or open surgical repair. However, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula, and mortality. Thus, experts have started to advocate the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. Five pediatric cases to date have reported sustained closure of TEF secondary to LBB with conservative management including strict NPO status and tube feeds/parenteral nutrition. The duration of healing has varied from 4 -11 weeks. We documented successful healing of acquired TEF within 21 days of initial diagnosis making it the shortest recovery period to date. We report the use of argon plasma coagulation at low settings to produce controlled heat coagulation at the fistula site in order to expose the submucosa and enhance healing by secondary intention. Successful closure of congenital TEF have been reported with injection of fibrin glue into the fistulous tract but this technique may not work for acquired TEF because of surrounding inflammation and a patulous tract. We opted to keep our patient sedated and intubated for 2 weeks to minimize movement, and promote healing of the TEF, but risk vs benefit needs to be weighed on a case-to-case basis. In conclusion, conservative management of acquired TEF is a feasible first step and may be considered before opting for surgical repair. Use of APC at low setting may reduce duration of closure of acquired TEF but high-powered, multi-center studies are needed.
ABSTRACT
Background: Stay-at-home orders and social distancing recommendations, combined with COVID-19 concerns, have caused significant disruptions in daily life. Throughout the pandemic, vulnerable populations, commonly seen within the University of Iowa emergency department, have been more negatively affected by COVID-19. Study Objectives: To assess how the social needs of the population cared for within the University of Iowa emergency department have changed in response to the COVID-19 pandemic. Methods: The Center for Medicare and Medicaid and Services (CMS) social risk assessment was adapted, covering 13 specific domains, to assess changes to participants’ social situations throughout the COVID-19 pandemic dated from January 2020 to February 2021. It was administered within the emergency department to individuals selected by a convenience sample who were stable enough to complete the form. Frequencies with percentages, fisher’s exact test, logistic regression were used to analyze the categorical data. Dependent variables of interest were analyzed by age group, sex, and race. Results: A total of 305 patients were approached and 207 (68%) responses were received. Of the included responses 7/177 (4%) identified as Hispanic or Latino, 15/175 (8.6%) as Black or African American, and 151/175 (86.3%) as white. The survey respondents indicated that 7.1% had worsened employment situation in comparison to before COVID-19. Moreover, 14.5% found it harder to pay for basics such as food, housing, medical care, and heating compared to prior to the pandemic, and 10.1% reported worsening lack of reliable transportation. Further, 26% stated that feelings of loneliness have worsened along with 30% reporting more stress, while 16.8% reported feelings of little interest or pleasure in doing things have improved along with 20.8% reported feeling down, depressed, or hopeless also improved in comparison to before the pandemic. Lastly, 2.5% stated their physical safety had worsened and 6.5% were experiencing worsening verbal abuse. The logistic regression showed that the odds ratio (95% CI) for increased financial difficulty for Non-Caucasians vs Caucasians is 10.5 (2.7 -40.3) and the odds ratio (95% CI) for increased financial difficulty for females vs males is 2.9 (1.1 – 7.7). Conclusion: The COVID-19 pandemic led to overall greater financial instability and increased stress. Non-Caucasians and females were more likely to report that their financial situations worsened. Isolation, stress, and forms of abuse were also found to worsen. Nevertheless, symptoms of worsening depression were found to be improve among our study population. In light of these findings, it is important to understand how the pandemic affected numerous social determinants of health, especially for individuals who were already experiencing unmet social needs. With a better understanding of the health needs of our population, identifying strategies to improve overall wellness can be better achieved.
ABSTRACT
[Formula presented] Background: The risk of bleeding remains high in thrombocytopenic pediatric hematology-oncology patients despite the use of prophylactic platelet transfusions. In one study, WHO grade 2 or higher bleeding occurred in >80% of pediatric subjects receiving hematopoietic stem cell transplantation or chemotherapy despite a platelet transfusion threshold of 10,000/µl. The risk of bleeding is not decreased with higher transfusion thresholds or increased platelet doses. Bleeding episodes are associated with increased mortality rates, greater utilization of resources and increased transfusion requirements. We examined the use of anti-fibrinolytic agents in decreasing bleeding events and platelet transfusions. Methods: We conducted a randomized double-blinded Phase 2 trial of tranexamic acid versus placebo in inpatient pediatric patients undergoing chemotherapy or HSCT expected to have prolonged thrombocytopenia. All patients admitted to the Oncology or HSCT services were screened for eligibility. Patients consenting for enrollment received either tranexamic acid 10m/kg/dose or normal saline every 8 hours while the platelet count as <30,000/ul until discharge or spontaneous platelet recovery (maximum 30 days). We conducted daily hemostatic assessments using the WHO bleeding scale and monitored adverse events and platelet transfusion requirements. Follow-up assessments took place at 7 and 30 days following completion of study medication. Primary aims were to assess safety and feasibility of tranexamic acid in children with hypoproliferative thrombocytopenia. Results: We screened 697 admissions over 11 months, 31 patients were eligible for enrollment. Enrollment was suspended in March 2020 for COVID reasons though screening continued through July 2020. An additional 10 eligible patients were identified in this period. The most common reasons for ineligibility included recent asparaginase administration, predicted inpatient stay <5 days and age ≤ 2 or ≥ 18 years. Eleven patients enrolled and completed all study procedures. There were no missed doses of medication, 88.4% of doses were administered within one hour of prescribed time. Patients remained on study for a mean of 11.1 days. Five patients each met criteria for spontaneous platelet count recovery or discharge, 1 patient received the study medication for 30 days. Bleeding (all grades) occurred on 29.5% of days. Grade 2 or higher bleeding occurred on 4.9% of days and was experienced by 27.3% of patients. The most common sites of bleeding were oral/nasal and cutaneous. Subjects received a median of 2 platelet transfusions per patient. There were no thromboembolic events or serious adverse events. Conclusion: Tranexamic acid is well tolerated can be safely administered to pediatric oncology patients as an adjunct to therapy. We are planning a multi-center randomized controlled trial to assess the efficacy of tranexamic acid in reducing bleeding complications in this population. Disclosures: Triulzi: Fresenius Kabi: Consultancy;Cerus Corp: Research Funding. OffLabel Disclosure: Tranexamic Acid - This medication is being studied as an adjuvant to therapy to prevent bleeding complications and reduce platelet transfusions in pediatric patients with hypoproliferative thrombocytopenia.