Studying moral distress (MD) and moral injury (MI) among inpatient and outpatient healthcare professionals during the COVID-19 pandemic.

BACKGROUND: COVID-19 increased moral distress (MD) and moral injury (MI) among healthcare professionals (HCPs). MD and MI were studied among inpatient and outpatient HCPs during March 2022. OBJECTIVES: We sought to examine (1) the relationship between MD and MI; (2) the relationship between MD/MI and pandemic-related burnout and resilience; and (3) the degree to which HCPs experienced pandemic-related MD and MI based on their background. METHODS: A survey was conducted to measure MD, MI, burnout, resilience, and intent to leave healthcare at 2 academic medical centers during a 4-week period. A convenience sample of 184 participants (physicians, nurses, residents, respiratory therapists, advanced practice providers) completed the survey. In this mixed-methods approach, researchers analyzed both quantitative and qualitative survey data and triangulated the findings. RESULTS: There was a moderate association between MD and MI (r = .47, P < .001). Regression results indicated that burnout was significantly associated with both MD and MI (P = .02 and P < .001, respectively), while intent to leave was associated only with MD (P < .001). Qualitative results yielded 8 sources of MD and MI: workload, distrust, lack of teamwork/collaboration, loss of connection, lack of leadership, futile care, outside stressors, and vulnerability. CONCLUSIONS: While interrelated conceptually, MD and MI should be viewed as distinct constructs. HCPs were significantly impacted by the COVID-19 pandemic, with MD and MI being experienced by all HCP categories. Understanding the sources of MD and MI among HCPs could help to improve well-being and work satisfaction.

Caring for Patients With Dementia at End of Life.

Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.

Palliative Care and Rapid Emergency Screening Tool and the Palliative Performance Scale to Predict Survival of Older Adults Admitted to the Hospital From the Emergency Department.

BACKGROUND: The Palliative Care and Rapid Emergency Screening (P-CaRES) tool has been validated to identify patients in the emergency department (ED) with unmet palliative care needs, but no prognostic data have been published. The Palliative Performance Scale (PPS) has been validated to predict survival based on performance status and separately has been shown to predict survival among adults admitted to the hospital from the ED. OBJECTIVE: To concurrently validate the 6-month prognostic utility of P-CaRES with a replication of prior studies that demonstrated the prognostic utility of the PPS among adults admitted to the hospital from the ED. DESIGN: Prospective cohort study. SETTING/SUBJECTS: Adults >55 years admitted to the hospital from the ED at an urban academic hospital in South Carolina. MEASUREMENT: Baseline PPS score and P-CaRES status were evaluated within 51 hours of admission. Vital status at 6 months was evaluated by phone or chart review. RESULTS: 131 of 145 participants completed the study. Six-month survival was 79.2% of those with a PPS of 60-100 (22/106 died) and 48% of those with a PPS of 10-50 (13/25 died) (p = 0.0004). Six-month survival was 85.2% for P-CaRES negative (13/88 died) and 48.8% for P-CaRES positive (22/43 died) (p < 0.0001). The inferred hazard ratio (HR) for PPS 10-50, as compared to PPS 60-100 was 3.003 (95%CI (1.475, 6.112) p = 0.0024) and the HR for P-CaRES positive, as compared to P-CaRES negative was 4.186 (95%CI (2.052, 8.536) p < 0.0001). CONCLUSION: The P-CaRES tool and PPS can predict 6-month survival of older adults admitted from the ED.

Evaluation of fever in the emergency department.

BACKGROUND: Fever is one of the most common complaints in the emergency department (ED) and is more complex than generally appreciated. The broad differential diagnosis of fever includes numerous infectious and non-infectious etiologies. An essential skill in emergency medicine is recognizing the pitfalls in fever evaluation. OBJECTIVE OF REVIEW: This review provides an overview of the complaint of fever in the ED to assist the emergency physician with a structured approach to evaluation. DISCUSSION: Fever can be due to infectious or non-infectious etiology and results from the body's natural response to a pyrogen. Adjunctive testing including C-reactive protein, erythrocyte sedimentation rate, and procalcitonin has been evaluated in the literature, but these tests do not have the needed sensitivity and specificity to definitively rule in a bacterial cause of fever. Blood cultures should be obtained in septic shock or if the results will change clinical management. Fever may not be always present in true infection, especially in elderly and immunocompromised patients. Oral temperatures suffer from poor sensitivity to diagnose fever, and core temperatures should be utilized if concern for fever is present. Consideration of non-infectious causes of elevated temperature is needed based on the clinical situation. CONCLUSION: Any fever evaluation must rigorously maintain a broad differential to avoid pitfalls that can have patient care consequences. Fever is complex and due to a variety of etiologies. An understanding of the pathophysiology, causes, and assessment is important for emergency physicians.

Distribution and functional expression of Kv4 family α subunits and associated KChIP ß subunits in the bed nucleus of the stria terminalis.

Regulation of BNSTALG neuronal firing activity is tightly regulated by the opposing actions of the fast outward potassium current, IA , mediated by α subunits of the Kv4 family of ion channels, and the transient inward calcium current, IT . Together, these channels play a critical role in regulating the latency to action potential onset, duration, and frequency, as well as dendritic back-propagation and synaptic plasticity. Previously we have shown that Type I-III BNSTALG neurons express mRNA transcripts for each of the Kv4 α subunits. However, the biophysical properties of native IA channels are critically dependent on the formation of macromolecular complexes of Kv4 channels with a family of chaperone proteins, the potassium channel-interacting proteins (KChIP1-4). Here we used a multidisciplinary approach to investigate the expression and function of Kv4 channels and KChIPs in neurons of the rat BNSTALG . Using immunofluorescence we demonstrated the pattern of localization of Kv4.2, Kv4.3, and KChIP1-4 proteins in the BNSTALG . Moreover, our single-cell reverse-transcription polymerase chain reaction (scRT-PCR) studies revealed that mRNA transcripts for Kv4.2, Kv4.3, and all four KChIPs were differentially expressed in Type I-III BNSTALG neurons. Furthermore, immunoelectron microscopy revealed that Kv4.2 and Kv4.3 channels were primarily localized to the dendrites and spines of BNSTALG neurons, and are thus ideally situated to modulate synaptic transmission. Consistent with this observation, in vitro patch clamp recordings showed that reducing postsynaptic IA in these neurons lowered the threshold for long-term potentiation (LTP) induction. These results are discussed in relation to potential modulation of IA channels by chronic stress.

Central CRF neurons are not created equal: phenotypic differences in CRF-containing neurons of the rat paraventricular hypothalamus and the bed nucleus of the stria terminalis.

Corticotrophin-releasing factor (CRF) plays a key role in initiating many of the endocrine, autonomic, and behavioral responses to stress. CRF-containing neurons of the paraventricular nucleus of the hypothalamus (PVN) are classically involved in regulating endocrine function through activation of the stress axis. However, CRF is also thought to play a critical role in mediating anxiety-like responses to environmental stressors, and dysfunction of the CRF system in extra-hypothalamic brain regions, like the bed nucleus of stria terminalis (BNST), has been linked to the etiology of many psychiatric disorders including anxiety and depression. Thus, although CRF neurons of the PVN and BNST share a common neuropeptide phenotype, they may represent two functionally diverse neuronal populations. Here, we employed dual-immunofluorescence, single-cell RT-PCR, and electrophysiological techniques to further examine this question and report that CRF neurons of the PVN and BNST are fundamentally different such that PVN CRF neurons are glutamatergic, whereas BNST CRF neurons are GABAergic. Moreover, these two neuronal populations can be further distinguished based on their electrophysiological properties, their co-expression of peptide neurotransmitters such as oxytocin and arginine-vasopressin, and their cognate receptors. Our results suggest that CRF neurons in the PVN and the BNST would not only differ in their response to local neurotransmitter release, but also in their action on downstream target structures.

Striatal-enriched protein tyrosine phosphatase-STEPs toward understanding chronic stress-induced activation of corticotrophin releasing factor neurons in the rat bed nucleus of the stria terminalis.

BACKGROUND: Striatal-enriched protein tyrosine phosphatase (STEP) is a brain-specific protein tyrosine phosphatase that opposes the development of synaptic strengthening and the consolidation of fear memories. In contrast, stress facilitates fear memory formation, potentially by activating corticotrophin releasing factor (CRF) neurons in the anterolateral cell group of the bed nucleus of the stria terminalis (BNSTALG). METHODS: Here, using dual-immunofluorescence, single-cell reverse transcriptase polymerase chain reaction, quantitative reverse transcriptase polymerase chain reaction, Western blot, and whole-cell patch-clamp electrophysiology, we examined the expression and role of STEP in regulating synaptic plasticity in rat BNSTALG neurons and its modulation by stress. RESULTS: Striatal-enriched protein tyrosine phosphatase was selectively expressed in CRF neurons in the oval nucleus of the BNSTALG. Following repeated restraint stress (RRS), animals displayed a significant increase in anxiety-like behavior, which was associated with a downregulation of STEP messenger RNA and protein expression in the BNSTALG, as well as selectively enhancing the magnitude of long-term potentiation (LTP) induced in Type III, putative CRF neurons. To determine if the changes in STEP expression following RRS were mechanistically related to LTP facilitation, we examined the effects of intracellular application of STEP on the induction of LTP. STEP completely blocked the RRS-induced facilitation of LTP in BNSTALG neurons. CONCLUSIONS: Hence, STEP acts to buffer CRF neurons against excessive activation, while downregulation of STEP after chronic stress may result in pathologic activation of CRF neurons in the BNSTALG and contribute to prolonged states of anxiety. Thus, targeted manipulations of STEP activity might represent a novel treatment strategy for stress-induced anxiety disorders.

Triple arthrodesis in adults with non-paralytic disease. A minimum ten-year follow-up study.

BACKGROUND: The triple arthrodesis was developed to treat sequelae of neurologic disorders affecting the hindfoot. Today, the typical adult patient undergoing this procedure has degenerative disease, usually not related to a neurologic disorder. The purpose of this study was to investigate the long-term outcome of triple arthrodesis in this patient population. METHODS: Twenty-seven adult patients (thirty-one feet) who had undergone triple arthrodesis for the treatment of chronic hindfoot pain and had been followed for a minimum of ten years completed an outcomes questionnaire, and twenty-two patients (twenty-six feet) were available for physical examination, radiographs, and functional testing. The mean age of the patients who were examined was forty-five years at the time of the surgery, and the mean duration of follow-up of those patients was fourteen years (range, eleven to eighteen years). RESULTS: Twenty-five (93%) of the patients were satisfied with the result of the treatment. However, only eleven (41%) reported that they could perform moderate activity with mild or no pain in the foot and ankle. Twenty patients (74%) reported moderate-to-severe difficulty with, or an inability to negotiate, uneven surfaces. The mean Short Form-36 (SF-36) physical component outcomes score was 35.2 points, well below the mean of 50 points for the United States population. The SF-36 score was significantly lower for patients with systemic inflammatory disease (primarily rheumatoid arthritis). There was an average 12 degrees (27%) loss of plantar flexion but no significant loss of dorsiflexion compared with the untreated foot. Severe arthrosis developed in seven of the twenty-six ankles, in seven naviculocuneiform joints, and in six tarsometatarsal joints. Some patients had severe arthrosis at more than one level, and three patients later required an ankle arthrodesis. There were no nonunions or revisions of the triple arthrodeses. The average patient performances on the six-minute walk and the 3-m up-and-go functional tests were well below the age-controlled means. CONCLUSIONS: Triple arthrodesis may provide patients with substantial long-term relief of preoperative symptoms. However, there may also be adverse consequences, particularly degenerative changes in adjacent joints, that may be reasons for orthopaedic surgeons to consider alternatives to triple arthrodesis when feasible. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.