Does teaching Optimism lower Burnout in residency training- a pilot study.

Background: Residents frequently experience burnout. Multiple interventions to decrease the risk of burnout have had inconsistent results. In non-medical settings, improving optimism promotes a positive outlook and enhances well-being. Thus, psychological interventions that improve optimism could have potential to decrease the risk for burnout. Objective: Using Lazarus' Ways of Coping as an organizational framework, this intervention sought to evaluate the impact of an optimism curriculum on residents' burnout. Methods: Thirty-six Internal Medicine residents participated in an optimism improvement program from November 2019 to April 2020. We determined pre- and post-curriculum measures of optimism, happiness, and burnout with validated surveys. The Optimism Curriculum was comprised of three one-hour long sessions, which included lectures, group and self-reflective exercises. A post - curriculum evaluation rating the effectiveness of the program was administered separately. Results: Thirty-four out of thirty-six residents completed the post curricular surveys. Individuals with low optimism scores had a higher score for burnout compared to those with higher optimism scores. The post-intervention survey showed numerical improvement in optimism, happiness and burnout, although these changes were not statistically significant. The post-intervention survey showed a decrease in the measure of burnout; however, this was not significant (p = 0.24) with an effect size of 0.34 (Cohen's d). Conclusions: Teaching optimism to residents with the objective of decreasing the risk of burnout is feasible and easily integrated into residency education sessions. The encouraging results of this pilot study lay the foundation for additional studies and suggest a practical role for implementing optimism curricula in residency training programs.

Prognostic implications of echocardiographic measures of left and right atrial pressures on survival in patients with end stage renal disease.

BACKGROUND: Volume excess is common in patients with end stage renal disease (ESRD). We examined the prognostic value of clinical and echocardiographic measures of left (LA) and right atrial (RA) hypertension in this population. METHOD: We prospectively collected demographic, clinical, pharmacological, echocardiographic data on 575 consecutive ESRD patients on hemodialysis undergoing cardiac evaluation before renal transplantation in a dedicated cardiac clinic. Survival was analyzed as a function of clinical and echocardiographic measures of LA and (RA) hypertension. RESULT: Elevated LA pressure was seen in 48% of the patients based on E/e' velocity ratio of ≥ 15, and 28% had elevated RA pressure based on inferior vena caval size. Physical examination grossly underestimated the prevalence of both LA and RA hypertension. Atrial pressures were normal in 46% and both atrial pressures were elevated in 20% of the patients. Elevated LA pressure in the presence of normal RA pressure was found in 30%. Over a period of 20 ± 8 months, there were 43 deaths. There was a graded increase in mortality with increases in LA and bi-atrial hypertension (p = .009). The 2-year mortality rate was 6% in those with normal atrial pressures, 13% in those with isolated LA hypertension and 28% in those with bi-atrial hypertension. CONCLUSION: Mitral E/e' ratio and inferior vena caval size are vastly more sensitive than physical examination for recognition of elevated atrial pressures and are strong predictors of survival in ESRD patients. Limited echocardiographic examination may have a role in ESRD patients undergoing dialysis to help achieve euvolemic status.

Frequency of hypertensive response to dobutamine stress and diminished diagnostic value in patients with end-stage renal disease awaiting renal transplant.

BACKGROUND: Patients with end-stage renal disease (ESRD) have a cardiovascular mortality about 15-30 times the general population and this is reduced by about 70% with renal transplant. Dobutamine stress echocardiography (DSE) is commonly performed for preoperative cardiac evaluation before renal transplantation. Hypertensive response during DSE occurs in about 1%-5% of DSE studies. However, it seems to be more frequent in patients with ESRD. But its frequency and clinical implications are not known. METHODS AND RESULTS: Of the 249-consecutive adult ESRD patients undergoing DSE for pre-kidney transplant cardiac risk assessment at our dedicated clinic, 53 (21%) had a hypertensive response. Half of the patients with a hypertensive response had stress-induced segmental wall motion abnormalities, of whom only half had angiographically significant coronary artery disease by quantitative coronary angiography. The hypertensive response was not a predictor of survival. Stress-induced segmental wall motion abnormalities predicted poor survival in those with a normotensive response, but not in those with a hypertensive response. The main and independent predictor of a hypertensive response was higher baseline systolic blood pressure (P < .0001). CONCLUSIONS: Hypertensive response to dobutamine stress is common in ESRD patients and is not a predictor of survival. Stress-induced segmental wall motion abnormalities occur nearly thrice as frequently with a hypertensive response, but this is a poor predictor of angiographically significant coronary artery disease and does not predict survival.

Code S: Redesigning Hospital-Wide Peer Review Processes to Identify System Errors.

Hospital medical errors that result in patient harm and death are largely identified as system failures. Most hospitals lack the tools to effectively identify most system errors. Traditional methods used in many hospitals, such as incident reporting (IR), departmental morbidity and mortality conferences, and root cause analysis committees, are often flawed by under reporting. We introduced the Code S designation into our hospital's ongoing physician peer review process as an additional and innovative way to identify system errors that contributed to adverse clinical outcomes. The authors conducted a retrospective review of all peer review cases from January 2008 to December 2011 and determined the quantity and type of system errors that occurred. System errors were categorized based on a modified 5M model which was adapted to reflect system errors encountered in healthcare. The Code S designation discovered 204 system errors that otherwise may not have previously been identified. The addition of the Code S designation to the peer review process can be readily adopted by other healthcare organizations as another tool to help identify, quantify and categorize system errors, and promote hospital-wide process improvements to decrease errors and improve patient safety.

Comparison of a 'two-bag system' versus conventional treatment protocol ('one-bag system') in the management of diabetic ketoacidosis.

OBJECTIVE: We compared the conventional 'one-bag protocol' of management of diabetic ketoacidosis (DKA) with the 'two-bag protocol' which utilizes two bags of fluids, one containing saline and supplemental electrolytes and the other containing the same solution with the addition of 10% dextrose. RESEARCH DESIGN AND METHODS: A retrospective chart review and analysis was done on adult patients admitted for DKA to the Riverside University Health System Medical Center from 2008 to 2015. There were 249 cases of DKA managed by the one-bag system and 134 cases managed by the two-bag system. RESULTS: The baseline patient characteristics were similar in both groups. The anion gap closed in 13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p value <0.0002). None of the individual factors significantly influenced the anion gap closure time; only the two-bag system favored earlier closure of the anion gap. Plasma glucose levels improved to <250 mg/dL earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of hypoglycemic events was significantly less frequent with the two-bag protocol compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither the time to improve serum HCO3 level >18 mg/dL nor the hospital length of stay differed between the two groups. CONCLUSIONS: Our study indicates that the two-bag protocol closes the anion gap earlier than the one-bag protocol in adult patients with DKA. Blood glucose levels improved faster with the two-bag protocol compared with the one-bag protocol with fewer associated episodes of hypoglycemia. Prospective studies are needed to evaluate the clinical significance of these findings.

Survival Benefit of Statins in Hemodialysis Patients Awaiting Renal Transplantation.

End-stage renal disease (ESRD) patients have extraordinarily high cardiovascular risk and mortality, yet the benefit of statins in this population remains unclear based on the randomized trials. We investigated the prognostic value of statins in a large, pure cohort of prospectively recruited patients with ESRD awaiting renal transplantation, and being followed up in a dedicated cardiac clinic. We prospectively collected demographic, clinical, laboratory, and pharmacological data on 423 consecutive ESRD patients on hemodialysis awaiting renal transplantation. Survival analysis was performed as a function of statin therapy. The baseline characteristics were as follows: age 57 ± 11 years, males 64%, diabetes mellitus in 68%, known coronary artery disease in 30%, left ventricular (LV) ejection fraction 61 ± 11%. Over a mean follow-up of 2 years, there were 43 deaths. Adjusted for age, gender, hypertension, body mass index, diabetes mellitus, coronary artery disease, smoking, and treatment with angiotensin converting enzyme inhibitor, ß blocker, and antiplatelet medications, statin use was a predictor of lower mortality (hazard ratio 0.30, 95% confidence interval 0.11-0.79, p = 0.01). This beneficial effect of statin was supported by propensity score analysis (p = 0.02) and was consistent across all clinical subgroups. The benefit of statins seemed to be greater in those with LV hypertrophy and smoking. Statin therapy in hemodialysis patients awaiting renal transplant is independently associated with better survival supporting its use in this high-risk population.

A rare case of amiodarone-induced hypothyroidism presenting with cardiac tamponade.

Subclinical pericardial effusions are common in patients with untreated hypothyroidism and usually resolve with thyroid replacement therapy, but cardiac tamponade is a rare presentation of prolonged untreated hypothyroidism. We report the first case of cardiac tamponade due to hypothyroidism produced by administration of amiodarone.