Factors driving burnout and professional fulfillment among emergency medicine residents: A national wellness survey by the Society for Academic Emergency Medicine.

Objectives: This study aimed to identify rates of and contributors to burnout and professional fulfillment among emergency medicine (EM) resident physicians. Methods: This was a cross-sectional, national survey of resident members of the Society for Academic Emergency Medicine (SAEM). Primary outcomes were burnout and professional fulfillment measured using a previously validated instrument with additional domains pertaining to the academic environment. The survey included question domains examining organizational factors (e.g., academic work environment, satisfaction with training, electronic health records, values alignment, and control over schedule) and individual factors (e.g., self-compassion, meaningfulness of clinical work, impact of work on health and personal relationships, perceived appreciation, thoughts of attrition, and expectations of the field of EM). Logistic regression was performed to determine the relationships between the primary outcomes and each domain. Results: The survey was sent electronically to 2641 SAEM resident members. A total of 275 residents completed the survey with a response rate of 10.4%. A total of 151 (55%) respondents were male, and 210 (76%) were White. A total of 132 (48%) residents reported burnout, and 75 (28%) reported professional fulfillment. All organizational and individual factors were significantly associated with both primary outcomes. EM residents reported that meaningfulness of clinical work had the most significant positive association with professional fulfillment (adjusted odds ratio [OR] 2.2 [95% confidence interval {CI} 1.8-2.7]) and negative association with burnout (adjusted OR 0.46 [95% CI 0.37-0.56]). Thoughts of attrition from academics and accurate expectations of EM were also associated with both primary outcomes, with adjusted ORs (95% CIs) of 0.40 (0.21-0.72) and 5.6 (1.9-23.8) for professional fulfillment and 4.1 (2.5-7.1) and 0.19 (0.08-0.40) for burnout, respectively. Conclusions: This study found a high prevalence of burnout and a low prevalence of professional fulfillment among EM residents. Multiple factors were significantly associated with each occupational phenomenon, with meaningfulness of clinical work demonstrating the strongest relationships with burnout and professional fulfillment.

Drivers of professional fulfillment and burnout among emergency medicine faculty: A national wellness survey by the Society for Academic Emergency Medicine.

BACKGROUND: Professional fulfillment and the mitigation of burnout can enhance clinician well-being and the resiliency of the health care organization. This study examined the extent to which specific individual and workplace factors are associated with professional fulfillment and burnout among a national sample of academic emergency physicians. METHODS: This was a cross-sectional survey of faculty members of the Society for Academic Emergency Medicine. Primary outcomes were professional fulfillment and burnout. The survey also examined individual and workplace factors as well as faculty's thoughts of attrition from academic and clinical medicine. Logistic regression was performed to determine the relationships between each outcome and each factor, respectively. RESULTS: A total of 771 of 3130 faculty completed the survey (response rate 24.6%). A total of 38.7% reported professional fulfillment and 39.1% reported burnout. Meaningfulness of work (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.9-2.5), perceived appreciation (OR 1.9, 95% CI 1.7-2.1), and the academic work environment (OR 1.7, 95% CI 1.5-1.9) had the highest odds of being associated with professional fulfillment. In contrast, low score responses for meaningfulness of work (OR 0.6, 95% CI 0.5-0.6), self-compassion (0.6, 95% CI 0.5-0.6), and control over schedule (OR 0.6, 95% CI 0.6-0.7) were most associated with burnout. Faculty with professional fulfillment were less likely to report plans for attrition from academics (OR 0.1, 95% CI 0.1-0.2) and from clinical medicine (OR 0.2, 95% CI 0.1-0.4). Faculty with burnout were more likely to report plans for attrition from academics (OR 7, 95% CI 4.8-10.4) and clinical medicine (OR 5.7, 95% CI 3.9-8.6). CONCLUSIONS: Individual and workplace factors that contributed to professional fulfillment and burnout were identified, with meaningfulness of clinical work demonstrating the strongest association with both occupational phenomena. Knowledge of which factors are most impactful in promoting professional fulfillment and mitigating burnout may be useful in guiding efforts to enhance clinician well-being.

Heart rate n-variability (HRnV) and its application to risk stratification of chest pain patients in the emergency department.

BACKGROUND: Chest pain is one of the most common complaints among patients presenting to the emergency department (ED). Causes of chest pain can be benign or life threatening, making accurate risk stratification a critical issue in the ED. In addition to the use of established clinical scores, prior studies have attempted to create predictive models with heart rate variability (HRV). In this study, we proposed heart rate n-variability (HRnV), an alternative representation of beat-to-beat variation in electrocardiogram (ECG), and investigated its association with major adverse cardiac events (MACE) in ED patients with chest pain. METHODS: We conducted a retrospective analysis of data collected from the ED of a tertiary hospital in Singapore between September 2010 and July 2015. Patients > 20 years old who presented to the ED with chief complaint of chest pain were conveniently recruited. Five to six-minute single-lead ECGs, demographics, medical history, troponin, and other required variables were collected. We developed the HRnV-Calc software to calculate HRnV parameters. The primary outcome was 30-day MACE, which included all-cause death, acute myocardial infarction, and revascularization. Univariable and multivariable logistic regression analyses were conducted to investigate the association between individual risk factors and the outcome. Receiver operating characteristic (ROC) analysis was performed to compare the HRnV model (based on leave-one-out cross-validation) against other clinical scores in predicting 30-day MACE. RESULTS: A total of 795 patients were included in the analysis, of which 247 (31%) had MACE within 30 days. The MACE group was older, with a higher proportion being male patients. Twenty-one conventional HRV and 115 HRnV parameters were calculated. In univariable analysis, eleven HRV and 48 HRnV parameters were significantly associated with 30-day MACE. The multivariable stepwise logistic regression identified 16 predictors that were strongly associated with MACE outcome; these predictors consisted of one HRV, seven HRnV parameters, troponin, ST segment changes, and several other factors. The HRnV model outperformed several clinical scores in the ROC analysis. CONCLUSIONS: The novel HRnV representation demonstrated its value of augmenting HRV and traditional risk factors in designing a robust risk stratification tool for patients with chest pain in the ED.

Cardiac Standstill With Intracardiac Clot Formation.

This case describes and depicts cardiac standstill with thrombosed blood within the chambers of the heart. This was likely due to stasis of blood from a prolonged no-flow state. After viewing this ultrasound finding, the decision was made to halt resuscitative efforts in this case of a patient in cardiac arrest.

Trauma in Pregnancy.

Although trauma in pregnancy is rare, it is one of the most common causes of morbidity and mortality to pregnant women and fetus. Pathophysiology of trauma is generally time sensitive, and this is still true in pregnant patients, with the additional challenge of rare presentation and balancing the management of two patients concurrently. Successful resuscitation requires understanding the physiologic changes to the woman throughout the course of pregnancy. Ultimately, trauma management is best approached by prioritizing maternal resuscitation.

Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta-analysis.

OBJECTIVES: Pain is a common complaint in the emergency department (ED). Its management currently depends heavily on pharmacologic treatment, but evidence suggests that nonpharmacologic interventions may be beneficial. The purpose of this systematic review and meta-analysis was to assess whether nonpharmacologic interventions in the ED are effective in reducing pain. METHODS: We conducted a systematic review of the literature on all types of nonpharmacologic interventions in the ED with pain reduction as an outcome. We performed a qualitative summary of all studies meeting inclusion criteria and meta-analysis of randomized controlled studies measuring postintervention changes in pain. Interventions were divided by type into five categories for more focused subanalyses. RESULTS: Fifty-six studies met inclusion criteria for summary analysis. The most studied interventions were acupuncture (10 studies) and physical therapy (six studies). The type of pain most studied was musculoskeletal pain (34 studies). Most (42 studies) reported at least one improved outcome after intervention. Of these, 23 studies reported significantly reduced pain compared to control, 24 studies showed no difference, and nine studies had no control group. Meta-analysis included 22 qualifying randomized controlled trials and had a global standardized mean difference of -0.46 (95% confidence interval = -0.66 to -0.27) in favor of nonpharmacologic interventions for reducing pain. CONCLUSION: Nonpharmacologic interventions are often effective in reducing pain in the ED. However, most existing studies are small, warranting further investigation into their use for optimizing ED pain management.

Heart Rate Variability Analysis in Patients Who Have Bradycardia Presenting to the Emergency Department with Chest Pain.

BACKGROUND: Heart rate variability (HRV) is a noninvasive method to measure the function of the autonomic nervous system. It has been used to risk stratify patients with undifferentiated chest pain in the emergency department (ED). However, bradycardia can have a modifying effect on HRV. OBJECTIVE: In this study, we aimed to determine how bradycardia affected HRV analysis in patients who presented with chest pain to the ED. METHODS: Adult patients presenting to the ED at Singapore General Hospital with chest pain were included in the study. Patients with non-sinus rhythm on electrocardiogram (ECG) were excluded. HRV parameters, including time domain, frequency domain, and nonlinear variables, were analyzed from a 5-min ECG segment. Occurrence of a major adverse cardiac event ([MACE], e.g., acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, or mortality) within 30 days of presentation to the ED was also recorded. RESULTS: A total of 797 patients were included for analysis with 248 patients (31.1%) with 30-day MACE and 135 patients with bradycardia (16.9%). Compared to non-bradycardic patients, bradycardic patients had significant differences in all HRV parameters suggesting an increased parasympathetic component. Among non-bradycardic patients, comparing those who did and did not have 30-day MACE, there were significant differences predominantly in time domain variables, suggesting decreased HRV. In bradycardic patients, the same analysis revealed significant differences in predominantly frequency-domain variables suggesting decreased parasympathetic input. CONCLUSIONS: Chest pain patients with bradycardia have increased HRV compared to those without bradycardia. This may have important implications on HRV modeling strategies for risk stratification of bradycardic and non-bradycardic chest pain patients.

Integrating heart rate variability, vital signs, electrocardiogram, and troponin to triage chest pain patients in the ED.

BACKGROUND: Current triage methods for chest pain patients typically utilize symptoms, electrocardiogram (ECG), and vital sign data, requiring interpretation by dedicated triage clinicians. In contrast, we aimed to create a quickly obtainable model integrating the objective parameters of heart rate variability (HRV), troponin, ECG, and vital signs to improve accuracy and efficiency of triage for chest pain patients in the emergency department (ED). METHODS: Adult patients presenting to the ED with chest pain from September 2010 to July 2015 were conveniently recruited. The primary outcome was a composite of revascularization, death, cardiac arrest, cardiogenic shock, or lethal arrhythmia within 72-h of presentation to the ED. To create the chest pain triage (CPT) model, logistic regression was done where potential covariates comprised of vital signs, ECG parameters, troponin, and HRV measures. Current triage methods at our institution and modified early warning score (MEWS) were used as comparators. RESULTS: A total of 797 patients were included for final analysis of which 146 patients (18.3%) met the primary outcome. Patients were an average age of 60years old, 68% male, and 56% triaged to the most acute category. The model consisted of five parameters: pain score, ST-elevation, ST-depression, detrended fluctuation analysis (DFA) α1, and troponin. CPT model>0.09, CPT model>0.15, current triage methods, and MEWS≥2 had sensitivities of 86%, 74%, 75%, and 23%, respectively, and specificities of 45%, 71%, 48%, and 78%, respectively. CONCLUSION: The CPT model may improve current clinical triage protocols for chest pain patients in the ED.

Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department.

BACKGROUND: The HEART, TIMI, and GRACE scores have been applied in the Emergency Department (ED) to risk stratify patients with undifferentiated chest pain. This study aims to compare the accuracy of HEART, TIMI, and GRACE for the prediction of major adverse cardiac events (MACE) in high acuity chest pain patients. METHODS: Adult patients who presented with chest pain suggestive of cardiac origin in the most acute triage category at an academic ED from September 2010 to October 2015 were included. The HEART, TIMI, and GRACE scores were calculated retrospectively from prospectively collected data. The primary outcome was occurrence of MACE (mortality, AMI, PCI, CABG) within 30-days of initial presentation. RESULTS: 604 patients were included in the study. Patient demographics include an average age of 61years, 69% male, and 48% with history of ischemic heart disease. 36% of patients met the primary outcome. The c-statistics of HEART, TIMI, and GRACE were 0.78 (95% CI: 0.74-0.81), 0.65 (95% CI: 0.60-0.69), and 0.62 (95% CI: 0.58-0.67), respectively. For the purpose of accurately ruling out patients for 30-day MACE, a HEART score of ≤3 had a sensitivity and NPV of 99% and 98%, respectively, compared to 97% and 91%, respectively, for TIMI=0, and 94% and 85%, respectively, for GRACE ≤75. The percent of patients with 30-day MACE with HEART scores between 0 and 3, 4-6, and 7-10 was 2%, 28%, and 63%, respectively. CONCLUSION: In high acuity chest pain patients, the HEART score is superior to the TIMI and GRACE scores in predicting 30-day MACE.

Characterizing the degradation of alginate hydrogel for use in multilumen scaffolds for spinal cord repair.

Alginate was studied as a degradable nerve guidance scaffold material in vitro and in vivo. In vitro degradation rates were determined using rheology to measure the change in shear modulus vs time. The shear modulus decreased from 155 kPa to 5 kPa within 2 days; however, alginate samples maintained their superficial geometry for over 28 days. The degradation behavior was supported by materials characterization data showing alginate consisted of high internal surface area (400 m2 /g), which likely facilitated the release of cross-linking cations resulting in the rapid decrease in shear modulus. To assess the degradation rate in vivo, multilumen scaffolds were fabricated using a fiber templating technique. The scaffolds were implanted in a 2-mm-long T3 full transection rodent spinal cord lesion model for 14 days. Although there was some evidence of axon guidance, in general, alginate scaffolds degraded before axons could grow over the 2-mm-long lesion. Enabling alginate-based scaffolds for nerve repair will likely require approaches to slow its degradation. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 611-619, 2016.

Independent Predictors of 30-Day Perioperative Deep Vein Thrombosis in 1346 Consecutive Patients After Spine Surgery.

BACKGROUND: Deep vein thrombosis (DVT) is a morbid postsurgical complication. Identifying the perioperative DVT risk profile will improve surgeons' ability to assess patients for surgical candidacy. In addition, these data will help to identify patients who would benefit from DVT chemoprophylaxis. METHODS: We evaluated all medical records for 1346 consecutive patients who underwent spinal surgery at Duke University for incidence of DVT within 30 days of surgery and documented all demographic, preoperative, operative, and postoperative variables. DVT treatment and long-term outcomes were also documented. Associations between postoperative DVT and individual risk factors in all patients were determined using adjusted logistic regression analysis. Patients were stratified into emergent and elective groups and a similar analysis was performed. RESULTS: Overall, 15 patients (1.1%) had a DVT in the 30 days after surgery, 7 patients (0.6%) after elective surgery and 8 patients (4.2%) after emergent surgery (P = 0.03). Overall, multivariate logistic regression determined that previous DVT, postoperative urinary tract infection, and creatinine level >2.0 mg/dL were identified as positive predictors. When stratified by emergent surgery, we found packed red blood cell transfusion, surgical blood loss >2.0 L, and deep surgical site infection to be independently associated with increased risk of postoperative DVT. When stratified by elective surgery, we found that coronary artery disease and atrial fibrillation were associated with increased risk of DVT. No patients died in the 30-day perioperative period and 5 (33.3%) patients died within 1 year. CONCLUSIONS: This study identifies patient factors predictive of postoperative DVT. Postoperative DVT prophylaxis may be warranted for patients undergoing emergent spine surgery because these patients have significantly higher risk of developing postoperative DVT.

Brain derived neurotrophic factor release from layer-by-layer coated agarose nerve guidance scaffolds.

Agarose nerve guidance scaffolds (NGS) seeded with cells expressing brain derived neurotrophic factor (BDNF) have demonstrated robust nerve regeneration in the rat central nervous system. The purpose of this work was to explore whether agarose NGS coated with hydrogen-bonded layer-by-layer (HLbL) could provide an acellular method of delivering prolonged and consistent dosages of active BDNF. Our results show that HLbL-coated agarose NGS could release BDNF over 10days in consistent dosages averaging 80.5±12.5(SD)ng/mL. Moreover, the BDNF released from HLbL was confirmed active by in vitro cell proliferation assays. To our knowledge, this is the first report demonstrating that HLbL assembled onto a hydrogel can provide consistent, prolonged release of active BDNF in clinically relevant dosages.

Excellent stability of a lithium-ion-conducting solid electrolyte upon reversible Li(+) /H(+) exchange in aqueous solutions.

Batteries with an aqueous catholyte and a Li metal anode have attracted interest owing to their exceptional energy density and high charge/discharge rate. The long-term operation of such batteries requires that the solid electrolyte separator between the anode and aqueous solutions must be compatible with Li and stable over a wide pH range. Unfortunately, no such compound has yet been reported. In this study, an excellent stability in neutral and strongly basic solutions was observed when using the cubic Li7 La3 Zr2 O12 garnet as a Li-stable solid electrolyte. The material underwent a Li(+) /H(+) exchange in aqueous solutions. Nevertheless, its structure remained unchanged even under a high exchange rate of 63.6 %. When treated with a 2 M LiOH solution, the Li(+) /H(+) exchange was reversed without any structural change. These observations suggest that cubic Li7 La3 Zr2 O12 is a promising candidate for the separator in aqueous lithium batteries.

Conversion efficiency of skutterudite-based thermoelectric modules.

Presently, the only commercially available power generating thermoelectric (TE) modules are based on bismuth telluride (Bi2Te3) alloys and are limited to a hot side temperature of 250 °C due to the melting point of the solder interconnects and/or generally poor power generation performance above this point. For the purposes of demonstrating a TE generator or TEG with higher temperature capability, we selected skutterudite based materials to carry forward with module fabrication because these materials have adequate TE performance and are mechanically robust. We have previously reported the electrical power output for a 32 couple skutterudite TE module, a module that is type identical to ones used in a high temperature capable TEG prototype. The purpose of this previous work was to establish the expected power output of the modules as a function of varying hot and cold side temperatures. Recent upgrades to the TE module measurement system built at the Fraunhofer Institute for Physical Measurement Techniques allow for the assessment of not only the power output, as previously described, but also the thermal to electrical energy conversion efficiency. Here we report the power output and conversion efficiency of a 32 couple, high temperature skutterudite module at varying applied loading pressures and with different interface materials between the module and the heat source and sink of the test system. We demonstrate a 7% conversion efficiency at the module level when a temperature difference of 460 °C is established. Extrapolated values indicate that 7.5% is achievable when proper thermal interfaces and loading pressures are used.

Lithium titanate aerogel for advanced lithium-ion batteries.

This work details the synthesis and characterization of a novel lithium titanate aerogel as an anode material for lithium ion batteries. Excessive loss of lithium during supercritical drying can be overcome by increasing the lithium precursor concentration during synthesis. Chronopotentiometry shows the aerogel to have a capacity about 80 % of theoretical at a symmetric C/3 rate, which is comparable to a commercial product. Cyclic voltammetry reveals a batt-cap behavior for the high-surface area aerogel, implying the potential for improved rate capability if electrical conductivity can be maintained.

Time controlled release of arabinofuranosylcytosine (Ara-C) from agarose hydrogels using layer-by-layer assembly: an in vitro study.

Experimentally induced axonal regeneration is compromised by glial scar formation arising from leptomeningeal fibroblasts cells in and around the hydrogel scaffold implanted for nerve repair. Strategies are needed to prevent such fibroblastic reactive cell layer formation for enhanced axonal regeneration. Here, we implement the technique of layer-by-layer assembled degradable, hydrogen bonded multilayers on agarose hydrogels to incorporate an anti-mitotic drug (1-ß-D-arabinofuranosylcytosine (Ara-C)) within the agarose hydrogels. We show controlled release of Ara-C under physiological conditions over a period of days. The concentrations of Ara-C released from agarose at the different time points were sufficient to inhibit fibroblast growth in vitro, while not adversely affecting the viability of the neuronal cells.

Precision microchannel scaffolds for central and peripheral nervous system repair.

In previous studies, we demonstrated the ability to linearly guide axonal regeneration using scaffolds comprised of precision microchannels 2 mm in length. In this work, we report our efforts to augment the manufacturing process to achieve clinically relevant scaffold dimensions in the centimeter-scale range. By selective etching of multi-component fiber bundles, agarose hydrogel scaffolds with highly ordered, close-packed arrays of microchannels, ranging from 172 to 320 µm, were fabricated with overall dimensions approaching clinically relevant length scales. Cross-sectional analyses determined that the maximum microchannel volume per unit volume of scaffold approached 80%, which is nearly twice that compared to our previously reported study. Statistical analyses at various points along the length of the microchannels also show a significant degree of linearity along the entire length of the scaffold. Two types of multi-component fiber bundle templates were evaluated; polystyrene and poly(methyl methacrylate). The scaffolds consisting of 2 cm long microchannels were fabricated with the poly(methyl methacrylate) fiber-cores exhibited a higher degree of linearity compared to those fabricated using polystyrene fibers. It is believed that the materials process developed in this study is useful for fabricating high aspect ratio microchannels in biocompatible materials with a wide range of geometries for guiding nerve regeneration.

Time Controlled Protein Release from Layer-by-Layer Assembled Multilayer Functionalized Agarose Hydrogels.

Axons of the adult central nervous system exhibit an extremely limited ability to regenerate after spinal cord injury. Experimentally generated patterns of axon growth are typically disorganized and randomly oriented. Support of linear axonal growth into spinal cord lesion sites has been demonstrated using arrays of uniaxial channels, templated with agarose hydrogel, and containing genetically engineered cells that secrete brain-derived neurotrophic factor (BDNF). However, immobilizing neurotrophic factors secreting cells within a scaffold is relatively cumbersome, and alternative strategies are needed to provide sustained release of BDNF from templated agarose scaffolds. Existing methods of loading the drug or protein into hydrogels cannot provide sustained release from templated agarose hydrogels. Alternatively, here it is shown that pH-responsive H-bonded poly(ethylene glycol)(PEG)/poly(acrylic acid)(PAA)/protein hybrid layer-by-layer (LbL) thin films, when prepared over agarose, provided sustained release of protein under physiological conditions for more than four weeks. Lysozyme, a protein similar in size and isoelectric point to BDNF, is released from the multilayers on the agarose and is biologically active during the earlier time points, with decreasing activity at later time points. This is the first demonstration of month-long sustained protein release from an agarose hydrogel, whereby the drug/protein is loaded separately from the agarose hydrogel fabrication process.