Burnout in Military Emergency Medicine Resident Physicians: A Cross-Sectional Study With Comparisons to Other Physician Groups.

INTRODUCTION: Physician burnout is of growing concern in the medical community and in emergency medicine (EM) in particular. It is unclear whether higher levels of burnout are associated with poorer academic or clinical performance. EM residency in military environments compared to civilian residencies has unique considerations related to additional military-specific training and operational requirements, which may contribute to burnout. The prevalence and effects of burnout on military EM resident physicians have not been investigated. METHODS: In this institutional review board-approved cross-sectional study, the prevalence of burnout and its effect on academic performance of 30 EM residents in a single 4-year military EM training program was examined. The primary instrument utilized to assess for burnout was the Maslach Burnout Inventory Health Services Survey (MBI-HSS). The primary definition of burnout utilized was a high score in both emotional exhaustion (EE) and depersonalization (DP), and a low score in personal achievement (PA). Additionally, at risk for burnout was defined as moderate or high scores in both EE and DP and low scores in PA. A secondary definition of burnout utilized was any high score in EE or DP, or a low score in PA. The findings in this cohort were compared with published reports of burnout in civilian EM resident and attending physicians as well as military orthopedic physicians. The annual American Board of Emergency Medicine In-Training Exam (ABEM-ITE) percentile ranks for each volunteer in that same academic year were collected as a measure of academic achievement. RESULTS: Thirty of the 40 eligible resident physicians consented to participate in this research project (75%). All 30 completed the MBI-HSS and ABEM-ITE. Burnout, using the primary definition, was found in 10% of residents with an additional 13% at risk for burnout. Using the secondary definition of burnout, 73% of residents demonstrated burnout. The prevalence of burnout as measured by the MBI-HSS was similar to that reported in civilian EM resident and practicing physician groups but 2.7 times the burnout rates found in a military orthopedic resident group. We found no relationship between any individual burnout measure in the MBI-HSS and the annual ABEM-ITE percentile scores. CONCLUSION: In a small study of military EM resident physicians, level of burnout as measured by the MBI-HSS is similar to other EM populations including civilian residents and practicing physicians, though it was much higher than that of military orthopedic residents. No relationship between presence or absence of burnout and academic performance as measured by the ABEM-ITE was found.

Obese trauma patients have increased need for dialysis.

PURPOSE: Obesity is a risk factor for the development of acute kidney injury but its effect on the need for dialysis in trauma has not been elucidated. Additionally, the contribution that obesity has towards risk of mortality in trauma is unclear. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis and mortality after trauma. METHODS: This is a retrospective analysis using the National Trauma Data Bank. All patients ≥ 8 years old were grouped based on BMI: normal (18.5-24.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2) and morbidly obese (≥ 40 kg/m2). The primary outcome was hemodialysis initiation. The secondary outcome was mortality during the index hospitalization. RESULTS: From 988,988 trauma patients, 571,507 (57.8%) had a normal BMI, 233,340 (23.6%) were obese, 94,708 (9.6%) were severely obese, and 89,433 (9.0%) were morbidly obese. The overall rate of hemodialysis was 0.3%. After adjusting for covariates, we found that obese (OR 1.36, CI 1.22-1.52, p < 0.001), severely obese (OR 1.89, CI 1.66-2.15, p < 0.001) and morbidly obese (OR 2.04, CI 1.82-2.29, p < 0.001) patients had a stepwise increased need for hemodialysis after trauma. Obese patients had decreased (OR 0.92, CI 0.88-0.95, p < 0.001), severely obese had similar (OR 1.02, CI 0.97-1.08, p = 0.50) and morbidly obese patients had increased (OR 1.06, CI 1.01-1.12, p = 0.011) risk of mortality after trauma. CONCLUSIONS: Obesity was associated with an increased risk for dialysis after trauma. Mortality risk was reduced in obese, similar in severely obese, and increased in morbidly obese trauma patients suggesting an inflection threshold BMI for risk of mortality in trauma.

Greening the operating room.

BACKGROUND: Climate change will affect most populations in the next decades and put the health of billions of people at risk. Health care facilities represent a significant source of pollution around the world and contribute to environmental changes. To address this topic, we performed a review of the available literature on tactics to reduce operating room (OR) waste and the potential of these strategies to impact the environment. DATA SOURCES: A literature search was performed querying PubMed, Web of Science, and Science Direct. No comparative data were found; most were opinion papers, white papers, and case studies. For this reason, we proceeded with a narrative review, which provides an overview of the evidence on this topic and identifies areas for future research. RESULTS: This systematic review summarizes the available literature on the 5 "Rs" of waste management: reduction, reusing, recycling, rethinking, and renewable energies. CONCLUSIONS: Surgery has a unique opportunity to transition to more environmentally-friendly operating room strategies, which may help decrease waste and lessen the impact of climate change.

Restoration of Mitochondrial Cardiolipin Attenuates Cardiac Damage in Swine Renovascular Hypertension.

BACKGROUND: Renovascular hypertension (RVH) impairs cardiac structure and left ventricular (LV) function, but whether mitochondrial injury is implicated in RVH-induced myocardial damage and dysfunction has not been defined. We hypothesized that cardiac remodeling in swine RVH is partly attributable to cardiac mitochondrial injury. METHODS AND RESULTS: After 12 weeks of hypercholesterolemic (HC)-RVH or control (n=14 each), pigs were treated for another 4 weeks with vehicle or with the mitochondrial-targeted peptide (MTP), Bendavia (0.1 mg/kg subcutaneously, 5 days/week), which stabilizes mitochondrial inner-membrane cardiolipin (n=7 each). Cardiac function was subsequently assessed by multidetector-computed tomography and oxygenation by blood-oxygen-level-dependent magnetic resonance imaging. Cardiolipin content, mitochondrial biogenesis, as well as sarcoplasmic-reticulum calcium cycling, myocardial tissue injury, and coronary endothelial function were assessed ex vivo. Additionally, mitochondrial cardiolipin content, oxidative stress, and bioenergetics were assessed in rat cardiomyocytes incubated with tert-butyl hydroperoxide (tBHP) untreated or treated with MTP. Chronic mitoprotection in vivo restored cardiolipin content and mitochondrial biogenesis. Thapsigargin-sensitive sarcoplasmic reticulum Ca(2+)-ATPase activity that declined in HC-RVH normalized in MTP-treated pigs. Mitoprotection also improved LV relaxation (E/A ratio) and ameliorated cardiac hypertrophy, without affecting blood pressure or systolic function. Myocardial remodeling and coronary endothelial function improved only in MTP-treated pigs. In tBHP-treated cardiomyocytes, mitochondrial targeting attenuated a fall in cardiolipin content and bioenergetics. CONCLUSIONS: Chronic mitoprotection blunted myocardial hypertrophy, improved LV relaxation, and attenuated myocardial cellular and microvascular remodeling, despite sustained HC-RVH, suggesting that mitochondrial injury partly contributes to hypertensive cardiomyopathy.

Effects of communication styles on marital satisfaction and distress of parents of pediatric cancer patients: a prospective longitudinal study.

OBJECTIVE: The aim of this study was to examine the longitudinal effects of communication styles on marital satisfaction and distress of parents of children treated for cancer. METHODS: Marital dissatisfaction (Maudsley Marital Questionnaire), intimacy, avoidance, destructive and incongruent communication (Communication Skills Inventory) and psychological distress (General Health Questionnaire) were assessed in 115 parents of pediatric cancer patients shortly after diagnosis (T1) and 5 years later (T2). RESULTS: Only mothers' marital dissatisfaction increased significantly over time. No gender differences in dissatisfaction were found. Mothers had a significantly higher lack of intimacy score than fathers. All T1 communication styles were significantly univariately related to fathers' and mothers' T2 marital dissatisfaction, while not to T2 distress. Mothers' T1 marital dissatisfaction accounted for 67% and fathers' for 12% in the explained variance of T2 dissatisfaction. T1 destructive communication uniquely affected fathers' T2 marital dissatisfaction and T1 avoidant communication that of mothers. CONCLUSIONS: Five years after cancer diagnosis in their children, the quality of parents' marital relationships seemed largely unchanged. Parents' use of communication skills at diagnosis appeared to have limited effect on their marital dissatisfaction and no effect on their distress 5 years later. While avoidant communication seemed indicative of mothers' marital distress, fathers' seemed affected by destructive communication.

Mitochondrial targeted peptides attenuate residual myocardial damage after reversal of experimental renovascular hypertension.

BACKGROUND: Renovascular hypertension (RVHT) increases cardiovascular morbidity and mortality. Renal revascularization with percutaneous transluminal renal angioplasty and stenting (PTRS) may reverse RVHT but may not fully regress cardiac remodeling and damage, possibly due to persistent myocardial insults. Bendavia is a mitochondrial targeted peptide that reduces ischemic cardiomyopathy by improving mitochondrial function. However, its potential for attenuating residual myocardial damage after reversal of RVHT has not been explored. We hypothesized that treatment with Bendavia as an adjunct to PTRS would improve cardiac function and oxygenation, and decrease myocardial injury in swine RVHT. METHODS AND RESULTS: After 6 weeks of RVHT (unilateral renal artery stenosis) or control, pigs underwent PTRS (or sham), with adjunct continuous infusion of Bendavia (0.05  mg/kg intravenously, 30  min before to 3.5  h after PTRS) or vehicle (n = 7 each). Four weeks later, systolic and diastolic function were assessed by multidetector computed tomography, myocardial oxygenation by blood oxygen level-dependent MRI, and myocardial morphology, apoptosis, mitochondrial biogenesis, and fibrosis evaluated ex vivo. PTRS restored blood pressure in both groups, yet E/A ratio remained decreased. Myocardial oxygenation and mitochondrial biogenesis improved, and myocardial inflammation, oxidative stress, and fibrosis normalized in association with improvement in diastolic function in RVHT + PTRS + Bendavia animals. CONCLUSION: Adjunct Bendavia during PTRS in swine RVHT improved diastolic function and oxygenation and reversed myocardial tissue damage. This approach may allow a novel strategy for preservation of cardiac function and structure in RVHT.

Coping and its effect on psychological distress of parents of pediatric cancer patients: a longitudinal prospective study.

OBJECTIVE: This prospective 5-year longitudinal study examined the use of coping styles of fathers and mothers of pediatric cancer patients over time and the prospective effects of coping on distress. METHODS: Psychological distress (General Health Questionnaire) and the use of seven coping styles (Utrecht Coping List: active problem focussing, palliative and passive reaction patterns, avoidance, social support seeking, expression of emotions, and comforting cognition) were assessed in 115 parents shortly after diagnosis, 6 and 12 months, and 5 years later. RESULTS: At diagnosis, parents' use of coping styles did not differ from the norm population except more frequent use of support seeking. No significant change over time was found in a palliative reaction pattern. Support seeking declined and emotional expression increased linearly, whereas use of the remaining coping styles decreased, followed by an increase. At 5 years, parents' use differed from the norm population only in less use of expression of emotions and comforting cognitions. Initial coping use significantly predicted fathers' future distress at 6 and 12 months but not at 5 years. This was not found for mothers. Changes in coping were significantly associated with both parents' changes in distress only during the first year. Increased passive reaction pattern and social support seeking were the risk factors for mothers. Increased avoidance, a passive reaction pattern, expression of emotions, and decreased active problem focussing formed the risk factors for fathers. CONCLUSION: Findings illustrate that coping seems to be a situation-specific process and that coping predictors vary as a function of parents' gender.

Self-transcendence in stem cell transplantation recipients: a phenomenologic inquiry.

PURPOSE/OBJECTIVES: To understand the meaning of self-transcendence, or the ability to go beyond the self, for patients who have had a stem cell transplantation. RESEARCH APPROACH: A phenomenologic investigation guided by the interpretive philosophy of Heidegger. SETTING: A cancer center in a major urban academic medical center. PARTICIPANTS: 4 men and 4 women ages 45-63 who had received a stem cell transplantation in the previous year. METHODOLOGIC APPROACH: Two or three unstructured, open-ended interviews were conducted with each participant. Data were extracted, analyzed, and interpreted according to the Colaizzi method. MAIN RESEARCH VARIABLES: Self-transcendence. FINDINGS: Self-transcendence emerged as a process that was triggered by the suffering the participants experienced as they lived through the physical effects of the treatment, faced death, drew strength from within themselves, and perceived a spiritually influenced turning point. The experience of a human connection lessened their feelings of vulnerability in the process. As the participants recovered, they described being transformed both physically and personally. CONCLUSIONS: The findings from this study highlight the power inherent in patients to not only meet the challenges they face, but to grow from their experiences. The findings also highlight patients' deep need for a human connection and the power that nurses and other healthcare professionals have to provide that connection. INTERPRETATION: The caring connections established by health-care professionals can ease the ability of patients to access the inner resource of self-transcendence and reduce their feelings of vulnerability.

Mathematical accuracy of Aztec land surveys assessed from records in the Codex Vergara.

Land surveying in ancient states is documented not only for Eurasia but also for the Americas, amply attested by two Acolhua-Aztec pictorial manuscripts from the Valley of Mexico. The Codex Vergara and the Códice de Santa María Asunción consist of hundreds of drawings of agricultural fields that uniquely record surface areas as well as perimeter measurements. A previous study of the Codex Vergara examines how Acolhua-Aztecs determined field area by reconstructing their calculation procedures. Here we evaluate the accuracy of their area values using modern mathematics. The findings verify the overall mathematical validity of the codex records. Three-quarters of the areas are within 5% of the maximum possible value, and 85% are within 10%, which compares well with reported errors by Western surveyors that postdate Aztec-Acolhua work by several centuries.

Aztec arithmetic revisited: land-area algorithms and Acolhua congruence arithmetic.

Acolhua-Aztec land records depicting areas and side dimensions of agricultural fields provide insight into Aztec arithmetic. Hypothesizing that recorded areas resulted from indigenous calculation, in a study of sample quadrilateral fields we found that 60% of the area values could be reproduced exactly by computation. In remaining cases, discrepancies between computed and recorded areas were consistently small, suggesting use of an unknown indigenous arithmetic. In revisiting the research, we discovered evidence for the use of congruence principles, based on proportions between the standard linear Acolhua measure and their units of shorter length. This procedure substitutes for computation with fractions and is labeled "Acolhua congruence arithmetic." The findings also clarify variance between Acolhua and Tenochca linear units, long an issue in understanding Aztec metrology.

An exploratory study of older adults' perspectives of spirituality.

Spirituality is multifaceted as it is a nonphysical meaning placed upon existence and is unique to each individual. This exclusivity makes it difficult to measure or analyze, but the need remains to discover answers to questions regarding spirituality, human life, and its factors. This exploratory, pilot study involved interviewing three older adults to address issues of individual perceptions of spirituality, integration of spirituality in daily life, and utilization of spirituality to address individual needs. Thematic results indicate spirituality is a principle-based and intrinsic factor integrated into daily life. It involves motivation and meaning as spirituality addresses personal needs by providing strength and inspiration. Finally, spirituality affects chosen occupations by providing a sense of purpose.

Psychological distress and the impact of social support on fathers and mothers of pediatric cancer patients: long-term prospective results.

OBJECTIVE: To explore the effects of social support on psychological distress of parents of pediatric cancer patients using a prospective design over a 5-year period. METHODS: Parents of children diagnosed with cancer participated at diagnosis (T1), 6 months (T2), 12 months (T3), and 5 years later (T4). Instruments The General Health Questionnaire and the Social Support List (SSL) measuring amount of support, (dis)satisfaction with support, and negative interactions were administered. RESULTS: Psychological distress and amount of support received decreased significantly from diagnosis to T4. No significant change in (dis)satisfaction with support and negative interactions was found. Social support variables did not show any concurrent or prospective significant effect on mothers' distress at T4. Dissatisfaction with support showed a significant unique concurrent effect on fathers' distress at T4 and negative interactions had a prospective unique effect. CONCLUSIONS: Dissatisfaction with support and negative interactions that fathers experienced significantly affected their levels of psychological distress. No such effect was found for mothers.

Psychological adjustment of parents of pediatric cancer patients revisited: five years later.

We investigated the psychological functioning of parents of children suffering from pediatric cancer using a prospective design over a five-year time period. Parents of children diagnosed with cancer participated at diagnosis (T1), six months (T2), twelve months (T3), and five years later (T4, n = 115). Repeated measures ANOVAs were calculated for the three measures of psychological distress (GHQ, SCL-90 and STAI-S) to examine changes over time and gender differences. Independent T-tests were computed to examine differences between the mean scores of the parents at T4 and the norm groups. The effects of health status and earlier levels of distress on T4 functioning were examined using ANOVA and partial correlational analysis. Results showed that levels of reported distress, psychoneurotic symptoms and state anxiety significantly decreased across time to normal levels at T4 except on the GHQ. A significantly higher percentage of parents (27%) than in the norm group (15%) showed clinically elevated scores on the GHQ. Mothers had higher scores than fathers only on state anxiety. Parents of relapsed children reported higher anxiety levels than parents of surviving and deceased children. Psychological functioning at T1 was significantly related to functioning at T4. These results support the conclusion that although parental distress decreases with time, a significant number of parents still suffer from clinical distress after five years. Parents of relapsed children are at risk for long-term psychological problems as are those with higher levels of psychosomatic complaints at diagnosis.

Maternal rigidity in infancy and level of intelligence at school age in children born preterm.

Forty-four children who had been born preterm and their mothers participated in the follow-up study. At 3 and 14 months (corrected age) cognitive development was assessed using the BOS 2-30, the Dutch version of the Bayley Scales of Infant Development. The BOS yields measures of mental and motor development. At 7.5 years, intelligence was measured using the WISC-RN, the Dutch version of the WISC-R. A composite measure of maternal rigidity, tapping rigidity as a personality trait and rigid attitudes to child-rearing was used. The results of a multiple regression analysis indicated that maternal rigidity, measured in the first year of the child's life, was not associated with mental performance at 3 or 14 months. At 7.5. years, however, it was strongly associated with cognitive development, contributing uniquely to performance IQ.