Optimizing Wellness in Academic Emergency Medicine

Introduction Academic Emergency Physicians (EPs) face additional unique challenges in optimizing wellness compared to community EPs. Objective Our objective was to explore specific individual and systems challenges that academic EPs encounter that affect their wellbeing and professional fulfillment in emergency medicine (EM). Methods An expert group of academic EPs convened in 2019 at the annual meeting of the Society of Academic Emergency Medicine to investigate the overall causes of burnout in healthcare providers, the effects of burnout on the healthcare system, specific causes of burnout in EM, and the distinct challenges facing academic emergency physicians. Results We outline specific causes of burnout in EM and the effects of burnout on the healthcare system. Scholarly productivity pressures, variable reimbursement gaps, time allotment, and work-life balance are challenges facing academic EPs. Conclusion Understanding the unique challenges of academic EPs in optimizing wellness is vital to inform future research and effective interventions

Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection

IMPORTANCE: SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals. OBJECTIVE: To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling. EXPOSURE: SARS-CoV-2 infection. MAIN OUTCOMES AND MEASURES: PASC and 44 participant-reported symptoms (with severity thresholds). RESULTS: A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months. CONCLUSIONS AND RELEVANCE: A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC

Researching COVID to Enhance Recovery (RECOVER) Adult Study Protocol: Rationale, Objectives, and Design

IMPORTANCE: SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. METHODS: RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms. DISCUSSION: RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options

Low level bacterial endotoxin activates two distinct signaling pathways in human peripheral blood mononuclear cells

<p>Abstract</p> <p>Background</p> <p>Bacterial endotoxin, long recognized as a potent pro-inflammatory mediator in acute infectious processes, has more recently been identified as a risk factor for atherosclerosis and other cardiovascular diseases. When endotoxin enters the bloodstream, one of the first cells activated is the circulating monocyte, which exhibits a wide range of pro-inflammatory responses.</p> <p>Methods</p> <p>We studied the effect of low doses of <it>E. coli </it>LPS on IL-8 release and superoxide formation by freshly isolated human peripheral blood mononuclear cells (PBMC).</p> <p>Results</p> <p>IL-8 release was consistently detectable at 10 pg/ml of endotoxin, reaching a maximum at 1 ng/ml, and was exclusively produced by monocytes; the lymphocytes neither produced IL-8, nor affected monocyte IL-8 release. Superoxide production was detectable at 30 pg/ml of endotoxin, reaching a maximum at 3 ng/ml. Peak respiratory burst activity was seen at 15-20 min, and superoxide levels returned to baseline by 1 h. IL-8 release was dependent on both membrane-associated CD14 (mCD14) and Toll-like receptor 4 (TLR4. Superoxide production was dependent on the presence of LBP, but was not significantly affected by a blocking antibody to TLR4. Moreover, treatment with lovastatin inhibited LPS-dependent IL-8 release and superoxide production.</p> <p>Conclusions</p> <p>These findings suggest that IL-8 release and the respiratory burst are regulated by distinct endotoxin-dependent signaling pathways in PBMC in low level of endotoxin exposure. Selectively modulating these pathways could lead to new approaches to treat chronic inflammatory diseases, such as atherosclerosis, while preserving the capacity of monocytes to respond to acute bacterial infections.</p

Research Priorities for Physician Wellness in Academic Emergency Medicine: Consensus from the Society of Academic Emergency Medicine Wellness Committee.

Background: Physicians and trainees in academic health care settings face unique challenges to maintaining and enhancing their well-being compared to their community practice counterparts. Objective: Our objective was to develop a research agenda focused on well-being, resilience, and career longevity issues specific to practicing emergency medicine in an academic setting. Methods: We convened an expert group of academic emergency physicians prior to the 2018 annual meeting of the Society for Academic Emergency Medicine to determine a set of uniformly accepted research priorities in the field by consensus. Results: Three themes emerged as components of a comprehensive research agenda: 1) origins and natural history of burnout, resilience, well-being and other related concepts; 2) influence of early training and the learning environment; and 3) impact of burnout, attrition, and lack of organizational or system support for wellness on operations. Conclusion: We believe that this agenda will inform future research and effective interventions to support physician and trainee well-being

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\u27s 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

Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL-ED): A Multicenter, Prospective, Observational Study.

BACKGROUND: Contemporary emergency department (ED) standard-of-care treatment of hyperkalemia is poorly described. OBJECTIVE: Our aim was to determine the treatment patterns of hyperkalemia management in the ED. METHODS: This multicenter, prospective, observational study evaluated patients aged ≥ 18 years with hyperkalemia (potassium [K + ] level ≥ 5.5 mmol/L) in the ED from October 25, 2015 to March 30, 2016. K + -lowering therapies and K + were documented at 0.5, 1, 2, and 4 h after initial ED treatment. The primary end point was change in K + over 4 h. RESULTS: Overall, 203 patients were enrolled at 14 U.S.-based sites. The initial median K+ was 6.3 (interquartile range [IQR] 5.7–6.8) mmol/L and median time to treatment was 2.7 (IQR 1.9–3.5) h post-ED arrival. Insulin/glucose (n = 130; 64%) was frequently used to treat hyperkalemia; overall, 43 different treatment combinations were employed within the first 4 h. Within 4 h, the median K + for patients treated with medications alone decreased from 6.3 (IQR, 5.8–6.8) mmol/L to 5.3 (4.8–5.7) mmol/L, while that for patients treated with dialysis decreased from 6.2 (IQR 6.0–6.6) mmol/L to 3.8 (IQR 3.6–4.2) mmol/L. Hypoglycemia occurred in 6% of patients overall and in 17% of patients with K + \u3e 7.0 mmol/L. Hyperkalemia-related electrocardiogram changes were observed in 23% of all patients; 45% of patients with K + \u3e 7.0 mmol/L had peaked T waves or widened QRS. Overall, 79% were hospitalized; 3 patients died. CONCLUSIONS: Hyperkalemia practice patterns vary considerably and, although treatment effectively lowered K + , only dialysis normalized median K + within 4 h