“Breaking” the Emergency Department: Does the Culture of Emergency Medicine Present a Barrier to Self-Care?

Introduction: Our goal was to critically examine emergency physician’s (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following: 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative.Methods: We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a “cut-and-sort” process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation.Results: We identified six themes that represented the pooled outcomes of both resident and faculty focus groups: 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care.Conclusion: The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care

An investigation of the neuroprotective effects of estrogen in a model of quinolinic acid-induced neurodegeneration

The hippocampus, located in the medial temporal lobe, is an important region of the brain responsible for the formation of memory. Thus, any agent that induces stress in this area has detrimental effects and could lead to various types of dementia. Such agents include the neurotoxin, Quinolinic acid. Quinolinic acid (QUIN) is a neurotoxic metabolite of the tryptophan-kynurenine pathway and is an endogenous glutamate agonist that selectively injures and kills vulnerable neurons via the activation of the NMDA class of excitatory amino acid receptors. Estrogen is a female hormone that is responsible for reproduction. However, in the last decade estrogen has been shown to exhibit a wide range of actions on the brain, including neuroprotection. Estrogen has been shown to exhibit intrinsic antioxidant activity and protects cultured neurons against oxidative cell death. This is achieved by estrogen’s ability to scavenge free radicals, which is dependent on the presence of the hydroxyl group at the C3 position on the A ring of the steroid molecule. Numerous studies have shown that estrogen protects neurons against various toxic substances and may play a role in delaying the onset of neurodegenerative diseases, such as Alzheimer’s disease. Neuronal damage due to oxidative stress has been implicated in several neurodegenerative disorders. The detection and measurement of lipid peroxidation is the evidence most frequently cited to support the involvement of free radical reactions in toxicology and in human disease. The study aims to elucidate and further characterise the mechanism behind estrogen’s neuroprotection, using QUIN as a model of neurotoxicity. Initial studies confirm estrogen’s ability to scavenge potent free radicals. In addition, the results show that estrogen forms an interaction with iron (II) and also acts at the NMDA receptor as an agonist. Both mechanisms reduce the ability of QUIN to cause damage to neurons, since QUIN-induced toxicity is dependent on the activation of the NMDA receptor and the formation of a complex with iron (II) to induce lipid peroxidation. Heat shock proteins, especially Hsp 70 play a role in cytoprotection by capturing denatured proteins and facilitating the refolding of these proteins once the stress has been relieved. Estrogen has been shown to increase the level of expression of Hsp70, both inducible and cognate forms of the protein. This suggests that estrogen helps to protect against cellular protein damage induced by any form of stress the cell may encounter. The discovery of neuroprotective agents, such as estrogen, is becoming important as accumulating evidence indicates a protective role in vivo. Thus further research may favour the use of these agents in the treatment of several neurodegenerative disorders. Considering how devastating diseases, such as Alzheimer’s disease, are to a patient and the patient’s families, the discovery of new protective agents are a matter of urgency

#MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment

Introduction: Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians’ experiences with workplace gender discrimination and sexual harassment.Methods: We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians’ experiences using correlation analyses.Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6–6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%-65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%-25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%-43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.Conclusion: Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.

Predictors of non-return to work 2 years post-injury in road traffic crash survivors: results from the UQ SuPPORT study

Individuals who have sustained an injury from a road traffic crash (RTC) are at increased risk for long lasting health problems and non-return to work (NRTW). Determining the predictors of NRTW is necessary to develop screening tools to identify at-risk individuals and to provide early targeted intervention for successful return to work (RTW). The aim of this study was to identify factors that can predict which individuals will not RTW following minor or moderate injuries sustained from a RTC.Participants were 194 claimants (63.4% female) within a common-law "fault-based" system from the UQ SuPPORT cohort who were working prior to their RTC. Participants were assessed at 6 months on a variety of physical and mental health measures and RTW status was determined at 2 years post-RTC. RTW rate was 78.4%.Univariate predictors of NRTW included being the driver or passenger, having a prior psychiatric diagnosis, high disability level, low mental or physical quality of life, predicted non-recovery, high pain, low function, high expectations of pain persistency, low expectations about RTW, having a psychiatric diagnosis, elevated depression or anxiety. The final multivariable logistic regression model included only two variables: disability level and expectations about RTW. Seventy-five percent of individuals who will not RTW by 2 years can be identified accurately at an early stage, using only these two predictors.The results are promising, because they suggest that having information about two factors, which are easily obtainable, can predict with accuracy those who will require additional support to facilitate RTW

Impact of Abamectin on Anagrus Nilaparvatae, an Egg Parasitoid of Nilaparvata Lugens

Anagrus nilaparvatae (Hymenoptera: Mymaridae) is an egg parasitoid potential for controlling the major pests on rice, the brown planthopper (Nilaparvata lugens [Hemiptera: Delphacidae]).Abamectin is one of insecticides registered for N. lugens. The research was aimed to investigate the impact of contact application of abamectin on the parasitism level of A. nilaparvatae under laboratory conditions. Adults of A. nilaparvatae and the first instars as well as adults of N. lugens were exposed to the residue of abamection inside the test tube. A. nilaparvatae was much more susceptible to abamectin compared to N. lugens. Application of abamectin at the recommended concentration (22.78 ppm) for 30 min caused 100% mortality, and it reduced to 85% when the concentration was decreased to 0.36 ppm. In contrast, the mortality for the first instar of N. lugens was only 15% at 22.78 and no mortality at 0.36 ppm. No N. lugens adults died even when they were exposed to 22.78 ppm. Furthermore, the parasitism test was conducted using 38 days after planting of IR-64 rice variety. Those plants were infested with 50 females of N. lugens for 2 days. A. nilaparvatae were exposed by contact to 0.02, 0.23, and 2.28 ppm of abamectin. The survivors were released to the rice plant containing eggs of N. lugens. Contact application of abamectin reduced parasitism level of A. nilaparvatae as much as 86.34, 70.01, and 28.43% with concentrations of 2.28 ppm, 0.23 and 0.02 ppm, respectively. In addition, the number of parasitoids emerged decreased with increasing concentration of abamectin. These results suggest that abamectin could be detrimental to A. nilaparvatae due to direct mortality, reduced the parasitism level, and decreased the number of progeny produced. IntisariAnagrus nilaparvatae (Hymenoptera: Mymaridae) merupakan salah satu parasitoid telur yang berpotensi untuk mengendalikan hama utama tanaman padi, wereng batang padi cokelat (Nilaparvata lugens [Hemiptera: Delphacidae]). Abamektin adalah salah satu insektisida yang terdaftar untuk pengendalian N. lugens. Penelitian ini bertujuan untuk mengetahui dampak aplikasi kontak abamektin terhadap suseptibilitas dan tingkat parasitasi A. nilaparvatae terhadap telur N. lugens pada kondisi laboratorium. Imago A. nilaparvatae serta instar satu dan imago N. lugens dipapar dengan residu abamektin di dalam tabung reaksi. A. nilaparvatae lebih peka terhadap abamektin dibandingkan N. lugens. Aplikasi abamektin pada konsentrasi anjuran (22,78 ppm) selama 30 menit menyebabkan mortalitas A. nilaparvatae 100%, dan mengurangi sampai dengan 85% pada konsentrasi yang lebih rendah 0,36 ppm. Sebaliknya, mortalitas instar satu N. lugens hanya sebesar 15% pada 22,78 ppm dan tidak menimbulkan kematian pada 0,36 ppm. Konsentrasi 22,78 ppm tidak menimbulkan kematian imago N. lugens. Selanjutnya, uji parasitasi dilakukan menggunakan media tanaman padi varietas IR-64 umur 38 hari setelah tanam. Tanaman diinfestasi dengan 50 ekor betina N. lugens selama dua hari. A. nilaparvatae dipapar abamektin dengan metode kontak pada konsentrasi 0.02, 0,23, dan 2,28 ppm. Parasitoid yang mampu bertahan hidup dilepaskan pada tanaman padi yang telah diinfestasi telur N. lugens. Aplikasi kontak abamektin mengurangi tingkat parasitasi A. nilaparvatae sebesar 86,34, 70.01, dan 28,43% pada konsentrasi 2,28; 0,23; dan 0,02 ppm. Selain itu, jumlah parasitoid yang muncul semakin menurun dengan peningkatan konsentrasi abamektin. Hasil ini menunjukkan bahwa abamektin dapat merugikan secara langsung terhadap mortalitas serta mengurangi tingkat parasitasi dan jumlah keturunan A. nilaparvatae

Utilization of Wellness Practices For Burnout and Stress During COVID-19 Among an Interdisciplinary Cohort of Emergency Healthcare Workers

Introduction: The Coronavirus Disease (COVID-19) introduced additional stress to the baseline occupational stressors of emergency care workers. The objectives of this study were to evaluate perceived stress and burnout and the utilization and perceived benefit of wellness practices among emergency healthcare workers (EHCWs), including: emergency physicians, advanced practice providers (APPs), nurses, and departmental administrative staff during the COVID-19 pandemic. Methods: A cross-sectional 28-item electronic survey of EHCWs at three hospitals in a major United States city was used to measure participants’ utilization and perceived benefit of wellness practices, burnout (2-item measure), overall stress (perceived stress scale), and stress related to COVID-19. Results: The sample consisted of 260 respondents (response rate 44.6%, 583 eligible). Over one-half (56.5%) reported burnout from their job and a majority (58.5%) reported moderate to high stress. Wellness activities including regular exercise and engaging in hobbies were associated with lower reports of burnout. Higher stress levels were reported by participants who had tested positive for COVID-19. Nurses reported the highest rates of burnout overall (80.6%). Females reported higher rates of burnout than males across the cohort (64.5 vs 41.9%, p = 0.001), and female APPs reported significantly higher burnout than did male APPs (69.2 vs 38.5%, p = 0.048). Participants reported donated personal protective equipment (PPE) and meals on shift were extremely helpful. Conclusion: The COVID-19 pandemic was a significant contributor to the stress of EHCWs. Regular engagement in wellness activities was associated with lower rates of burnout. The benefit of engagement in wellness practices, both individual practices and organizational interventions are paramount to mitigate stress and burnout in EHCWs

A Comprehensive Residency Wellness Curriculum

Introduction: Resident physician burnout is an epidemic in medical education. There are several wellness curricula published, but few describe a comprehensive program to address wellness. Our objectives were to develop and pilot a longitudinal resident wellness curriculum and assess for feasibility and sustainability. Methods: We surveyed emergency medicine (EM) residents from two residency programs in the United States to assess a baseline level of burnout using the Maslach Burnout Inventory. We developed a comprehensive and longitudinal wellness curriculum for EM residents that incorporated all domains identified by the American College of Emergency Physicians Wellness Wheel. Mindfulness practice was incorporated throughout the curriculum. Results: A convenience sample of 106 EM residents were sent the baseline survey. A response rate of 69% was achieved, the median age of the respondents was 29 years, and 44.5% were female. Overall, 67.5% (95% CI: 50.5; 80.8%) reported burnout in at least one of the three domains of the Maslach Burnout inventory. 34.8% reported burnout in the personal accomplishment domain, 40.8% reported depersonalization, and 44.3% reported emotional exhaustion. The wellness curriculum was successfully implemented at the Georgia-based residency program. The curriculum has proven to be sustainable since it began in 2016. Quantitative statistical testing for the post-intervention survey was not possible due to a low response rate. However, subjective receivability was high, with participants describing these sessions as high-yield, informative and practical. Conclusions: Burnout is highly prevalent among EM residents. We provide a curriculum developed for an EM residency program that is multifaceted and comprehensive, including basic wellness topics, mindfulness, financial and medicolegal issues, as well as topics that address the stresses specific to clinical emergency medicine. The curriculum has been in place in its current form since 2016 and has proven to be sustainable

Rationale and Design of a Remote Web-Based Daily Dairy Study Examining Sexual Minority Stress, Relationship Factors, And Alcohol Use In Same-Sex Female Couples Across the United States: Study Protocol of Project Relate

Background: The Healthy People 2020 initiative aims to reduce health disparities, including alcohol use, among sexual minority women (SMW; eg, lesbian, bisexual, queer, and pansexual). Compared with heterosexual women, SMW engage in more hazardous drinking and report more alcohol-related problems. Sexual minority stress (ie, the unique experiences associated with stigmatization and marginalization) has been associated with alcohol use among SMW. Among heterosexuals, relationship factors (eg, partner violence and drinking apart vs together) have also been associated with alcohol use. Negative affect has also been identified as a contributor to alcohol use. To date, most studies examining alcohol use among SMW have used cross-sectional or longitudinal designs. Objective: Project Relate was designed to increase our understanding of alcohol use among young SMW who are at risk for alcohol problems. The primary objectives of this study are to identify daily factors, as well as potential person-level risk and protective factors, which may contribute to alcohol use in SMW. Secondary objectives include examining other physical and mental concerns in this sample (eg, other substance use, eating, physical activity, and stress). Methods: Both partners of a female same-sex couple (aged 18-35 years; n=150 couples) are being enrolled in the study following preliminary screening by a market research firm that specializes in recruiting sexual minority individuals. Web-based surveys are being used to collect information about the primary constructs of interest (daily experiences of alcohol use, sexual minority stress, relationship interactions, and mood) as well as secondary measures of other physical and mental health constructs. Data are collected entirely remotely from women across the United States. Each member of eligible couples completes a baseline survey and then 14 days of daily surveys each morning. Data will be analyzed using multilevel structural equation modeling. Results: To date, 208 women (ie, 104 couples) were successfully screened and enrolled into the study. In total, 164 women have completed the 14-day daily protocol. Compliance with completing the daily diaries has been excellent, with participants on average completing 92% of the daily diaries. Data collection will be completed in fall 2018, with results published as early as 2019 or 2020. Conclusions: Project Relate is designed to increase our understanding of between- and within-person processes underlying hazardous drinking in understudied, at-risk SMW. The study includes a remote daily diary methodology to provide insight into variables that may be associated with daily hazardous alcohol use. Before the development of programs that address hazardous alcohol use among young SMW, there is a need for better understanding of individual and dyadic variables that contribute to risk in this population. The unique challenges of recruiting and enrolling SMW from across the United States in a daily diary study are discussed