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

A core outcome set for studies of gestational diabetes mellitus prevention and treatment

AIMS/HYPOTHESIS: The aim of this systematic review was to develop core outcome sets (COSs) for trials evaluating interventions for the prevention or treatment of gestational diabetes mellitus (GDM). METHODS: We identified previously reported outcomes through a systematic review of the literature. These outcomes were presented to key stakeholders (including patient representatives, researchers and clinicians) for prioritisation using a three-round, e-Delphi study. A priori consensus criteria informed which outcomes were brought forward for discussion at a face-to-face consensus meeting where the COS was finalised. RESULTS: Our review identified 74 GDM prevention and 116 GDM treatment outcomes, which were presented to stakeholders in round 1 of the e-Delphi study. Round 1 was completed by 173 stakeholders, 70% (121/173) of whom went on to complete round 2; 84% (102/121) of round 2 responders completed round 3. Twenty-two GDM prevention outcomes and 30 GDM treatment outcomes were discussed at the consensus meeting. Owing to significant overlap between included prevention and treatment outcomes, consensus meeting stakeholders agreed to develop a single prevention/treatment COS. Fourteen outcomes were included in the final COS. These consisted of six maternal outcomes (GDM diagnosis, adherence to the intervention, hypertensive disorders of pregnancy, requirement and type of pharmacological therapy for hyperglycaemia, gestational weight gain and mode of birth) and eight neonatal outcomes (birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, neonatal hypoglycaemia, neonatal death and stillbirth). CONCLUSIONS/INTERPRETATION: This COS will enable future GDM prevention and treatment trials to measure similar outcomes that matter to stakeholders and facilitate comparison and combination of these studies. TRIAL REGISTRATION: This study was registered prospectively with the Core Outcome Measures in Effectiveness Trials (COMET) database: http://www.comet-initiative.org/studies/details/686/

Universal genetic screening uncovers a novel presentation of an sdhaf2 mutation

Context: Hereditary pheochromocytoma/paraganglioma (PC/PGL) accounts for up to 60% of previously considered sporadic tumors. Guidelines suggest that phenotype should guide genetic testing. Next-generation sequencing technology can simultaneously sequence 9 of the 18 known susceptibility genes in a timely, cost-efficient manner. Objective: Our aim was to confirm that universal screening is superior to targeted testing in patients with histologically confirmed PC and PGL. Methods: In two tertiary referral hospitals in Ireland, NGS was carried out on all histologically confirmed cases of PC/PGL diagnosed between 2004 and 2013. The following susceptibility genes were sequenced: VHL, RET, SDHA, SDHB, SDHC, SDHD, SDHAF2, TMEM127, and MAX. A multiplex ligation-dependent probe amplification analysis was performed in VHL, SDHB, SDHC, SDHD, and SDHAF2 genes to detect deletions and duplications. Results: A total of 31 patients were tested, 31% (n = 10) of whom were found to have a genetic mutation. Of those patients with a positive genotype, phenotype predicted genotype in only 50% (n = 5). Significant genetic mutations that would have been missed in our cohort by phenotypic evaluation alone include a mutation in TMEM127, two mutations in SDHAF2, and two mutations in RET. Target testing would have identified three of the latter mutations based on age criteria. However, 20% of patients (n = 2) would not have satisfied any criteria for targeted testing including one patient with a novel presentation of an SDHAF2 mutation. Conclusion: This study supports the value of universal genetic screening for all patients with PC/PGL

Vitamin D and SARS-CoV-2 Infection—Evolution of Evidence Supporting Clinical Practice and Policy Development - a Position Statement from the Covit-D Consortium

Abstract Observational ecological and epidemiological studies have suggested increased risks of SARS-CoV-2 infection and severity in groups with high prevalence of vitamin D deficiency (older adults, and those with obesity, pre-existing medical conditions or darker skin). Emerging observational clinical studies have confirmed these associations, reporting higher risk of SARS-CoV-2 infection, severe Covid-19 disease and mortality in those who are vitamin D deplete. Further experimental studies have described the immunological and metabolomic mechanisms by which vitamin D deficiency increases these risks, while recent prospective RCT data have shown reduced Covid-19 disease severity and mortality with vitamin D supplementation, further supporting a causal association. Dietary vitamin D intakes are low (~3-6μg/d (120-240 IU/d)) and sunshine exposure inadequate to achieve optimal vitamin D status in Ireland. Consequently, vitamin D deficiency (serum 25(OH)D\u3c50nmol/l) is common, with roughly half of the adult population, and an even greater proportion of older adults, affected. In Ireland, oral vitamin D intakes of 25-30μg/d (1000-1200 IU/d) are required to maintain serum 25(OH)D levels \u3e50nmol/l on a year round basis. Supplementation with 20-25μg/d (800-1000 IU/d) is therefore required to avoid deficiency and meet the minimum 25(OH)D threshold of 50nmol/l for enhanced immunity to viral respiratory infection. For older adults, and those with obesity, underlying conditions or darker skin, supplementation at higher doses under medical supervision is indicated. Practice and policy development are now required to ensure that Irish adults are supplemented with vitamin D3 at these safe and effective doses to reduce their risks of SARS-CoV-2 infection and severe disease