Accelerated Education Intervention: A Pilot Study to Assess the Effectiveness of a Brief, Self-Paced Intervention to Prevent Burnout in Physician Assistant Students

PURPOSE

Physician assistant (PA) programs have an academically rigorous curriculum, which places a myriad of pressures on students and contributes to burnout. The benefits of optimal quality and quantity of sleep are well documented, yet students still view sacrificing sleep as a necessary step in academic success. The purpose of this pilot study was to create behavior changes to promote optimal sleep hygiene in PA school and decrease measurements of burnout.

METHODS

39 PA students from a single institution volunteered to take part in an 8-week study. Wrist actigraphy was used to measure students' sleeping habits, resting heart rate, and physical activity. Additionally, the students completed a questionnaire regarding stimulant and sleep aid use and burnout (Maslach Burnout Inventory) at two time points. The intervention was 8 weeks in duration split into 2, 4-week blocks separated by a 1-hour, evidence-based education intervention to promote beneficial behavior change and sleep hygiene.

RESULTS

Sleep duration, wake time, and bedtime remained consistent across the study period with no changes post-intervention (p > 0.05). Moderate to high levels of cynicism and emotional exhaustion were seen in more than three-quarters of students. There was no relationship between sleep duration and exam scores, heart rate, or steps. Shorter sleep duration predicted increased emotional exhaustion and cynicism (p < 0.05).

CONCLUSION

Sleeping habits influence emotional well-being and are likely minimally affected by educational interventions alone. Combatting the high prevalence of burnout in PA schools can begin with targeting environmental and policy-level changes that can influence student recovery and well-being opportunities throughout the academic year.

Diabetes, Aging, and Insulin's Reponic Features: Review

The aging process and the concomitant physiological changes that come with increasing age have been a focus of researchers and the general population for centuries. The pursuit of knowledge and understanding of the aging process was famously articulated by Aristotle, stating, "education is the best provision for old age." This remains true today in our quest to understand the physiological underpinnings of aging and the incessant attempt to slow or reverse many of the processes. The need to understand normal aging physiology is important to guide future targeted interventions to promote autonomy and prevent impairment of functioning. The risk of frailty, "vulnerability to stressors" and impaired or decreased functioning of a multitude of body systems is a major public health consideration for adults 65 years or older [1]. While there has been a plethora of research on the aging effects of different systems throughout the body, the following literature review will focus on our recent understanding of the components of nutrient handling, specifically the endocrine system in older adults. By understanding the normal physiological changes that occur in response to nutrients, future interventions can be targeted to promote an extension of optimal functioning throughout the lifespan. The endocrine system is responsible for directing and controlling many homeostatic pathways within the body and many of those pathways begin with nutrient intake. The endocrine system is composed of a convoluted, complicated, and interconnected network of pathways that determine important mechanistic actions occur such as growth, development, energy storage, cell differentiation, and cell death and recycling. Regarding nutrient intake, the pancreas represents one of the first hormonal decision-makers. Notably, the pancreas responds to nutrient intake by releasing insulin in response to the macronutrient composition of the ingested food. The physiological response of the pancreas to nutrient intake is critical throughout the lifespan to maintain glucose homeostasis and ensure adequate energy storage in the body. The normal physiological aging process has the potential to impact the efficiency of this system and therefore impact many of the downstream features of insulin and the pancreatic response to nutrients. The following literature review will detail the normal physiological action of the pancreas in response to nutrient intake and describe nutrient handling in aging. Then, extend the findings into the aging process to provide insight for future interventions aimed at prolonging the optimal functioning of the endocrine system.

An Ergogenic Medical Education: Building Curricula to Optimize Performance and Decrease Burnout

One of the most pervasive myths in our culture today is the belief that training increases performance. When, in fact, training decreases performance. The current structure of training programs and educational curriculums provide the evidence regarding the acceptance of this belief. Intense focus is placed on the quantity of training time with little regard for additional factors. In pursuit of excellence, maximizing training opportunity and learning exposure insists upon the sacrifice of recovery time. However, recovery is the necessary training period to increase performance. In athletics, training without recovery leads to overtraining syndrome. Burnout is the non-athletic equivalency seen in under-recovered learners and workers. As demonstrated by the climbing burnout rates, the current structure of educational programs, epitomized by medical residency, perpetuates the myth that more training equals better performance. The purpose of the article does not revolve around the presentation of novel research discoveries, but it insists upon the implementation of previously established performance data in curricula development beyond athletics. The inflection and deflection points along the growth and adaptation curves can be explicitly utilized to meet the educational and professional standards set forth by educational institutions. When tracking performance as the metric, initial training stimuli creates a descending slope, e.g., "training decreases performance." The concept that training creates a negative deflection is a neglected concept in academics. By incorporating this feature into learning environments, training can transition from surviving training redundancy to thriving with an optimal work:recovery ratio.

Including sheath effects in the interpretation of planar retarding potential analyzer's low-energy ion data

The interpretation of planar retarding potential analyzers (RPA) during ionospheric sounding rocket missions requires modeling the thick 3D plasma sheath. This paper overviews the theory of RPAs with an emphasis placed on the impact of the sheath on current-voltage (I-V) curves. It then describes the Petite Ion Probe (PIP) which has been designed to function in this difficult regime. The data analysis procedure for this instrument is discussed in detail. Data analysis begins by modeling the sheath with the Spacecraft Plasma Interaction System (SPIS), a particle-in-cell code. Test particles are traced through the sheath and detector to determine the detector's response. A training set is constructed from these simulated curves for a support vector regression analysis which relates the properties of the I-V curve to the properties of the plasma. The first in situ use of the PIPs occurred during the MICA sounding rocket mission which launched from Poker Flat, Alaska in February of 2012. These data are presented as a case study, providing valuable cross-instrument comparisons. A heritage top-hat thermal ion electrostatic analyzer, called the HT, and a multi-needle Langmuir probe have been used to validate both the PIPs and the data analysis method. Compared to the HT, the PIP ion temperature measurements agree with a root-mean-square error of 0.023 eV. These two instruments agree on the parallel-to-B plasma flow velocity with a root-mean-square error of 130 m/s. The PIP with its field of view aligned perpendicular-to-B provided a density measurement with an 11% error compared to the multi-needle Langmuir Probe. Higher error in the other PIP's density measurement is likely due to simplifications in the SPIS model geometry.

Refill adherence by the elderly for asthma/chronic obstructive pulmonary disease drugs dispensed over a 10-year period

OBJECTIVE

The objective was to survey prescription refill adherence for preventive asthma/chronic obstructive pulmonary disease (COPD) medication dispensed to patients 60 years and older over a 10-year period.

METHODS

A retrospective analysis was conducted based on a Swedish pharmacy record database in the county of Jämtland for the years 1994-2003. Satisfactory refill adherence was set as dispensed refills covering 80-120% of the prescribed treatment time for inhaled corticosteroids, combination products of adrenergics and steroids and anticholinergics.

RESULTS AND DISCUSSION

Only 28% (n=160) of the repeat prescriptions for inhaled corticosteroids had been dispensed with a satisfactory refill adherence, 59% showed an undersupply and 12% showed an oversupply. There was no difference in refill adherence in relation to age and gender. However, during the 10-year study period repeat prescriptions being dispensed for 2-4 years showed higher satisfactory refill adherence than those being dispensed for <2 years.

CONCLUSIONS

Our study shows that over half of the repeat prescriptions for inhaled corticosteroids dispensed to patients over 60 years showed an undersupply. Therefore, it is likely that elderly patients on long-term therapy have a non-optimal drug use of their preventive asthma/COPD medication.

Refill adherence to repeat prescriptions of cancer drugs to ambulatory patients

The objective was to study the refill adherence among ambulatory patients with prescribed cancer drugs. The study was based on copies of repeat prescriptions, which were collected at three large Swedish pharmacies during the last 3 months of 2004. Copies of 141 repeat prescriptions were analysed. There was no statistical significant difference between the number of patients with undersupply of cancer drugs (i.e. <80% of prescribed cancer drugs) and that of patients with undersupply of all other drugs, or between the number of patients with oversupply of cancer drugs (>120% of prescribed cancer drugs) and that of patients with oversupply of all other drugs. Undersupply of drugs was found among 14% of the patients. The median treatment gap for these patients was 39 (range 29-49 days) per 98-100 days of prescribed treatment time, meaning that the undersupply leads to treatment gaps that may jeopardize their therapeutic outcome. It is reasonable to expect that more seriously ill patients would be adherent to prescribed medication, and consequently that cancer patients would have high adherence. However, our data show that cancer patients on oral long-term treatment have a non-adherence similar to that of patients in general.

The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study

We quantified the accuracy of trained nurses to correctly assess the pre-operative health status of surgical patients as compared to anaesthetists. The study included 4540 adult surgical patients. Patients' health status was first assessed by the nurse and subsequently by the anaesthetist. Both needed to answer the question: 'is this patient ready for surgery without additional work-up, Yes/No?' (primary outcome). The secondary outcome was the time required to complete the assessment. Anaesthetists and nurses were blinded for each other's results. The anaesthetists' result was the reference standard. In 87% of the patients, the classifications by nurses and anaesthetists were similar. The sensitivity of the nurses' assessment was 83% (95% CI: 79-87%) and the specificity 87% (95% CI: 86-88%). In 1.3% (95% CI: 1.0-1.6%) of patients, nurses classified patients as 'ready' whereas anaesthetists did not. Nurses required 1.85 (95% CI: 1.80-1.90) times longer than anaesthetists. By allowing nurses to serve as a diagnostic filter to identify the subgroup of patients who may safely undergo surgery without further diagnostic workup or optimisation, anaesthetists can focus on patients who require additional attention before surgery.

Preoperative prediction of severe postoperative pain

We developed and validated a prediction rule for the occurrence of early postoperative severe pain in surgical inpatients, using predictors that can be easily documented in a preoperative setting. A cohort of surgical inpatients (n=1416) undergoing various procedures except cardiac surgery and intracranial neurosurgery in a University Hospital were studied. Preoperatively the following predictors were collected: age, gender, type of scheduled surgery, expected incision size, blood pressure, heart rate, Quetelet index, the presence and severity of preoperative pain, health-related quality of life the (SF-36), Spielberger's State-Trait Anxiety Inventory (STAI) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The outcome was the presence of severe postoperative pain (defined as Numeric Rating Scale > or =8) within the first hour postoperatively. Multivariate logistic regression in combination with bootstrapping techniques (as a method for internal validation) was used to derive a stable prediction model. Independent predictors of severe postoperative pain were younger age, female gender, level of preoperative pain, incision size and type of surgery. The area under the receiver operator characteristic (ROC) curve was 0.71 (95% CI: 0.68-0.74). Adding APAIS scores (measures of preoperative anxiety and need for information), but not STAI, provided a slightly better model (ROC area 0.73). The reliability of this extended model was good (Hosmer and Lemeshow test p-value 0.78). We have demonstrated that severe postoperative pain early after awakening from general anesthesia can be predicted with a scoring rule, using a small set of variables that can be easily obtained from all patients at the preoperative visit. Before this internally validated preoperative prediction rule can be applied in clinical practice to support anticipatory pain management, external validation in other clinical settings is necessary.

Randomized controlled trial of total intravenous anesthesia with propofol versus inhalation anesthesia with isoflurane-nitrous oxide: postoperative nausea with vomiting and economic analysis

BACKGROUND

To assess the incidence of postoperative nausea and vomiting after total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide, the authors performed a randomized trial in 2,010 unselected surgical patients in a Dutch academic institution. An economic evaluation was also performed.

METHODS

Elective inpatients (1,447) and outpatients (563) were randomly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air. Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers. Cost data of anesthetics, antiemetics, disposables, and equipment were collected. Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed.

RESULTS

Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15% among inpatients (from 61% to 46%, P < 0.001) and by 18% among outpatients (from 46% to 28%, P < 0.001). This effect was most pronounced in the early postoperative period. The cost of anesthesia was more than three times greater for propofol TIVA. Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for inpatients (P < 0.001) and 160 min after isoflurane versus 150 min after TIVA for outpatients (P = 0.039). Duration of hospitalization was equal in both arms.

CONCLUSION

Propofol TIVA results in a clinically relevant reduction of postoperative nausea and vomiting compared with isoflurane-nitrous oxide anesthesia (number needed to treat = 6). Both anesthetic techniques were otherwise similar. Anesthesia costs were more than three times greater for propofol TIVA, without economic gains from shorter stay in the postanesthesia care unit

Orientational research into dismissed managers in health care

The importance of the competence of managers is illustrated by findings of provisional research conducted on the failure of managers in health care (15 case studies of dismissed managers in hospitals, nursing homes, and convalescent homes). The first guarded conclusion that may be drawn from the preliminary study is that, as a rule, the dismissal is based on the attitude and competence of the manager ("software") and not on business expertise or technical skill ("hardware"). It could be said that the manager in health care is judged more on the process than the results.

Small-bowel obstruction caused by heterotopic pancreas in an adult

Aberrant pancreatic tissue has been found in several abdominal and intrathoracic locations, most frequently in the stomach or duodenum. Heterotopic pancreas in the jejunum or ileum is a rare, usually asymptomatic, incidental finding. A review of the English language literature since 1950 shows only one pediatric and one adult case of heterotopic pancreas causing small bowel intussusception. The authors report a case of ileo-ileal intussusception caused by a submucosal mass of aberrant pancreatic tissue that remained undetected during several diagnostic tests and two laparotomies.

Preservation of dog liver, kidney, and pancreas using the Belzer-UW solution with a high-sodium and low-potassium content

The UW solution developed for cold storage of the liver, pancreas, and kidney was used in a modified form in this study and tested in the orthotopic transplantation of dog livers, kidneys, and pancreases preserved for 48 hr. The modification was the alteration of the concentrations of potassium and sodium. The original UW solution contained 120 mM K+ and 30 mM Na+. In this study the Na+ was 140 mM and the K+ only 9 mM, all other agents were identical to the original UW solution. Six of 11 dogs survived with livers preserved for 48 hr. The five deaths were due to technical complications and unrelated to preservation failure. Postoperative AST and partial thromboplastin time (PTT) values were lower (statistically significant on days 1, 3, and 4) in livers preserved in the high Na+ UW solution than as previously shown in the high-k+ UW solution. Other measures of liver function (bilirubin and fibrinogen) were similar between the high-Na+ and high-K+ groups. Six dogs survived with kidneys preserved for 48 hr in the high-Na+ UW solution. The results were comparable to those obtained with the high K+ solution. Four of six dogs survived for up to 28 days with pancreases preserved for 48 hr. The two deaths were due to technical complications unrelated to preservation failure. Three of the four dogs had normal blood glucose values for one month, and intravenous glucose tolerances test on day 7 and 28 were identical to those obtained in pancreases preserved with the high-K+ UW solution. The high-Na+ version of the UW solution appears equally or slightly more effective for 48-hr organ preservation than the original high-K+ UW solution. The use of a high-Na+ UW solution reduces the problems of hyperkalemic cardiac arrest in in situ flushing of the donor for multiple organ harvesting and in transplantation of the liver. Thus, with this solution livers do not need to be flushed with a low K+-containing solution prior to transplantation.

Preservation of the canine liver for 24-48 hours using simple cold storage with UW solution

The results of a series of 29 orthotopic liver transplants in the dog are described. The livers were preserved in a new cold storage fluid, UW solution, and were successfully transplanted after periods of storage of 24, 30, 36, and 48 hr. All six animals transplanted after 24 hr survived beyond 5 days after transplantation and had excellent graft function. Four of six survived for at least 5 days after 30 hr of cold storage, and five of five after 36 hr. Five of six consecutive dogs that received transplants that had been cold-stored for 48 hr survived for 5 or more days. This solution represents a substantial advance over all existing cold storage solutions for liver preservation.