Suicidal ideation, perception of personal safety, and career regret among emergency medicine residents during the COVID-19 pandemic

Objectives

The COVID-19 pandemic was disruptive for trainees and may have affected career decisions for some learners. This study examined the impact of the pandemic on emergency medicine (EM) resident perceptions of their mental health, perceptions of personal safety, and career choice regret.

Methods

This was a cross-sectional survey study administered following the 2021 American Board of Emergency Medicine In-Training Examination (ITE). Survey measures included suicidal ideation (SI), COVID concerns in terms of infection prevention and control (IPC) training, COVID risk to self and/or COVID risk to family, and COVID-related career regret. COVID concerns were compared by gender and race/ethnicity using Pearson's chi-square tests. Multivariable logistic regression models were used to test the association between SI and COVID concerns, resident characteristics, and program characteristics.

Results

A total of 6980 out of 8491 EM residents (82.2%) from 244 programs completed the survey. Only 1.1% of participants reported insufficient training in COVID IPC practices. Participants were concerned about COVID risk to themselves (40.3%) and to their families (63.3%) due to their job roles. These concerns were more common among women or nonbinary (vs. men); all other races/ethnicities (vs. non-Hispanic Whites); senior residents (vs. PGY-1, PGY-2 residents); and residents who were married or in relationships (vs. single or divorced). A total of 6.1% of participants reported that COVID made them reconsider choosing EM as their career. Career regret in this cohort was higher than that in the proportion (3.2%) expressing career regret in the 2020 ITE (p < 0.001). Career regret was more common among women or nonbinary (vs. men); all other races/ethnicities (vs. non-Hispanic Whites); and senior residents (vs. PGY-1, PGY-2 residents). The overall SI rate was 2.6%, which did not differ from that of the 2020 sample of EM residents (2.5%, p = 0.88).

Conclusions

Many EM residents reported concerns about COVID risks to themselves and their families. Although the rate of SI remained unchanged, more EM residents reported career regret during the COVID pandemic.

"Cold feet": A qualitative study of medical students who seriously considered emergency medicine but chose another specialty

Introduction

Emergency medicine (EM) has historically been among the most competitive specialties in the United States. However, in 2022 and 2023, 219 of 2921 and 554 of 3010 respective National Resident Matching Program positions were initially unfilled. Medical students' selection of a medical specialty is a complex process. To better understand recent trends in the EM residency match, this qualitative study explored through one-on-one interviews the rationale of senior medical students who seriously considered EM but ultimately pursued another specialty.

Methods

A convenience sample of senior medical students from across the United States was recruited via multiple mechanisms after the 2023 match. Participant characteristics were collected via an online survey. Qualitative data were generated through a series of one-on-one semistructured interviews and thematic analysis of the data was performed using a constant comparative approach.

Results

Sixteen senior medical students from 12 different institutions participated in the study. Thematic saturation was reached after 12 interviews but data from all 16 interviews were included for qualitative analyses. Five major themes emerged as important in students' consideration but ultimate rejection of EM as a career: (1) innate features of EM attracted or dissuaded students, (2) widespread awareness of a recent workforce report, (3) burnout in EM, (4) their perception of EM's standing in the health care landscape, and (5) early EM experience and exposure.

Conclusions

This qualitative study identified five major themes in the career decisions of senior medical students who seriously considered EM but chose another specialty. These findings may help inform the perceptions of students and guide future EM recruitment efforts.

Prospective validity evidence for the abbreviated emergency medicine Copenhagen Burnout Inventory

BACKGROUND

Prior research has provided retrospective validity evidence for an abbreviated Copenhagen Burnout Inventory (CBI) to measure burnout among emergency medicine (EM) residents. We sought to provide additional validity and reliability evidence for the two-factor, six-item abbreviated CBI.

METHODS

This cross-sectional study used data from the abbreviated CBI that was administered following the 2022 American Board of Emergency Medicine In-training Examination. Confirmatory factor analysis (CFA) was performed and the prevalence of burnout among EM residents was determined.

RESULTS

Of the 8918 eligible residents, 7465 (83.7%) completed the abbreviated CBI. CFA confirmed the previously developed model of two factors using six items answered with a 1- to 5-point Likert scale. The internal factor was derived from personal and work-related burnout and the external factor was related to caring for patients. The reliability was determined using Cronbach's alpha (0.87). The overall prevalence of burnout was 49.4%; the lowest prevalence was at the EM1 level (43.1%) and the highest was at the EM2 level (53.8%).

CONCLUSIONS

CFA of the abbreviated CBI demonstrated good reliability and model fit. The two-factor, six-item survey instrument identified an increase in the prevalence of burnout among EM residents that coincided with working in the COVID-19 environment. The abbreviated CBI has sufficient reliability and validity evidence to encourage its broader use.

From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout

PURPOSE

Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice.

METHOD

The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated.

RESULTS

The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict.

CONCLUSIONS

I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.

Burnout and Workplace Incivility Among Emergency Medical Services Practitioners: A Preliminary Report

OBJECTIVE

Burnout has detrimental consequences for health care organizations, clinicians, and the quality of care that patients receive. Prior work suggests that workplace incivility (negative interpersonal acts) contributes to burnout. While workplace incivility is linked to EMS practitioner job dissatisfaction, absenteeism, and planned attrition, the relationship between workplace incivility and burnout has not been evaluated among EMS practitioners. This study aimed to characterize the prevalence and association of burnout and workplace incivility among EMS practitioners.

METHODS

A cross-sectional survey of EMS personnel in King County, Washington was performed in January to March of 2021 with burnout as the primary outcome and workplace incivility as a secondary outcome. Multivariable logistic regression was used to evaluate associations between outcomes and EMS practitioner factors that included age, sex, race/ethnicity, years of EMS experience, and current job role.

RESULTS

835 completed surveys were received (response rate 25%). The prevalence of burnout was 39.2%. Women were more likely to have burnout than men (59.3% vs. 33.7%, aOR 2.2, 95% CI 1.3-3.7). Workplace incivility was experienced weekly by 32.1% of respondents, with women more likely to experience incivility compared to men (41.9% vs. 27.2%, aOR 2.0, 95% CI 1.2-3.3). Respondents who experienced frequent workplace incivility were more likely to have burnout than those who did not experience frequent incivility (61.9% vs. 38.1%, OR 4.0, 95% CI 3.0-5.5).

CONCLUSIONS

The prevalence of burnout and workplace incivility were concerning among EMS practitioners, with women more likely to experience both compared to men. EMS practitioners who experienced frequent workplace incivility were also more likely to have burnout than those who did not experience frequent incivility.

Workplace Mistreatment, Career Choice Regret, and Burnout in Emergency Medicine Residency Training in the United States

STUDY OBJECTIVE

The influence of workplace mistreatment on the well-being and career satisfaction of emergency medicine residents is unknown. This study examined the relationships between burnout, career choice regret, and workplace mistreatment in a national sample of emergency medicine residents.

METHODS

This was a secondary analysis of a survey study on the prevalence of workplace mistreatment among emergency residents. Residents who reported emotional exhaustion or depersonalization at least once per week were considered to have burnout. Residents who reported dissatisfaction with their decision to become an emergency physician were considered to have career choice regret. Respondents also reported the type (discrimination, abuse, sexual harassment) and frequency of mistreatment over the academic year. Multivariable logistic regression, adjusting for program characteristics, was used to examine resident characteristics associated with burnout and career choice regret, with the frequency of mistreatment as a covariate.

RESULTS

Of the 8,162 eligible residents, 7,680 (94.1 %) participated. About a third of respondents reported burnout (2,188 of 6,902, 31.7%), whereas a minority (224 of 6,923, 3.2%) reported career choice regret. Of the 7,087 responses on mistreatment frequency, 2,117 (29.9%) reported "a few times per year," and 1,296 (18.3%) reported "a few times per month or more." Compared with residents who never experienced mistreatment, residents who reported increasing frequencies of mistreatment were associated with having burnout-from mistreatment a few times per year (OR [odds ratio],1.6; 99% CI [confidence interval], 1.3 to 1.9) to a few times per month or more (OR, 3.3; 99% CI, 2.7 to 4.1). Compared with residents without burnout, residents who reported burnout were associated with having career choice regret (OR, 11.3; 99% CI, 7.0 to 18.1). After adjusting for burnout, there were no significant relationships between the frequency of mistreatment and career choice regret.

CONCLUSIONS

Workplace mistreatment is associated with burnout, but not career choice regret, among emergency medicine residents. Efforts to address workplace mistreatment may improve emergency medicine residents' professional well-being.

"Going through the motions": A qualitative exploration of the impact of emergency medicine resident burnout on patient care

Objectives

Burnout occurs frequently in emergency medicine (EM) residents and has been shown to have a negative impact on patient care. The specific effects of burnout on patient care are less well understood. This study qualitatively explores how burnout may change the way EM residents provide patient care.

Methods

Qualitative data were obtained from a sample of 29 EM residents in four semistructured focus groups across four institutions in the United States in early 2019. Transcripts were coded and organized into major patient care themes.

Results

Residents described many ways in which feelings of burnout negatively impacted patient care. These detrimental effects most often fit into one of four main themes: reduced motivation to care for patients, poor communication with patients, difficult interactions with health care colleagues, and impaired decision making.

Conclusions

According to EM residents, burnout negatively impacts several important aspects of patient care. Resident engagement with clinical care, communication with patients and colleagues, and clinical care may suffer as a result of burnout.

Factors driving burnout and professional fulfillment among emergency medicine residents: A national wellness survey by the Society for Academic Emergency Medicine

OBJECTIVES

This study aimed to identify rates of and contributors to burnout and professional fulfillment among emergency medicine (EM) resident physicians.

METHODS

This was a cross-sectional, national survey of resident members of the Society for Academic Emergency Medicine (SAEM). Primary outcomes were burnout and professional fulfillment measured using a previously validated instrument with additional domains pertaining to the academic environment. The survey included question domains examining organizational factors (e.g., academic work environment, satisfaction with training, electronic health records, values alignment, and control over schedule) and individual factors (e.g., self-compassion, meaningfulness of clinical work, impact of work on health and personal relationships, perceived appreciation, thoughts of attrition, and expectations of the field of EM). Logistic regression was performed to determine the relationships between the primary outcomes and each domain.

RESULTS

The survey was sent electronically to 2641 SAEM resident members. A total of 275 residents completed the survey with a response rate of 10.4%. A total of 151 (55%) respondents were male, and 210 (76%) were White. A total of 132 (48%) residents reported burnout, and 75 (28%) reported professional fulfillment. All organizational and individual factors were significantly associated with both primary outcomes. EM residents reported that meaningfulness of clinical work had the most significant positive association with professional fulfillment (adjusted odds ratio [OR] 2.2 [95% confidence interval {CI} 1.8-2.7]) and negative association with burnout (adjusted OR 0.46 [95% CI 0.37-0.56]). Thoughts of attrition from academics and accurate expectations of EM were also associated with both primary outcomes, with adjusted ORs (95% CIs) of 0.40 (0.21-0.72) and 5.6 (1.9-23.8) for professional fulfillment and 4.1 (2.5-7.1) and 0.19 (0.08-0.40) for burnout, respectively.

CONCLUSIONS

This study found a high prevalence of burnout and a low prevalence of professional fulfillment among EM residents. Multiple factors were significantly associated with each occupational phenomenon, with meaningfulness of clinical work demonstrating the strongest relationships with burnout and professional fulfillment.

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's 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.

Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US

IMPORTANCE

The prevalence of workplace mistreatment and its association with the well-being of emergency medicine (EM) residents is unclear. More information about the sources of mistreatment might encourage residency leadership to develop and implement more effective strategies to improve professional well-being not only during residency but also throughout the physician's career.

OBJECTIVE

To examine the prevalence, types, and sources of perceived workplace mistreatment during training among EM residents in the US and the association between mistreatment and suicidal ideation.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study conducted from February 25 to 29, 2020, all residents enrolled in EM residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) who participated in the 2020 American Board of Emergency Medicine computer-based In-training Examination were invited to participate. A multiple-choice, 35-item survey was administered after the examination asking residents to self-report the frequency, sources, and types of mistreatment experienced during residency training and whether they had suicidal thoughts.

MAIN OUTCOMES AND MEASURES

The types and frequency of workplace mistreatment and the sources of the mistreatment were identified, and rates of self-reported suicidality were obtained. Multivariable logistic regression models were used to examine resident and program characteristics associated with suicidal thoughts.

RESULTS

Of 8162 eligible EM residents, 7680 (94.1%) responded to at least 1 question on the survey; 6503 (79.7%) completed the survey in its entirety. A total of 243 ACGME-accredited residency programs participated, and 1 did not. The study cohort included 4768 male residents (62.1%), 2698 female residents (35.1%), 4919 non-Hispanic White residents (64.0%), 2620 residents from other racial/ethnic groups (Alaska Native, American Indian, Asian or Pacific Islander, African American, Mexican American, Native Hawaiian, Puerto Rican, other Hispanic, or mixed or other race) (34.1%), 483 residents who identified as lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) (6.3%), and 5951 residents who were married or in a relationship (77.5%). Of the total participants, 3463 (45.1%) reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) during the most recent academic year. A frequent source of mistreatment was identified as patients and/or patients' families; 1234 respondents (58.7%) reported gender discrimination, 867 (67.5%) racial discrimination, 282 (85.2%) physical abuse, and 723 (69.1%) sexual harassment from patients and/or family members. Suicidal thoughts occurring during the past year were reported by 178 residents (2.5%), with similar prevalence by gender (108 men [2.4%]; 59 women [2.4%]) and race/ethnicity (113 non-Hispanic White residents [2.4%]; 65 residents from other racial/ethnic groups [2.7%]).

CONCLUSIONS AND RELEVANCE

In this survey study, EM residents reported that workplace mistreatment occurred frequently. The findings suggest common sources of mistreatment for which educational interventions may be developed to help ensure resident wellness and career satisfaction.

"Pulling the Parachute": A Qualitative Study of Burnout's Influence on Emergency Medicine Resident Career Choices

OBJECTIVES

About half of all resident physicians report symptoms of burnout. Burnout negatively influences multiple aspects of their education and training. How burnout may impact residents' career choices remains unclear. The authors explored the role burnout played in residents' career decisions.

METHODS

This was a qualitative study among a sample of 29 emergency medicine residents from four institutions. Qualitative data were generated through four semistructured focus groups. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major themes.

RESULTS

Five major themes connecting burnout with residents' career choices emerged: 1) residents' current burnout and the prevention of future burnout figured prominently in their career considerations, 2) residents aimed to mitigate sources of burnout through their career choices, 3) residents' view of clinical work as a burden and a burnout contributor spurred the pursuit of other interests, 4) faculty advice and role modeling in relation to burnout shaped residents' career perspectives, and 5) residents weighed long-term burnout concerns with short-term financial needs.

CONCLUSION

Burnout played an important role in multiple aspects of residents' career considerations. Educators, program directors, and organization leaders can focus on identified target areas to address burnout's influence on residents' career decisions.

"Necessary Compromises": A Qualitative Exploration of the Influence of Burnout on Resident Education

OBJECTIVE

Burnout is prevalent among resident physicians and has a negative impact on their well-being and effectiveness at work. How burnout shapes residents' educational experiences, attitudes, habits, and practices is not well understood. There is also a lack of research regarding self-identified mitigation strategies for residents. The authors qualitatively explored burnout's role in the educational experiences of resident physicians.

METHODS

Qualitative data were generated from a sample of 29 emergency medicine residents through four semistructured focus groups across four institutions in January and February 2019. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major and minor themes.

RESULTS

Residents reported that a misalignment of their individual versus institutional priorities and a lack of agency were significant contributors to their burnout. Residents described how burnout affected multiple aspects of their education, including their motivation and curiosity to learn, engagement in scholarly activity, and teaching of others. Residents identified several ways of building a sense of community that they explained was most useful in mitigating their experiences with burnout.

CONCLUSION

Burnout had a negative influence on many facets of residents' educational experiences during training. Program directors and educators can take resident-identified steps to moderate its detrimental role on trainee education.

Academic Emergency Medicine Faculty Experiences with Racial and Sexual Orientation Discrimination

INTRODUCTION

Despite the increasing diversity of individuals entering medicine, physicians from racial and sexual minority groups continue to experience bias and discrimination in the workplace. The objective of this study was to determine the current experiences and perceptions of discrimination on the basis of race and sexual orientation among academic emergency medicine (EM) faculty.

METHODS

We conducted a cross-sectional survey of a convenience sample of EM faculty across six programs. Survey items included the Overt Gender Discrimination at Work (OGDW) Scale adapted for race and sexual orientation, and the frequency and source of experienced and observed discrimination. Group comparisons were made using t-tests or chi-square analyses, and relationships between race or sexual orientation, and we evaluated physicians' experiences using correlation analyses.

RESULTS

A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Non-White physicians reported higher mean racial OGDW scores than their White counterparts (13.4 vs 8.6; 95% confidence interval (CI) for difference, -7.7 - -2.9). Non-White EM faculty were also more likely to report having experienced discriminatory treatment based on race than were White EM faculty (48.0% vs 12.6%; CI for difference, 16.6% - 54.2%), although both groups were equally likely to report having observed race-based discrimination of another physician. EM faculty who identified as sexual minorities reported higher mean sexual minority OGDW scores than their heterosexual counterparts (11.1 vs 7.1; 95% CI for difference, -7.3 - -0.6). There were no significant differences between sexual minority and heterosexual faculty in their reports of experiencing or observing discrimination based on sexual orientation.

CONCLUSION

EM faculty from racial and sexual minority groups perceived more discrimination based on race or sexual orientation in their workplace than their majority counterparts. EM faculty regardless of race or sexual orientation were similar in their observations of discriminatory treatment of another physician based on race or sexual orientation.

The Implementation of a National Multifaceted Emergency Medicine Resident Wellness Curriculum Is Not Associated With Changes in Burnout

BACKGROUND

The Accreditation Council for Graduate Medical Education Common Program Requirements effective 2017 state that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence.

OBJECTIVES

The authors sought to determine if the implementation of a multifaceted wellness curriculum improved resident burnout as measured by the Maslach Burnout Inventory (MBI).

METHODS

We performed a multicenter educational interventional trial at 10 emergency medicine (EM) residencies. In February 2017, we administered the MBI at all sites. A year-long wellness curriculum was then introduced at five intervention sites while five control sites agreed not to introduce new wellness initiatives during the study period. The MBI was readministered in August 2017 and February 2018.

RESULTS

Of 523 potential respondents, 437 (83.5%) completed at least one MBI assessment. When burnout was assessed as a continuous variable, there was a statistically significant difference in the depersonalization component favoring the control sites at the baseline and final survey administrations. There was also a higher mean personal accomplishment score at the control sites at the second survey administration. However, when assessed as a dichotomous variable, there were no differences in global burnout between the groups at any survey administration and burnout scores did not change over time for either control or intervention sites.

CONCLUSIONS

In this national study of EM residents, MBI scores remained stable over time and the introduction of a multifaceted wellness curriculum was not associated with changes in global burnout scores.

#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.

Why Residents Quit: National Rates of and Reasons for Attrition Among Emergency Medicine Physicians in Training

Introduction

Recruiting and retaining residents who will complete their emergency medicine (EM) training is vital, not only because residency positions are a limited and costly resource, but also to prevent the significant disruptions, increased workload, and low morale that may arise when a resident prematurely leaves a program. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition.

Methods

In this retrospective, observational study we used national data from the American Medical Association National Graduate Medical Education Census for all residents who entered Accreditation Council for Graduate Medical Education-accredited EM programs between academic years 2006–2007 and 2015–2016. Our main outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main reason for attrition as well as resident factors associated with attrition.

Results

Compared to the other 10 largest specialties, EM had the lowest rate of attrition (0.8%, 95% confidence interval [CI] [0.7–0.9]), or approximately 51.6 (95% CI [44.7–58.5]) residents per year. In the attrition population, 44.2% of the residents were women, a significantly higher proportion when compared to the proportion of female EM residents overall (38.8%, p=0.011). A greater proportion of Hispanic/Latino (1.8%) residents also left their programs when compared to their White (0.9%) counterparts (p<0.001). In examining reasons for attrition as reported by the program director, female residents were significantly more likely than male residents to leave due to “health/family reasons” (21.5% vs 9.6%, p=0.019).

Conclusion

While the overall rate of attrition among EM residents is low, women and some under-represented minorities in medicine had a higher than expected rate of attrition. Future studies that qualitatively investigate the factors contributing to greater attrition among female and some ethnic minority residents are necessary to inform efforts promoting inclusion and diversity within the specialty.

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.

Emergency Medicine Trainee Burnout Is Associated With Lower Patients' Satisfaction With Their Emergency Department Care

INTRODUCTION

Emergency medicine (EM) physicians and trainees report high levels of burnout. Burnout negatively impacts physician well-being and career satisfaction but it remains unclear how burnout may influence patient care. We examined the degree to which EM trainee burnout at one institution was associated with patients' satisfaction with their emergency department (ED) care.

METHODS

In this cross-sectional, pilot study conducted at a single institution, we measured EM trainee burnout using the Maslach Burnout Inventory through a confidential, electronic survey. We subsequently linked individual trainee burnout results with their individual Press Ganey (PG) ED patient satisfaction scores. We compared burnout scores across sex and postgraduate year using chi-square tests and PG results via analysis of variance.

RESULTS

Twenty-seven of 53 (50.9%) eligible EM trainees completed the burnout assessment. Trainees reported an overall burnout rate of 77.8% (95% confidence interval = 59.2%-89.4%). There were no significant differences in burnout based on sex (p = 0.888) or postgraduate year (p = 0.671). Trainee burnout was significantly associated with lower trainee-specific PG scores, including patient ratings of resident physician courtesy (p = 0.011), taking the time to listen (p = 0.004), keeping informed of treatment (p = 0.014), and concern for patient comfort (p = 0.006). There was no significant association between trainee burnout and patients' overall likelihood to recommend the ED to others (p = 0.364).

CONCLUSION

Emergency medicine trainee burnout is associated with lower trainee-specific PG ED patient satisfaction scores across all four physician domains. In addition to its detrimental impact on physician wellness, burnout may play a significant adverse role in patients' perceptions of their ED providers' interpersonal and communication skills.

Emergency Medicine Faculty Are Poor at Predicting Burnout in Individual Trainees: An Exploratory Study

OBJECTIVE

Burnout is common among emergency medicine (EM) physicians, and it is prevalent even among EM trainees. Recently proposed Accreditation Council for Graduate Medical Education requirements encourage faculty to alert residency leadership when trainees display signs of burnout. It remains uncertain how trainees experiencing burnout can be reliably identified. We examined if EM faculty advisers at one institution can accurately predict burnout in their EM resident advisees.

METHODS

In this cross-sectional, exploratory study at a single institution, we measured EM trainee burnout using the Maslach Burnout Inventory through a confidential, electronic survey. We subsequently asked EM faculty to predict if their designated advisees were experiencing burnout through a separate confidential, electronic survey. Burnout results were dichotomized from each survey and compared using a 2 × 2 contingency table and Fisher's exact test.

RESULTS

Thirty-six of 54 (66.7%) eligible EM trainees completed the burnout assessment. Eleven of 19 (57.9%) eligible faculty advisers completed trainee burnout predictions, resulting in 30 of 54 (55.6%) trainees who completed the burnout assessment and had a faculty burnout prediction. Trainees reported an overall burnout rate of 70.0% (95% confidence interval [CI] = 53.6% to 86.4%). Cumulative faculty predictions of trainee burnout resulted in an overall burnout rate of 16.7% (95% CI = -5.3% to 38.7%). The sensitivity and specificity of faculty predictions of trainee burnout were 19.1% (95% CI = 5.5% to 41.9%) and 88.9% (95% CI = 51.8% to 99.7%), respectively. Faculty prediction of trainee burnout had a positive predictive value of 80.0% (95% CI = 28.4% to 99.5%) and a negative predictive value of 32.0% (95% CI = 15.0% to 53.5). The difference between trainees' reported rate of burnout and faculty predictions of trainee burnout was significant (p < 0.001).

CONCLUSION

Emergency medicine faculty prediction of trainee burnout was poor. Education on recognizing burnout and other methods of identifying trainee burnout may be necessary.

An Investigation of the Relationship Between Emergency Medicine Trainee Burnout and Clinical Performance in a High-fidelity Simulation Environment

OBJECTIVE

Burnout is prevalent among emergency medicine (EM) physicians, with physicians experiencing burnout more likely to report committing medical errors or delivering suboptimal care. The relationship between physician burnout and identifiable differences in clinical care, however, remains unclear. We examined if EM trainee burnout was associated with differences in clinical performance using high-fidelity simulation as a proxy for patient care.

METHODS

In this cross-sectional study across six institutions, we measured trainee performance over four simulation scenarios based on recognized EM milestones. For each scenario a faculty rater assessed whether the trainee performed predefined critical actions specific to each case. A summation of performed actions across all cases resulted in a cumulative task (CT) score (range = 0-85). Raters also assigned an impression score on a 10-point scale (0 = poor; 10 = outstanding) assessing the trainee's overall performance after each scenario, with the mean of the scores resulting in an overall impression (OI) score. After the simulation assessment, we measured trainees' burnout via the Maslach Burnout Inventory through a confidential, electronic survey. Trainee depression, quality of life (QOL) and daytime sleepiness were also evaluated. Survey results were compared to simulation scores using analysis of variance and covariance.

RESULTS

Fifty-eight of 89 (65.2%) eligible participants completed the survey and simulation assessment. Thirty-one of 58 (53.4%, 95% CI = 40.2% to 66.7%) trainees reported burnout. In trainees with burnout compared to those without, mean CT scores (73.4 vs. 75.2, 95% CI of difference = 0.06 to 3.51) and OI scores (6.4 vs 6.8, 95% CI of difference = 0.03 to 0.79) were negatively associated with burnout after controlling for training program. In contrast, QOL were positively associated with CT [F(1,48) = 4.796, p = 0.033] and OI [F(1,48) = 4.561, p = 0.038] scores. There were no significant associations between simulation performance and depression or daytime sleepiness.

CONCLUSION

Emergency medicine trainees with burnout received lower cumulative performance scores over four high-fidelity simulation scenarios than trainees without burnout.

Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians

INTRODUCTION

Burnout is a syndrome of depersonalization, emotional exhaustion and sense of low personal accomplishment. Emergency physicians (EPs) experience the highest levels of burnout among all physicians. Burnout is associated with greater rates of self-reported suboptimal care among surgeons and internists. The association between burnout and suboptimal care among EPs is unknown. The objective of the study was to evaluate burnout rates among attending and resident EPs and examine their relationship with self-reported patient care practices.

METHODS

In this cross-sectional study burnout was measured at two university-based emergency medicine residency programs with the Maslach Burnout Inventory. We also measured depression, quality of life (QOL) and career satisfaction using validated questionnaires. Six items assessed suboptimal care and the frequency with which they were performed.

RESULTS

We included 77 out of 155 (49.7%) responses. The EP burnout rate was 57.1%, with no difference between attending and resident physicians. Residents were more likely to screen positive for depression (47.8% vs 18.5%, p=0.012) and report lower QOL scores (6.7 vs 7.4 out of 10, p=0.036) than attendings. Attendings and residents reported similar rates of career satisfaction (85.2% vs 87.0%, p=0.744). Burnout was associated with a positive screen for depression (38.6% vs 12.1%, p=0.011) and lower career satisfaction (77.3% vs 97.0%, p=0.02). EPs with high burnout were significantly more likely to report performing all six acts of suboptimal care.

CONCLUSION

A majority of EPs demonstrated high burnout. EP burnout was significantly associated with higher frequencies of self-reported suboptimal care. Future efforts to determine if provider burnout is associated with negative changes in actual patient care are necessary.

Physician assistants and the disclosure of medical error

Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

Adaptation of EPEC-EM Curriculum in a Residency with Asynchronous Learning

OBJECTIVE

The Education in Palliative and End-of-life Care for Emergency Medicine Project (EPEC™-EM) is a comprehensive curriculum in palliative and end-of-life care for emergency providers. We assessed the adaptation of this course to an EM residency program using synchronous and asynchronous learning.

METHODS

Curriculum adaptation followed Kern's standardized six-step curriculum design process. Post-graduate year (PGY) 1-4 residents were taught all EPEC™-EM cognitive domains, divided as seven synchronous and seven asynchronous modules. All synchronous modules featured large group didactic lectures and review of EPEC™-EM course materials. Asynchronous modules use only EPEC™-EM electronic course media for resident self-study. Targeted evaluation for EPEC™-EM knowledge objectives was conducted by a prospective case-control crossover study, with synchronous learning serving as the quasi-control, using validated exam tools. We compared de-identified test scores for effectiveness of learning method, using aggregate group performance means for each learning strategy.

RESULTS

Of 45 eligible residents 55% participated in a pre-test for local needs analysis, and 78% completed a post-test to measure teaching method effect. Post-test scores improved across all EPEC™-EM domains, with a mean improvement for synchronous modules of +28% (SD=9) and a mean improvement for asynchronous modules of +30% (SD=18). The aggregate mean difference between learning methods was 1.9% (95% CI -15.3, +19.0). Mean test scores of the residents who completed the post-test were: synchronous modules 77% (SD=12); asynchronous modules 83% (SD=13); all modules 80% (SD=12).

CONCLUSION

EPEC™-EM adapted materials can improve resident knowledge of palliative medicine domains, as assessed through validated testing of course objectives. Synchronous and asynchronous learning methods appear to result in similar knowledge transfer, feasibly allowing some course content to be effectively delivered outside of large group lectures.

Ethics curriculum for emergency medicine graduate medical education

BACKGROUND

Ethics education is an essential component of graduate medical education in emergency medicine. A sound understanding of principles of bioethics and a rational approach to ethical decision-making are imperative.

OBJECTIVE

This article addresses ethics curriculum content, educational approaches, educational resources, and resident feedback and evaluation.

DISCUSSION

Ethics curriculum content should include elements suggested by the Liaison Committee on Medical Education, Accreditation Council for Graduate Medical Education, and the Model of the Clinical Practice of Emergency Medicine. Essential ethics content includes ethical principles, the physician-patient relationship, patient autonomy, clinical issues, end-of-life decisions, justice, education in emergency medicine, research ethics, and professionalism.

CONCLUSION

The appropriate curriculum in ethics education in emergency medicine should include some of the content and educational approaches outlined in this article, although the optimal methods for meeting these educational goals may vary by institution.

Declining use of the eponym “Reiter's syndrome” in the medical literature, 1998–2003

The German physician Hans Reiter (1881-1969) is associated eponymously with the syndrome of arthritis, urethritis, and conjunctivitis occurring during or after episodes of diarrhea or urethritis. During World War II, Reiter, a physician leader of the Nazi party, authorized medical experiments on concentration camp prisoners. Because of this, some physicians have argued against further use of the Reiter eponym. We investigated trends in use of the Reiter eponym from 1998 to 2003. We searched MEDLINE to identify English-language articles published between 1998 and 2003. Articles were classified by whether the eponym was used without qualification (ie, without mentioning its disfavored use) or not. Five hundred thirty-nine articles were identified. Use of the eponym without qualification was less common in articles published later (34.0% in 2003 vs 57.0% in 1998; adjusted relative risk [RR], 0.49, 95% confidence interval [CI], 0.27-0.71; P = .001) and in articles published in higher impact journals (36.8% vs 56.8% in journals without calculated impact factors; adjusted RR, 0.51; 95% CI, 0.29-0.73; P = .002). Use without qualification was more common in articles written by US-based authors (60.6% vs 31.1% for European-based authors; adjusted RR, 2.28; 95% CI, 1.58-2.97; P < .001). We concluded that use of the Reiter eponym without qualification decreased from 1998 to 2003.

Statistical reviewing policies in dermatology journals: results of a questionnaire survey of editors

BACKGROUND

Problems with statistical methods and reporting have been noted in articles published in dermatology journals. Conclusions presented in published reports may be misleading if based on inappropriate or misinterpreted statistical analysis.

OBJECTIVE

We sought to assess dermatology journal editors' policies and perceptions regarding statistical review of submitted manuscripts.

DESIGN

We mailed and e-mailed a questionnaire survey.

PARTICIPANTS

A total of 43 dermatology journal editors, representing 35 dermatology journals from the United States and abroad, participated in this study.

RESULTS

In all, 32 editors (74.4%), representing 30 journals (85.7%), returned questionnaires. A total of 24 editors (75%) reported having requested statistical reviews on less than 5% of published manuscripts containing original quantitative analysis (ie, excluding reviews and case reports), whereas 3 editors (9.4%) reported having requested statistical reviews on more than 75% of such manuscripts. Most editors reported requesting statistical reviews on a case-by-case basis either after initial favorable review by subject-matter (nonstatistical) reviewers (12 editors; 37.5%) or at the same time that subject-matter review was requested (6 editors; 18.8%). A total of 4 editors (12.5%) reported requesting statistical review for all manuscripts at the same time they are sent for subject-matter review. Another 10 editors (31.3%) said their journals had no general policy on statistical reviewing, and statistical review is almost never needed. For 15 editors (46.9%), ideal statistical reviewing policy was identical to their current policy, whereas 13 (40.6%) favored a more rigorous and 3 (9.4%) a less rigorous policy.

CONCLUSIONS

Dermatology journals infrequently perform statistical reviews of submitted manuscripts. Dermatology journal editors' statistical review policies range from no general policy to (most frequently) requesting reviews on a case-by-case basis to reviewing all submitted manuscripts. Many editors favor more rigorous statistical reviewing policies for their journals. Increased use of statistical reviewing may increase the reliability of conclusions published in dermatology journals.

In vitro and in vivo evaluation of an ocular delivery system of 5-fluorouracil microspheres

Solvent evaporation technique with O/O (oil/oil) emulsion was used to prepare 5-FU (5-fluorouracil) biodegradable microspheres with a polymer of poly(dl-lactide-co-glycolide) combining lecithin as an emulsifier. In vitro drug release was conducted in phosphate buffer with pH 7.4 at 37 degrees C. For in vivo studies, 10 mg of 5-FU microspheres (containing 1 mg of 5-FU) were implanted in the conjunctival area of the rabbit eye. Rabbits were sacrificed at certain time intervals within 7 days after drug application. Samples of aqueous humor and sclera were prepared and analyzed by the high performance liquid chromatography (HPLC) method. The tested 5-FU microsphere contained 10% drug with a mean particle size of 4.4 +/- 0.6 microm. The microsphere had a burst release initially (64.9 +/- 1.5%), followed by a sustained release; the cumulative release at time points of 1, 10 and 21 days were 71.9 +/- 1.9%, 80.1 +/- 2.1% and 89.8 +/- 2.3%, respectively. For in vivo studies, aqueous humor levels showed a peak at the first sampling point (2 hr), then maintained low levels of 5-FU with a range 0.2-1 microg/mL. Scleral levels were 20-80 microg/mL during a 7-day study. Our results indicate that the prepared 5-FU microsphere provided a long-term release for more than 1 week. The preparation showed no irritation and low toxicity (< 100 microg/mL). For application to the eye, it might be potentially useful as a complement drug system in glaucoma filtration surgery.

Adrenergic supersensitivity of rabbit choroidal blood vessels after sympathetic denervation

PURPOSE

To demonstrate the phenomenon of adrenergic denervation supersensitivity in rabbit choroidal blood vessels after superior cervical ganglionectomy.

METHODS

Twenty four albino rabbits of both sexes weighing 2-3 kg were randomly separated into two groups. Twelve rabbits received bilateral superior cervical sympathectomy 2 weeks prior to the study (group s). The other 12 rabbits served as controls (group n). Four different concentrations of 0.1 ml phenylephrine, 0.05%, 0.025%, 0.013%, and 0.007% were slowly injected into the vitreous body near the retinal surface in group (n) and (s) rabbits (n = 6 in each group). The choroidal blood flow (PF), blood volume (CMBC), and velocity (V) were measured simultaneously by laser Doppler flowmetry (Perimed, PF 4001).

RESULTS

The PF showed similar decreases in group (n) and (s) rabbits after injection of 0.05%, 0.025%, and 0.013% phenylephrine. With 0.007% phenylephrine, the PF remained unchanged in group (n) rabbits, but decreased significantly in group (s) rabbits (p = 0.0007). Velocity decreased similarly in both group (n) and (s) rabbits except for the 0.007% phenylephrine, concentration in which velocity decreased significantly in group s rabbits (p = 0.0001). There was no statistical difference in CMBC between group n and s rabbits at any of the test concentrations.

CONCLUSIONS

The difference in PF decrease between group (n) and (s) rabbits with 0.007% phenylephrine demonstrated the existence of choroidal blood vessel denervation supersensitivity. The decrease in PF was achieved mainly through a decrease in blood cell velocity.

Immunohistochemical distinction between primary adenocarcinoma of the bladder and secondary colorectal adenocarcinoma

Primary adenocarcinoma of the urinary bladder sometimes causes a diagnostic dilemma because it can be indistinguishable morphologically from adenocarcinoma of colorectal origin secondarily involving the bladder by metastasis or direct extension. It is much less well studied than conventional urothelial carcinoma and colorectal adenocarcinoma because of its rarity. The current study was specifically designed to investigate whether an important mechanism involved in the pathogenesis of colorectal adenocarcinoma, beta-catenin dysregulation, was also important for the development of primary bladder adenocarcinoma and whether these two morphologically similar tumors could be distinguished immunohistochemically. Formalin-fixed, paraffin-embedded tissues from 17 primary adenocarcinomas of the urinary bladder, 16 colorectal adenocarcinomas involving the bladder, and 10 conventional urothelial (transitional) carcinomas were included in this study. Thirteen of the primary bladder adenocarcinomas were moderately to well differentiated (enteric type) and morphologically indistinguishable from colorectal cancers. The remaining four primary tumors were poorly differentiated (two cases) or of clear cell type (two cases). Immunohistochemical studies using a panel of monoclonal antibodies demonstrated positive nuclear staining for beta-catenin expression in 13 of the 16 (81%) colorectal adenocarcinomas secondarily involving the bladder but in none of the primary adenocarcinomas or the urothelial carcinomas. Instead, positive membranous (and some cytoplasmic) staining was present in all primary bladder tumors with the exception of two poorly differentiated adenocarcinomas where no beta-catenin staining was detected. All secondary colorectal adenocarcinomas stained negatively for CK7 and thrombomodulin (TM), whereas positivity for CK20 was observed in 15 (94%) cases. All urothelial carcinomas stained positively for CK7 and TM, and four of them also for CK20. Primary adenocarcinomas of the bladder showed mixed staining patterns for CK7, CK20, and TM with a positive rate of 65%, 53%, and 59%, respectively. These data indicate that dysregulation of beta-catenin, an important aberration seen in colorectal carcinogenesis, does not appear to play a role in the pathogenesis of the bladder adenocarcinoma. In addition, our data demonstrate that a panel of immunostains, including CK7, CK20, TM, and beta-catenin, is of diagnostic value in differentiating primary bladder adenocarcinoma from secondary adenocarcinoma of colorectal origin.

The use of autologous fibrinogen concentrate in treating ocular hypotony after glaucoma filtration surgery

Antimetabolite therapy with 5-fluouracil (5-FU) or mitomycin-C (MMC) has significantly improved the success rate of glaucoma filtration surgery. However, in some eyes, when filtration is excessive, persistent hypotony may develop. In this study, we describe the experience of using autologous fibrinogen concentrate (AFC) to treat patients with persistent hypotony after glaucoma filtration surgery. Among seven MMC-augmented trabeculectomy patients who developed persistent postoperative hypotony, the effects of AFC intrableb injections were evaluated. Under a microscope, 0.2 ml AFC and bovine thrombin were injected into the blebs of the patients from both sides of the filtering blebs. Postoperative best-corrected visual acuity, anterior chamber status, intraocular pressure (IOP) and fundus examination were followed and compared with those preoperative. On the second day, the mean IOP of seven eyes elevated from preoperative 3.4 +/- 2.1 mmHg to 12.6 +/- 4.2 mmHg, and the anterior chamber became deep without obvious inflammatory response. Within two weeks, macular edema and visual acuity were noted to improve in six eyes (85.7%). In addition, after a mean follow-up of 25 months, the trabeculectomy procedure remained successful in all eyes. AFC appears to be safe and effective in the treatment of ocular hypotony after glaucoma filtration surgery.

The changes of vitreous pH values in an acute glaucoma rabbit model

The changes of vitreous pH values under acute glaucoma status have never been reported. In this study, we measured the changes of vitreous pH values in an acute glaucoma rabbit model. Under ketamine and xylazine anesthesia, the anterior chamber of the right eye of New Zealand white rabbits was cannulated and connected to a polygraph for continuous intraocular pressure (IOP) monitoring and a mini-pump for persistent injection of viscoelastic substance, Healon GV. The measurement of vitreous pH was done by inserting a pH probe via a third opening through the sclera into the vitreous. Different IOP levels were maintained by varied amounts of Healon GV injections into the anterior chamber. The changes of vitreous pH values following the intracameral injections were recorded and evaluated. The changes of vitreous pH values were minimal when IOPs were maintained at lower than 35 mmHg. Vitreous pH values decreased significantly from 7.32 to less than 7.03, when the IOPs were kept at 70 mmHg or higher. However, the decrease of pH values was reversible if IOP was held at 70 mmHg for less than 10 minutes and then reduced to normal level at once. In addition, with MTT viability assay, it was noted that the decrease in vitreous pH was associated with a higher percentage of retinal cell death.

Formulation factors for preparing ocular biodegradable delivery system of 5-fluorouracil microparticles

Microparticles containing 5-fluorouracil (5-FU) were prepared using poly(DL-lactide-co-glycolide) with an oil-in-oil emulsion/solvent extraction technique. Particle characteristics including size distribution, 5-FU loading efficiencies, in vitro release and degradation were investigated. The dispersed phase was composed of PLG dissolved in dichloromethane, and the continuous phase was paraffin oil containing lecithin. 5-FU was successfully entrapped in the microparticles with trapping efficiencies up to 76%, loading level 10% w/v, and particle size 3 microm. Release profiles of 5-FU loaded microparticles were determined to follow a first-order-time relationship. An optimized preparation of 5-FU microparticles was achieved and was capable of controlling the release of 5-FU over 21 days with an in vitro delivery rate of 0.4 microg 5-FU/mg particles/day in the study. Preliminary animal studies indicated that the 5-FU loaded microparticles as an ocular delivery system showed no ocular toxicity and no significant inflammatory response in rabbits for 2 months. The 5-FU loaded microparticles approach, with PLG, might be a potential for the application of long-term delivery of hydrophilic drugs in the eye.

Bilateral superior cervical ganglionectomy increases choroidal blood flow in the rabbit

In this study, we evaluate the effect of bilateral superior cervical ganglionectomy on albino rabbit choroidal blood flow (CBF) in changes of perfusion pressure (PP). Twenty albino rabbits of either sex weighing between 2.0 and 3.0 kg were randomly divided into two groups. The experimental group (group S) included 10 rabbits (20 eyes) that received bilateral superior cervical ganglionectomy one week prior to the study. The other 10 rabbits (20 eyes) served as a control (group N): each received the same procedure as group S except that the superior cervical ganglion was preserved. By means of a laser Doppler flowmeter (Perimed PF4001), blood cell flux (PF), velocity (V), and concentration of moving blood cells (CMBC) were recorded simultaneously while intraocular pressure was increased linearly by a syringe pump. Blood pressure and intraocular pressure were continuously monitored. The laser beam focused on the posterior pole away from major retinal vessels. When PP decreased from 75 to 0 mm Hg, in group N, PF, V and CMBC decreased from 100% to 6.94+/-0.91%, 8.41+/-0.87%, and 19.38+/-1.11%; in group S, it was 17.75+/-2.58%, 16.78+/-1.48%, and 34.58+/-4.42%, respectively. Group S poses higher PF, V, and CMBC than group N while PP decreased gradually. These results indicate that the superior cervical ganglion plays a role in CBF regulation. Bilateral sympathectomy led to a higher PF in the group S rabbits, indicating increased CBF. PF, V, and CMBC remained constant until PP <55 mm Hg demonstrated the existence of CBF autoregulation within a limited perfusion range in both groups. This autoregulation did not change after sympathectomy.

Phenomenological theory on refrigeration effect of practical type-I superconductor

In accordance with the phenomenological theory of thermodynamics, we discussed the Magnetocaloric effect of type-I superconductors, which are exposed to a varying magnetic field. It is concluded theoretically that the refrigeration effect is closely associated with demagnetization effect for practical specimens, which is different from the situation for ideal superconductor sample having no demagnetization effect. From the thermodynamic formulation of superconductivity, we deduced the integrating function of the thermal effect. By numerical calculation, we found a quantitative relation between the refrigeration effect and the demagnetizing factor which is determined by the shape of the sample.

Wound modulation after trabeculectomy by different formulations of antimetabolites in rabbits

A prospective, randomized study was performed to examine the effects of subconjunctival retention of 5-fluorouracil (5-FU) microparticles or 5-FU microparticles combined with mitomycin-C (MMC) on the success of trabeculectomy procedure in 32 New Zealand white rabbits. Drug-loaded microparticles were prepared using a biodegradable polymer, 50:50 ploy (D,L-lactide-co-glycolide) (50:50, PLG, MW 9000), by an oil-in-oil emulsification/solvent extraction technique. Each rabbit underwent trabeculectomy on both eyes, then one of the 5-FU and/or MMC preparations was placed at the site of the filtering surgery intraoperatively in the right eye, while the left eye was used as a control. The rabbits were randomly allocated to one of four treatment groups: group 1 rabbits received 5% 5-FU microparticles 10 mg; group 2 rabbits received 10% 5-FU microparticles 10 mg; group 3 rabbits received 10% 5-FU microparticles 5 mg and MMC 0.01 mg (5-FU/MMC); and group 4 rabbits received MMC 0.02 mg. Postoperatively, intraocularpressure (IOP), bleb survival, complications and IOP dynamics were compared during a follow-up period of 42 days. The results showed that IOPs were significantly lower in the eyes that received groups 3 and 4 treatments, while the eyes that received low concentrations of 5-FU microparticles resulted in no difference in IOPs as compared with those of controls. At 42 days, blebs were present in 100% of the eyes treated with 5-FU/MMC and MMC, but 0% of the eyes treated with 5-FU microparticles. The blebs in the eyes treated with MMC 0.02 mg were thinner, and significant complications (endophthalmitis, transient corneal opacification and neovascularization) occurred. In addition, the IOP dynamics study revealed that the eyes treated with 5-FU/MMC and MMC resulted in less IOP spikings after intravenous infusion of 0.9% NaCl solution. Our study suggested that the use of 5-FU microparticles in promoting the success of trabeculectomy in rabbits is dose-dependent, and its effect is less potent than a single intraoperative application of MMC.

Aqueous humor nitric oxide levels differ in patients with different types of glaucoma

Nitric oxide (NO) has effects on the regulation of aqueous humor dynamics, but the exact mechanism is not yet established. To investigate the possible roles of NO in glaucoma, we determined NO levels in aqueous humor and plasma in glaucoma patients and a control group, cataract patients. The study is an open trial with purposed sampling. One hundred fifty-two patients, including 87 glaucoma patients and 65 cataract patients from two medical centers, were recruited. NO levels in the samples were measured by a chemiluminescence assay. We found that, although the mean aqueous humor NO level (mean +/- SEM) was higher in the glaucoma patients than in the cataract patients (39.7 +/- 1.5 microM vs. 35.5 +/- 1.3 microM, p < 0.05), NO levels varied significantly in different types of glaucoma. The juvenile glaucoma patients had the lowest mean NO level (8.4 +/- 0.9 microM), while the acute angle-closure glaucoma and neovascular glaucoma patients had the highest mean NO levels (64.8 +/- 7.6 microM, 67.3 +/- 8.2 microM). In comparison, the mean plasma NO level in the glaucoma patients was not statistically different from that in the cataract patients (14.1 +/- 1.2 microM vs. 13.9 +/- 1.1 microM, p = 0.91). Our data may provide information for applying NO-mimicking nitrovasodilators in the treatment of glaucoma.

The short-term effect of pentoxifylline on rabbit choroidal blood flow

This study evaluates the effect of different doses ofpentoxifylline on rabbit choroidal blood flow (CBF). Sixteen albino rabbits of both sexes, weighing 2.0-3.0 kg, were randomly separated into four groups. The first group of rabbits received 2 ml normal saline injection through the ear vein. They served as the control group (group n). Three different doses of pentoxifylline, 1 mg/kg, 5 mg/kg, and 10 mg/kg, were injected intravenously to groups p1, p5 and p10, respectively. By means of a laser Doppler flowmeter, the blood cell flux (PF), velocity, and the concentration of moving blood cells (CMBC) were recorded simultaneously. The laser probe was advanced through the pars plana and positioned near the retinal surface. The mean arterial pressure was recorded at the same time. There was a significant increase in PF at 1, 5 and 10 min in group p10 rabbits compared with the control group (p=0.0005, 0.0416, and 0.0087, respectively). The velocity increased at 5 min in group p5 rabbits (p=0.0082) and at 1, 5 and 10 min in group p10 rabbits (p=0.0188, 0.0080, and 0.0207, respectively) as compared with the controls. The CMBC decreased after injection of pentoxifylline and reached statistical significance at 5 and 10 min in group p5 rabbits (p=0.0019 and 0.0046, respectively) and at 5 min in group p10 rabbits (p=0.0447). These results show that larger doses of pentoxifylline (10 mg/kg) increased the CBF of rabbits. This effect was achieved primarily by an increase in blood cell velocity.

Origin of innervation in the feline ophthalmic artery

In this study, we investigate the innervation to the feline ophthalmic artery by the horseradish peroxidase (HRP) tracing method. Five adult cats with body weights ranging between 2.0 and 3.0 kg were used. Under microscopic dissection, the ophthalmic artery was identified and isolated. A gelfoam (Upjohn Co.), 1 x 3 mm in size, containing 0.1 ml of HRP was applied to the prepared artery segment for 2 h. The cat was sacrificed 3 days later. The trigeminal, stellate, superior cervical, middle cervical and nodal ganglia, and oculomotor, trochlear and abducens nuclei were removed, sectioned and stained for HRP-positive cells. HRP-labeled neurons were found in the ipsilateral trigeminal (TRG) and superior cervical ganglia (SCG). The middle cervical, stellate, Edinger-Westphal, trochlear and abducens nuclei were all deemed negative for HRP-labeled cells. In the TRG, HRP-labeled neurons ranged from 21 to 250 (mean +/- SE = 93.8 +/- 42.5/ganglion). The labeled neurons were distributed primarily in the ophthalmic branch. In the SCG, the HRP-labeled neurons were distributed evenly in the ganglion, ranging from 6 to 180 (mean +/- SE = 91.6 +/- 31.5/ganglion). Two additional cats having received a sham operation revealed a negative finding. The feline ophthalmic artery is innervated by the ipsilateral TRG and SCG. Such innervation may play a role in regulating blood flow to the optic nerve.

The application of water drinking test on the evaluation of trabeculectomy patency

The water drinking test (WDT) was once frequently used as a diagnostic tool for glaucoma, but not so often nowadays. In this study, we investigated the potential use of the WDT on the evaluation of trabeculectomy patency. Twenty age-matched volunteers and thirty-six glaucoma patients who were to receive trabeculectomy procedure were enrolled in this study. The WDT was given to the volunteers once and to all glaucoma patients before undergoing trabeculectomy and at certain intervals after the procedure. The WDT was performed in a standard manner. We defined four parameters after performing the WDT: Initial Pressure [IP, intraocular pressure (IOP) level before the WDT]; Slope of Ascending Trend (SOAT, the slope between baseline IOP and the highest IOP level); Peak Pressure (PP, the highest IOP level during the WDT); and End Pressure (EP, the IOP level after the WDT). It was found that the results of the WDT and trabeculectomy patency were strongly correlated. The four parameters in success and failure cases were significantly different at the last follow up: IP: (15.2 +/- 3.6 vs. 25.3 +/- 6.4, p<0.01); SOAT: (0.9 +/- 0.3 vs. 1.8 +/- 1.2, p<0.01); PP: (19.2 +/- 6.4 vs. 39.5 +/- 12.2, p<0.01); EP: (15.5 +/- 4.8 vs. 29.4 +/- 8.2, p<0.01). Thus, it was observed in this study that WDT was not only easy and safe to perform, but also valuable in evaluating the patency of trabeculectomy.

A comparison of trabeculectomy with topically applied timolol in a rabbit ocular hypertension model

The difference in intraocular pressure (IOP) dynamics between trabeculectomy and topical instillation of timolol was compared in a rabbit ocular hypertension model. Twenty New Zealand white rabbits trabeculectomized with subconjunctival retention of 0.3 mL C3F8 gas in the right eyes were used as animal models. One week and three weeks after the operation, the left eyes of the rabbits were given three drops of 0.5% timolol, and IOP dynamics were compared between the two fellow eyes after intravenous infusion of 0.9% NaCl sterile solution. There were four parameters available in comparing IOP dynamics: Time Needed to Reach Peak IOP (TNRPI); Ascending Slope (AS); Peak IOP (PI); and Time Needed to Return to the Original IOP (TNROI). By this method, it was noted that, at the 7th day after the operation, the eyes trabeculectomized with subconjunctival retention of C3F8 gas had lower IOPs than the eyes that received topical instillation of timolol (baseline IOP: 14.7 +/- 4.2 vs. 19.5 +/- 2.5, p < 0.001, PI: 16.4 +/- 5.2 vs. 26.2 +/- 9.3, p < 0.001). In addition, at the 21st postoperative day, after intravenous infusion of 0.9% NaCl solution, the operated eyes showed less IOP spiking than the eyes that received topical instillation of timolol (TNRPI: 5.7 +/- 2.1 vs. 3.9 +/- 2.3, p = 0.014; AS: 0.8 +/- 0.5 vs. 2.7 +/- 2.6, p = 0.003; PI: 21.2 +/- 7.8 vs. 27.9 +/- 8.6, p = 0.014; and TNROI: 8.4 +/- 6.5 vs. 12.6 +/- 7.3, p = 0.06). These results suggested that trabeculectomy, rather than topical timolol, yielded better protection against IOP spiking in a transient rabbit ocular hypertension model.

Subconjunctival retention of C3F8 gas increased success rates of trabeculectomy in rabbits

The effect of subconjunctival retention of perfluoropropane (C3F8) gas on rabbit trabeculectomy was evaluated in this study to determine if this maneuver would increase the success rate of the surgery. Sixteen New Zealand white rabbits underwent trabeculectomy in the right eyes and trabeculectomy with subconjunctival retention of 0.3 mL C3F8 gas in the left eyes were used as animal models. One week and six weeks after the operations, the intraocular pressure (IOP) dynamics were compared between the two eyes after intravenous infusion of 0.9% NaCl sterile solution. The results showed that the average retention time of C3F8 gas within the subconjunctival space in the rabbits was 9.5 +/- 2.3 days. There were four parameters available in comparing IOP dynamics: Time Needed to Reach Peak IOP (TNRPI); Ascending Slope (AS); Peak IOP (PI) and Time Needed to Return to the Original IOP (TNROI). It was noted that at the 7th day after the operations, the IOPs in both eyes of the rabbits were not significantly increased after intravenous infusion of 0.9% NaCl solution. At the 42nd day, after 0.9% NaCl intravenous infusion, the eyes that had undergone trabeculectomy and subconjunctival retention of C3F8 gas had less IOP spiking than eyes that had undergone trabeculectomy alone (TNRPI: 6.7 +/- 2.2 vs. 4.2 +/- 2.9, p = 0.01, AS: 0.5 +/- 0.3 vs. 2.8 +/- 2.7, p = 0.002, PI: 24.4 +/- 9.6 vs. 18.7 +/- 7.4, p = 0.07 and TNROI: 6.8 +/- 5.8 vs. 14.7 +/- 11, p = 0.02). Our study suggested that subconjunctival retention of C3F8 gas increased the success rate of trabeculectomy in rabbits in the short-term follow-up period.

Intraocular pressure lowering effects of novel arylpiperazine derivatives

Arylpiperazine derivatives were synthesized and investigated in this study. Two animal models, including an intraocular pressure (IOP) recovery method and an alpha-chymotrypsin-induced glaucoma model, were used to determine the ocular pharmacological effects of the arylpiperazine derivatives. In the IOP recovery method, New Zealand rabbits with normal IOP were instilled with 50 microliters of 0.5% eye drops, then 10% sodium chloride solution was infused through the ear marginal vein. The relative percent of IOPs were calculated, then delta IOPt% was obtained from the difference of IOPt% between the treated and controlled eye. In the alpha-chymotrypsin-induced glaucoma model, the induced glaucoma rabbits were topically instilled with 0.5% arylpiperazines onto the eyes, and then the IOP changes were calculated to evaluate the effect of eye drops. Our results showed that in the IOP recovery method, BG31 and YCT2-2 demonstrated a very significant effect for reducing IOP; delta IOPt% were -27.6 and -25.5 for BG31 and YCT2-2, respectively. Two other compounds, C219 and C220 also lowered IOP, but the effects were less significant. In alpha-chymotrypsin-induced glaucoma, the maximum effect of YCT2-2 on the IOP was found at 5 hrs. The delta IOP and delta delta IOP were -12.5 +/- 1.7 and -5.8 +/- 1.1 mmHg (p < 0.01), respectively. For BG-31 and C220, there existed a trend to increase IOP with time. In the study, we found that YCT2-2 with higher solubility in the acidic condition was correlated to the significant IOP lowering effect.

Subconjunctival retention of C3F8 gas increased the success rates of trabeculectomy in young people

In this study, the effect of subconjunctival retention of perfluoropropane (C3F8) gas on trabeculectomy was evaluated to determine if this maneuver would increase the success rate of the surgery. Thirty-two patients (under 35 years old) with a diagnosis of primary open-angle glaucoma or steroid-induced glaucoma were randomized into two groups to receive trabeculectomy: Group A (trabeculectomy alone, 16 eyes) and Group B (trabeculectomy with subconjunctival retention of 0.5 mL pure C3F8 gas, 16 eyes). The results showed that the typical appearance of a subconjunctivally retained C3F8 filtering bleb is highly distended in the first two weeks after surgery, followed by flattening and diffusing gradually. The average retention time of C3F8 gas within the subconjunctival space is 28 +/- 6 days. A higher success rate was noted in Group B than in Group A (94% versus 50%, p = 0.016) at a mean follow-up time of 12 months. However, there were no differences in complication rates and results of final visual acuity between the two groups (both groups had two patients lose more than two lines of vision, p = 1.0). Our study suggests that subconjunctival retention of C3F8 gas increases the success rate of trabeculectomy in young people in the intermediate-term (12 months) follow-up period.