Self-Compassion for Healthcare Communities: Exploring the Effects of a Synchronous Online Continuing Medical Education Program on Physician Burnout.

INTRODUCTION: Physician burnout is a common problem for which self-compassion training has shown positive effects. In this program evaluation, we explore the effects of a synchronous online continuing medical education program (Self-Compassion for Healthcare Communities, SCHC) to improve physician burnout and related outcomes. METHODS: The SCHC program was delivered online via Zoom and consisted of six 1-hour weekly sessions to enhance self-compassion and well-being. The primary outcome was the "burnout" subscale of the Professional Quality of Life scale; compassion satisfaction, secondary traumatic stress, self-compassion, resilience activation and decompression, and job satisfaction were evaluated, and qualitative data were also collected. RESULTS: A total of 116 physicians attended at least one session of the program, 48 of whom completed both the preprogram and postprogram surveys. The results showed that physicians experienced a reduction in their burnout levels (P = .001) as well as improvements in compassion satisfaction (P = .027), secondary traumatic stress (P = .001), self-compassion (P < .001), resilience decompression (P = .012), and job satisfaction (P = .038). Qualitative data, obtained from a total of 91 participants who attended at least one session, indicated that participants were satisfied with the SCHC program: they found it useful for learning to be compassionate with themselves and they highly valued having the chance to connect with other colleagues who experience similar struggles. DISCUSSION: The live online SCHC program showed benefits on physician burnout and related outcomes such as compassion satisfaction, secondary traumatic stress, self-compassion, resilience decompression, and job satisfaction. Nonetheless, in addition to individual-focused well-being programs, systemic changes in health care delivery were also deemed necessary to decrease burnout.

Reduced visual acuity is mirrored in low vision imagery.

Research has examined the nature of visual imagery in normally sighted and blind subjects, but not in those with low vision. Findings with normally sighted subjects suggest that imagery involves primary visual areas of the brain. Since the plasticity of visual cortex appears to be limited in adulthood, we might expect imagery of those with adult-onset low vision to be relatively unaffected by these losses. But if visual imagery is based on recent and current experience, we would expect images of those with low vision to share some properties of impaired visual perception. We examined key parameters of mental images reported by normally sighted subjects, compared to those with early- and late-onset low vision, and with a group of subjects with restricted visual fields using an imagery questionnaire. We found evidence that those with reduced visual acuity report the imagery distances of objects to be closer than those with normal acuity and also depict objects in imagery with lower resolution than those with normal visual acuity. We also found that all low vision groups, like the normally sighted, image objects at a substantially greater distance than when asked to place them at a distance that 'just fits' their imagery field (overflow distance). All low vision groups, like the normally sighted, showed evidence of a limited visual field for imagery, but our group with restricted visual fields did not differ from the other groups in this respect. We conclude that imagery of those with low vision is similar to that of those with normal vision in being dependent on the size of objects or features being imaged, but that it also reflects their reduced visual acuity. We found no evidence for a dependence on imagery of age of onset or number of years of vision impairment.

Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival.

By ignoring the root causes of disease and neglecting to prioritize lifestyle measures for prevention, the medical community is placing people at harm. Advanced nations, influenced by a Western lifestyle, are in the midst of a health crisis, resulting largely from poor lifestyle choices. Epidemiologic, ecologic, and interventional studies have repeatedly indicated that most chronic illnesses, including cardiovascular disease, cancer, and type 2 diabetes, are the result of lifestyles fueled by poor nutrition and physical inactivity.In this article, we describe the practice of lifestyle medicine and its powerful effect on these modern instigators of premature disability and death. We address the economic benefits of prevention-based lifestyle medicine and its effect on our health care system: A system on the verge of bankruptcy. We recommend vital changes to a disastrous course. Many deaths and many causes of pain, suffering, and disability could be circumvented if the medical community could effectively implement and share the power of healthy lifestyle choices. We believe that lifestyle medicine should become the primary approach to the management of chronic conditions and, more importantly, their prevention. For future generations, for our own health, and for the Hippocratic Oath we swore to uphold ("First do no harm"), the medical community must take action. It is our hope that the information presented will inspire our colleagues to pursue lifestyle medicine research and incorporate such practices into their daily care of patients. The time to make this change is now.

Omitting late-night eating may cause hypoglycemia in "well controlled" basal insulin-treated type 2 diabetes.

OBJECTIVE: To assess hypoglycemia caused by eating the last meal of the day earlier or its omission in "well controlled" type 2 diabetes mellitus patients treated with once-nightly basal insulin. METHODS: Previously basal insulin-titrated subjects (n = 20) (fasting plasma glucose, FPG, <110 mg/dL and no self-reported hypoglycemia) underwent continuous glucose monitoring (CGM) during 3 consecutive eating conditions of 3 days each; (1) usual eating, (2) the last meal restricted to 18:00, and (3) 1 sequential meal omitted/day thereby creating a fasting day after transposing the 4-hour period after a meal with that when the meal was omitted. One 24-hour (00:00 to 00:00) period within each eating condition was selected for comparison. RESULTS: The mean duration in all hypoglycemic ranges doubled (P = .0584 or greater) when the last meal was omitted or eaten at 18:09 ± 0:39 instead of 19:43 ± 1:01, the usual time for the subjects' undisturbed eating. The mean duration of hypoglycemia was greatest between 00:00 to 06:00 compared to the 3 other 6-hour periods of the day. CONCLUSIONS: Increased hypoglycemia occurs when the subject's last meal is eaten earlier or omitted and may not be recognized because it occurs predominately during sleep. When titrating basal insulin from the morning FPG, considerations should be given to the effect of the last meal of the day and possible hypoglycemia between 00:00 and 06:00 to avoid excessive basal insulin treatment.

The number of basal rates required to achieve near-normal basal glucose control in pump-treated type 2 diabetes.

BACKGROUND: It has been reported that most pump-treated patients with type 2 diabetes require only two or fewer basal rates. Using daily continuous glucose monitoring (CGM)-directed titration, this premise was re-evaluated at near-normal glycemic control. PATIENTS AND METHODS: Thirty subjects who were insulin-naive (n = 10), on basal insulin (n = 10), or on basal-bolus insulin therapy (n=10) ate a fixed diet. The basal rate was started as a single rate and then adjusted to a basal glucose goal of 70-130 mg/dL. The insulin-to-carbohydrate ratio (ICR) (in g/U) was adjusted to 2-4-h postmeal CGM glucose goal of 80-120% of premeal glucose. RESULTS: The mean (SE) CGM basal glucose was 99.9 (4.9) mg/dL, and 4.5% (1.4%) of the readings were <70 mg/dL. The mean 2-4-h postmeal glucose was 113.3% (4.8%) of the premeal glucose. Only six subjects (20%) required two basal rates, while the remainder needed only one. The mean (SE) dosing relationships were as follows: total basal dose (TBD) (in U/day) = 0.226(0.018) × weight (in kg); TBD (in U/day) = 0.339(0.012) × total daily dose (TDD) (in U/day); ICR (in g/U) = 126(8)/TBD (in U/day); and ICR (in g/U) = 365(14)/TDD (in U/day). CONCLUSIONS: This study confirms that one basal rate is adequate for the majority of subjects with type 2 diabetes. The mathematical proportionality between dosing factors closely agrees with those obtained in CGM-titrated pump-treated type 1 diabetes but differs from those derived from clinical studies in which insulin titration was based on infrequent self-monitored plasma glucose testing and while on an unstructured diet.

Contribution of the dawn phenomenon to the fasting and postbreakfast hyperglycemia in type 1 diabetes treated with once-nightly insulin glargine.

OBJECTIVE: To observe the effect of the dawn phenomenon on basal glucose and postbreakfast hyperglycemia in patients with type 1 diabetes treated with once-nightly insulin glargine and premeal insulin lispro. METHODS: In 49 study subjects consuming a fixed isocaloric (50% carbohydrate) diet of usual food, the insulin glargine dose was titrated from daily continuous glucose monitoring downloads to achieve a basal glucose goal of <130 mg/dL 4 hours after meals and during serial meal omissions but with fewer than 10% of readings at <70 mg/dL during 24 hours. Patients also performed self-monitoring of plasma glucose 7 times a day (before and 2 hours after each meal or omitted meal and at bedtime). RESULTS: The target mean basal glucose level was achieved only during the non-dawn phenomenon period (1400 hours to 0400 hours). During the dawn phenomenon, the mean (standard deviation) basal glucose level increased from 118 (57) mg/dL at 0400 hours to 156 (67) mg/dL before the breakfast meal, a 32% increase (P = .00149). The mean self-monitored plasma glucose level with meal omission was 63.8% of that increase with a breakfast meal. CONCLUSION: The fasting morning glucose concentration is considerably elevated because of the dawn phenomenon. Targeting insulin titration to this glucose level may result in excessive basal insulin dosing for the non-dawn phenomenon periods of the day. The dawn phenomenon is a large component of the postbreakfast hyperglycemia. Rather than increasing the morning premeal insulin bolus, consideration should be given to pretreating the earlier dawn phenomenon with an insulin pump with use of a variable basal insulin rate.

How much do I give? Dose estimation formulas for once-nightly insulin glargine and premeal insulin lispro in type 1 diabetes mellitus.

OBJECTIVE: To evaluate the mathematical relationships between dosing factors in type 1 diabetic patients using multiple daily injections. METHODS: In this single-center, prospective study in type 1 diabetic patients, the basal continuous glucose monitoring glucose target was less than 130 mg/dL with fewer than 10% of 24-hour readings at less than 70 mg/dL. Basal glucose for the 4-hour meal periods was obtained from once-daily serial meal omissions. On an isocaloric, 50% carbohydrate, fixed diet, the insulin to carbohydrate ratio was adjusted to achieve a 2- to 4-hour postbolus glucose value within ±20% of premeal glucose. For determining dosing formulas, the slope of the linear regression line comparing the variables of weight, total daily dose (TDD), total basal dose (TBD), insulin-to-carbohydrate ratio (ICR), and correction factor (CF) was determined. RESULTS: Forty-nine patients were included. Titrating insulin glargine to the morning glucose led to hypoglycemia during the rest of the day (2 PM to 4 AM). Therefore the basal glucose target was the nondawn phenomenon portion of the day. The resulting estimation formulas could be rounded to the following: TBD = 0.2 x weight (kg) | TBD = 0.33 x TDD | 90/TBD = ICR = CF/4.5. CONCLUSIONS: Smaller insulin glargine doses to achieve control are in contrast to those much larger doses reported in clinical trials in multiple daily injection-treated type 1 diabetes in which the morning fasting glucose is the basal insulin target.

Cell cycle genes PEDF and CDKN1C in growing deer antlers.

Deer antlers are the only mammalian appendage to display an annual cycle of full regeneration. The growth phase in antler involves the rapid proliferation of several tissues types, including epidermis, dermis, cartilage, bone, blood vessels, and nerves. Antlers thus provide an excellent model to study the developmental regulation of these tissues. We describe here the identification of two genes, pigment epithelium-derived factor (PEDF) and cyclin-dependent kinase inhibitor 1C (CDKN1C), both of which are known to be involved in cell proliferation and differentiation. These genes were identified as the result of screening an expressed sequence tag database derived from a cDNA library enriched for sequences from the growing antler tip. PEDF mRNA was detected in developing skin, cartilage, and bone during endochondral ossification. PEDF mRNA was not detected within endothelial cells that exhibited positive immunoreactivity to a CD146 antibody. CDKN1C mRNA was expressed by only the immature chondrocytes within the precartilage region. These results suggested that PEDF and CDKN1C are important genes involved in cell proliferation and differentiation during antler growth.

Nerve growth factor mRNA expression in the regenerating antler tip of red deer (Cervus elaphus).

Deer antlers are the only mammalian organs that can fully regenerate each year. During their growth phase, antlers of red deer extend at a rate of approximately 10 mm/day, a growth rate matched by the antler nerves. It was demonstrated in a previous study that extracts from deer velvet antler can promote neurite outgrowth from neural explants, suggesting a possible role for Nerve Growth Factor (NGF) in antler innervation. Here we showed using the techniques of Northern blot analysis, denervation, immunohistochemistry and in situ hybridization that NGF mRNA was expressed in the regenerating antler, principally in the smooth muscle of the arteries and arterioles of the growing antler tip. Regenerating axons followed the route of the major blood vessels, located at the interface between the dermis and the reserve mesenchyme of the antler. Denervation experiments suggested a causal relationship exists between NGF mRNA expression in arterial smooth muscle and sensory axons in the antler tip. We hypothesize that NGF expressed in the smooth muscle of the arteries and arterioles promotes and maintains antler angiogenesis and this role positions NGF ahead of axons during antler growth. As a result, NGF can serve a second role, attracting sensory axons into the antler, and thus it can provide a guidance cue to define the nerve track. This would explain the phenomenon whereby re-innervation of the regenerating antler follows vascular ingrowth. The annual growth of deer antler presents a unique opportunity to better understand the factors involved in rapid nerve regeneration.

Antler regeneration: a dependent process of stem tissue primed via interaction with its enveloping skin.

Deer antlers are unique mammalian appendages in that each year they are cast and fully regenerate from permanent bony protuberances, called pedicles. In a previous study, we found that there is a difference in the degree of association between pedicle bone and its enveloping skin: tight at the distal third and loose at the proximal two thirds of a pedicle stump. The distal part has been termed the "potentiated" region, and the proximal part the "dormant" region. In the present study, pedicle stumps were artificially created in yearling sika deer by cutting off the tissue distal to either the potentiated or the dormant region. A piece of impermeable membrane was then inserted into the space between the bone and the skin of each treated pedicle stump, while the control pedicles had the same surgery without membrane insertion. The results showed that the inserted membrane blocked pedicle skin participation in the process of antler regeneration. All three potentiated bony pedicle stumps regenerated skin-less antlers; whereas, one of the three dormant bony pedicle stumps failed to regenerate any antler tissue. The other two dormant stumps eventually regenerated normal antlers; however, this only occurred after loss of the inserted membrane. No antler tissue regenerated from the dormant stumps while the inserted membrane remained in place (up to 55 days). All control pedicle stumps regenerated normal antlers. Therefore, we conclude that it is the pedicle bone, but not pedicle skin, that gives rise to regenerating antlers, and that pedicle bone can acquire the potential to regenerate an antler only when it is primed via interaction with its enveloping skin.

Identification of key tissue type for antler regeneration through pedicle periosteum deletion.

Epimorphic regeneration is the "holy grail" of regenerative medicine. Research aimed at investigating the various models of epimorphic regeneration is essential if a fundamental understanding of the factors underpinning this process are to be established. Deer antlers are the only mammalian appendages that are subject to an annual cycle of epimorphic regeneration. In our previous studies, we have reported that histogenesis of antler regeneration relies on cells resident within the pedicle periosteum (PP). The present study elaborates this finding by means of functional studies involving the deletion of PP. Four yearling and four 2-year-old stags were selected for total PP deletion or partial PP deletion experiments. Of the animals in the total PP deletion group, one showed no signs of antler regeneration throughout the antler growth season. Two showed substantial and one showed marginal delays in antler regeneration (at 34, 20 and 7 days, respectively) compared with the corresponding sham-operated sides. Histological investigation revealed that the delayed antlers were derived from regenerated PP. Unexpectedly, the regenerative capacity of the antler from the total periosteum-deleted pedicles depended on antler length at surgery. Of the four deer that had partial PP deletion, two regenerated antlers exclusively from the left-over PP on the pedicle shafts in the absence of participation from the pedicle bone proper. The combined results from the PP deletion experiments convincingly demonstrate that the cells of the PP are responsible for antler regeneration.

Expression of VEGF and pleiotrophin in deer antler.

Deer antlers represent a unique model of mammalian regeneration in that they cast and fully regenerate every year. The deer antler thus provides a fascinating model of both rapid angiogenesis and chondrogenesis and the opportunity to investigate unique growth regulatory processes. One such phenomenon is the presence of vascularized cartilage in the growing antler tip-unlike other cartilage, which is typically avascular. The mechanisms by which blood vessels grow in the cartilage as well as the factors that drive antler extension at approximately 1 cm a day have been hitherto largely unknown. The aim of this study was to determine the expression of VEGF and pleiotrophin within the growing antler tip. We isolated cervine VEGF121 and VEGF165 from deer antler and found that mRNA is produced for VEGF in the precartilage and cartilage regions. By in situ hybridization, we examined whether the VEGF receptors Flt-1 and KDR are present in deer antler and found only KDR mRNA within the endothelial cells of the precartilage region. This finding is compatible with VEGF having an angiogenic effect within antler. Pleiotrophin mRNA was found in the vascular smooth muscle cells of the dermis, thus supporting a possible role in vascular growth. High levels of pleiotrophin mRNA were also detected in the precartilage region with possible implications for both angiogenesis and chondrogenesis. This is the first report of cervine angiogenic growth factors within the growing antler tip.

Vascular localization and proliferation in the growing tip of the deer antler.

The process of angiogenesis is of interest because of the significant clinical benefits associated with controlling vascular growth. Within the antler, chondrogenesis and antler elongation are occurring at the rate of 1-2 cm per day and thus blood vessels are growing at this same rapid pace. We demonstrate that the process of angiogenesis in the antler is controlled at various tissue locations. The findings clearly differentiate the spatial location of the stem cells that drive chondrogenesis from the proliferation process driving the angiogenesis. Vessels within the lateral dermis contained BrdU-positive cells, suggesting that these vessels were elongating. Within the precartilage region, proliferating vessels were detected in bundles of complex structure evenly distributed throughout this tissue layer. The support cells within these bundles of vessels were detected by staining with alpha-smooth muscle actin, while the endothelial cells were negative. Additionally, the alpha-smooth muscle actin staining was found in association with the cartilage cells of the antler. The marked proliferation of the vascular associated cells in the precartilage region identified this area as a major region of vascular growth in the antler. We propose that within the precartilage region, the most likely mechanisms to explain the observed vascular morphology are that of vascular extension of the existing vessels and intussusceptive angiogenesis or sprouting to generate the small bundles of vessels. Wiley-Liss, Inc.

Histological examination of antler regeneration in red deer (Cervus elaphus).

Annual antler renewal presents the only case of epimorphic regeneration (de novo formation of a lost appendage distal to the level of amputation) in mammals. Epimorphic regeneration is also referred to as a blastema-based process, as blastema formation at an initial stage is the prerequisite for this type of regeneration. Therefore, antler regeneration has been claimed to take place through initial blastema formation. However, this claim has never been confirmed experimentally. The present study set out to describe systematically the progression of antler regeneration in order to make a direct histological comparison with blastema formation. The results showed that wound healing over a pedicle stump was achieved by ingrowth of full-thickness pedicle skin and resulted in formation of a scar. The growth centers for the antler main beam and brow tine were formed independently at the posterior and anterior corners of the pedicle stump, respectively. The hyperplastic perichondrium surmounting each growth center was directly formed in situ by a single type of tissue: the thickening distal pedicle periosteum, which is the derivative of initial antlerogenic periosteum. Therefore, the cells residing in the pedicle periosteum can be called antler stem cells. Antler stem cells formed each growth center by initially forming bone through intramembranous ossification, then osseocartilage through transitional ossification, and finally cartilage through endochondral ossification. There was an overlap between the establishment of antler growth centers and the completion of wound healing over the pedicle stump. Overall, our results demonstrate that antler regeneration is achieved through general wound healing- and stem cell-based process, rather than through initial blastema formation. Pedicle periosteal cells directly give rise to antlers. Histogenesis of antler regeneration may recapitulate the process of initial antler generation.

Morphological observation of antler regeneration in red deer (Cervus elaphus).

Deer antler offers a unique opportunity to explore how nature solves the problem of mammalian appendage regeneration. Annual antler renewal is an example of epimorphic regeneration, which is known to take place through initial blastema formation. Detailed examination of the early process of antler regeneration, however, has thus far been lacking. Therefore, we conducted morphological observations on antler regeneration from naturally cast and artificially created pedicle/antler stumps. On the naturally cast pedicle stumps, early antler regeneration underwent four distinguishable stages (with the Chinese equivalent names): casting of previous hard antlers (oil lamp bowl), early wound healing (tiger eye), late wound healing and early regeneration (millstone), and formation of main beam and brown tine (small saddle). Overall, no cone-shaped regenerate, a common feature to blastema-based regeneration, was observed. Taken together with the examination on the sagittal plane of each regenerating stage sample, we found that there are considerable overlaps between late-stage wound healing and the establishment of posterior and anterior growth centers. Observation of antler regeneration from the artificially created stumps showed that the regeneration potential of antler remnants was significantly reduced compared with that of pedicle tissue. Interestingly, the distal portion of a pedicle stump had greater regeneration potential than the proximal region, although this differential potential may not be constitutive, but rather caused by whether or not pedicle antlerogenic tissue becomes closely associated with the enveloping skin at the cut plane. Antler formation could take place from the distal peripheral tissues of an antler/pedicle stump, without the obvious participation of the entire central bony portion. Overall, our morphological results do not support the notion that antler regeneration takes place through the initial formation of a blastema; rather, it may be a stem cell-based process.

Activation of the early B-cell-specific mb-1 (Ig-alpha) gene by Pax-5 is dependent on an unmethylated Ets binding site.

Methylation of cytosine in CpG dinucleotides promotes transcriptional repression in mammals by blocking transcription factor binding and recruiting methyl-binding proteins that initiate chromatin remodeling. Here, we use a novel cell-based system to show that retrovirally expressed Pax-5 protein activates endogenous early B-cell-specific mb-1 genes in plasmacytoma cells, but only when the promoter is hypomethylated. CpG methylation does not directly affect binding of the promoter by Pax-5. Instead, methylation of an adjacent CpG interferes with assembly of ternary complexes comprising Pax-5 and Ets proteins. In electrophoretic mobility shift assays, recruitment of Ets-1 is blocked by methylation of the Ets site (5'CCGGAG) on the antisense strand. In transfection assays, selective methylation of a single CpG within the Pax-5-dependent Ets site greatly reduces mb-1 promoter activity. Prior demethylation of the endogenous mb-1 promoter is required for its activation by Pax-5 in transduced cells. Although B-lineage cells have only unmethylated mb-1 genes and do not modulate methylation of the mb-1 promoter during development, other tissues feature high percentages of methylated alleles. Together, these studies demonstrate a novel DNA methylation-dependent mechanism for regulating transcriptional activity through the inhibition of DNA-dependent protein-protein interactions.

Early B-cell factor, E2A, and Pax-5 cooperate to activate the early B cell-specific mb-1 promoter.

Previous studies have suggested that the early-B-cell-specific mb-1(Igalpha) promoter is regulated by EBF and Pax-5. Here, we used in vivo footprinting assays to detect occupation of binding sites in endogenous mb-1 promoters at various stages of B-cell differentiation. In addition to EBF and Pax-5 binding sites, we detected occupancy of a consensus binding site for E2A proteins (E box) in pre-B cells. EBF and E box sites are crucial for promoter function in transfected pre-B cells, and EBF and E2A proteins synergistically activated the promoter in transfected HeLa cells. Other data suggest that EBF and E box sites are less important for promoter function at later stages of differentiation, whereas binding sites for Pax-5 (and its Ets ternary complex partners) are required for promoter function in all mb-1-expressing cells. Using DNA microarrays, we found that expression of endogenous mb-1 transcripts correlates most closely with EBF expression and negatively with Id1, an inhibitor of E2A protein function, further linking regulation of the mb-1 gene with EBF and E2A. Together, our studies demonstrate the complexity of factors regulating tissue-specific transcription and support the concept that EBF, E2A, and Pax-5 cooperate to activate target genes in early B-cell development.