Effects of the COVID-19 Crisis on Resident Well-Being in a Community Teaching Hospital.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has been an unexpected crisis that continues to challenge the medical community at large. Healthcare environments have been forced to change dramatically, including for medical residents, who are vital members of the innovative emergency response teams. Articles have previously been published on the effects of crises on the well-being of healthcare practitioners; however, there is a paucity of literature targeting medical residents' experiences and general wellness during devastating events. The objective of our study aimed at understanding the emotional impact of the COVID-19 pandemic on residents' stress, academics, and support systems. METHODS: An anonymous, voluntary Likert scale questionnaire was sent via SurveyMonkey to Internal Medicine and Family Medicine residents in July 2020. Questions focused on residents' mood; stress levels; sense of support; and academics before, during, and immediately after the first surge of COVID-19 at our hospital between March 13 and June 15, 2020. RESULTS: Residents felt sad, stressed, and overworked during the first wave, as opposed to feelings of neutrality and happiness before and immediately after. Levels of concern for personal and loved ones' safety were significantly increased during and after our first wave. The impact on educational training was rated as neutral. Residents noted that institutional support could be improved by the provision of wellness activities and sponsored social events. CONCLUSIONS: This study provides insight on resident well-being during the initial months of the pandemic and identifies areas that could be improved. Our results demonstrated that the pandemic affected many aspects of residents' well-being and education, and the lessons learned can help guide healthcare institutions when implementing wellness activities for trainees during subsequent crises.

Compassionate Use of Remdesivir in Pregnant Women With Severe Coronavirus Disease 2019.

BACKGROUND: Remdesivir is efficacious for severe coronavirus disease 2019 (COVID-19) in adults, but data in pregnant women are limited. We describe outcomes in the first 86 pregnant women with severe COVID-19 who were treated with remdesivir. METHODS: The reported data span 21 March to 16 June 2020 for hospitalized pregnant women with polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection and room air oxygen saturation ≤94% whose clinicians requested remdesivir through the compassionate use program. The intended remdesivir treatment course was 10 days (200 mg on day 1, followed by 100 mg for days 2-10, given intravenously). RESULTS: Nineteen of 86 women delivered before their first dose and were reclassified as immediate "postpartum" (median postpartum day 1 [range, 0-3]). At baseline, 40% of pregnant women (median gestational age, 28 weeks) required invasive ventilation, in contrast to 95% of postpartum women (median gestational age at delivery 30 weeks). By day 28 of follow-up, the level of oxygen requirement decreased in 96% and 89% of pregnant and postpartum women, respectively. Among pregnant women, 93% of those on mechanical ventilation were extubated, 93% recovered, and 90% were discharged. Among postpartum women, 89% were extubated, 89% recovered, and 84% were discharged. Remdesivir was well tolerated, with a low incidence of serious adverse events (AEs) (16%). Most AEs were related to pregnancy and underlying disease; most laboratory abnormalities were grade 1 or 2. There was 1 maternal death attributed to underlying disease and no neonatal deaths. CONCLUSIONS: Among 86 pregnant and postpartum women with severe COVID-19 who received compassionate-use remdesivir, recovery rates were high, with a low rate of serious AEs.

Sterol Biosynthesis in Four Green Algae: A Bioinformatic Analysis of the Ergosterol Versus Phytosterol Decision Point.

Animals and fungi produce cholesterol and ergosterol, respectively, while plants produce the phytosterols stigmasterol, campesterol, and ß-sitosterol in various combinations. The recent sequencing of many algal genomes allows the detailed reconstruction of the sterol metabolic pathways. Here, we characterized sterol synthesis in two sequenced Chlorella spp., the free-living C. sorokiniana, and symbiotic C. variabilis NC64A. Chlamydomonas reinhardtii was included as an internal control and Coccomyxa subellipsoidea as a plant-like outlier. We found that ergosterol was the major sterol produced by Chlorella spp. and C. reinhardtii, while C. subellipsoidea produced the three phytosterols found in plants. In silico analysis of the C. variabilis NC64A, C. sorokiniana, and C. subellipsoidea genomes identified 22 homologs of sterol biosynthetic genes from Arabidopsis thaliana, Saccharomyces cerevisiae, and C. reinhardtii. The presence of CAS1, CPI1, and HYD1 in the four algal genomes suggests the higher plant cycloartenol branch for sterol biosynthesis, confirming that algae and fungi use different pathways for ergosterol synthesis. Phylogenetic analysis for 40 oxidosqualene cyclases (OSCs) showed that the nine algal OSCs clustered with the cycloartenol cyclases, rather than the lanosterol cyclases, with the OSC for C. subellipsoidea positioned in between the higher plants and the eight other algae. With regard to why C. subellipsoidea produced phytosterols instead of ergosterol, we identified 22 differentially conserved positions where C. subellipsoidea CAS and A. thaliana CAS1 have one amino acid while the three ergosterol producing algae have another. Together, these results emphasize the position of the unicellular algae as an evolutionary transition point for sterols.

Measuring and Monitoring Healthcare-Associated Infections: A Canadian Collaboration to Better Understand the Magnitude of the Problem.

Patients should never have to worry about getting an infection while in hospital. Yet every year, many hospitalized Canadians continue to acquire an infection during their hospital stay and experience increased morbidity and mortality as a result of these healthcare-associated infections (HAIs) (PHAC 2019b). Measuring and monitoring HAIs provide key data to better understand the magnitude of the problem. In Canada, there are inconsistencies in the use of standardized HAI case definitions and surveillance practices. These inconsistencies make it difficult to provide benchmarks and set targets to help reduce the rate of HAIs in Canadian hospitals.

Ecophysiology and lipid dynamics of a eukaryotic mangrove decomposer.

Aurantiochytrium limacinum is an osmo-heterotrophic Stramenopile and a pioneering mangrove decomposer which is taxonomically assigned to the family of Thraustochytriaceae (class: Labyrinthulomycetes). The life cycle of A. limacinum involves different cell types including mono- and multi-nucleated cells as well as flagellated zoospores which colonize new fallen leaves. The ecological relevance of thraustochytrids is underestimated and eclipsed by their biotechnological importance, due to their ability to accumulate large amount of lipids, mainly triacylglycerols (TAGs). In this study, we aimed to understand the ecophysiological parameters that trigger zoospore production and the interplay between the life cycle of A. limacinum and its lipid metabolism. When grown in a rich medium, cells accumulated large amounts of TAGs at the end of their growth period, but no zoospores were produced. In poor media such as artificial sea water, zoospores were produced in massive quantities. In the absence of organic carbon, the zoospores remained swimming for at least 6 days, consuming their TAGs in the process. Addition of glucose rapidly triggered the maturation of the zoospores. On the basis of these data, we propose a life cycle for A. limacinum integrating the potential perturbations/changes in the environment surrounding a mangrove leaf that could lead to the production of zoospores and colonization of new areas.

Defending Racial and Ethnic Diversity in Undergraduate and Medical School Admission Policies.

This Viewpoint argues that reversing or restricting the use of race and ethnicity in academic admission policies could also threaten the diversity of medical schools, both directly by restricting race consciousness in medical school admission practices and indirectly by reducing the overall number of minoritized undergraduate students attending US colleges and universities who could apply to medical school.

In the clinic. Constipation.

This issue provides a clinical overview of constipation, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Respiratory syncytial virus and other respiratory viral infections in older adults with moderate to severe influenza-like illness.

BACKGROUND: Few studies have prospectively assessed viral etiologies of acute respiratory infections in community-based elderly individuals. We assessed viral respiratory pathogens in individuals ≥65 years with influenza-like illness (ILI). METHODS: Multiplex reverse-transcriptase polymerase chain reaction identified viral pathogens in nasal/throat swabs from 556 episodes of moderate-to-severe ILI, defined as ILI with pneumonia, hospitalization, or maximum daily influenza symptom severity score (ISS) >2. Cases were selected from a randomized trial of an adjuvanted vs nonadjuvanted influenza vaccine conducted in elderly adults from 15 countries. RESULTS: Respiratory syncytial virus (RSV) was detected in 7.4% (41/556) moderate-to-severe ILI episodes in elderly adults. Most (39/41) were single infections. There was a significant association between country and RSV detection (P = .004). RSV prevalence was 7.1% (2/28) in ILI with pneumonia, 12.5% (8/64) in ILI with hospitalization, and 6.7% (32/480) in ILI with maximum ISS > 2. Any virus was detected in 320/556 (57.6%) ILI episodes: influenza A (104/556, 18.7%), rhinovirus/enterovirus (82/556, 14.7%), coronavirus and human metapneumovirus (each 32/556, 5.6%). CONCLUSIONS: This first global study providing data on RSV disease in ≥65 year-olds confirms that RSV is an important respiratory pathogen in the elderly. Preventative measures such as vaccination could decrease severe respiratory illnesses and complications in the elderly.

Isolation and characterization of lipid rafts in Emiliania huxleyi: a role for membrane microdomains in host-virus interactions.

Coccolithoviruses employ a suite of glycosphingolipids (GSLs) to successfully infect the globally important coccolithophore Emiliania huxleyi. Lipid rafts, chemically distinct membrane lipid microdomains that are enriched in GSLs and are involved in sensing extracellular stimuli and activating signalling cascades through protein-protein interactions, likely play a fundamental role in host-virus interactions. Using combined lipidomics, proteomics and bioinformatics, we isolated and characterized the lipid and protein content of lipid rafts from control E. huxleyi cells and those infected with EhV86, the type strain for Coccolithovirus. Lipid raft-enriched fractions were isolated and purified as buoyant, detergent-resistant membranes (DRMs) in OptiPrep density gradients. Transmission electron microscopy of vesicle morphology, polymerase chain reaction amplification of the EhV major capsid protein gene and immunoreactivity to flotillin antisera served as respective physical, molecular and biochemical markers. Subsequent lipid characterization of DRMs via high performance liquid chromatography-triple quadrapole mass spectrometry revealed four distinct GSL classes. Parallel proteomic analysis confirmed flotillin as a major lipid raft protein, along with a variety of proteins affiliated with host defence, programmed cell death and innate immunity pathways. The detection of an EhV86-encoded C-type lectin-containing protein confirmed that infection occurs at the interface between lipid rafts and cellular stress/death pathways via specific GSLs and raft-associated proteins.

A Pharmacy-Based Observational Study of Digest-8 Dietary Supplement in a Consumer Healthcare Context.

Background: Functional gastrointestinal disorders (FGIDs), a frequent cause of gastrointestinal (GI) symptomology, impact 40%-69% of the United States population. People who suffer from FGIDs often self-manage their symptoms using consumer healthcare products such as dietary supplements. Objective: To investigate use of Digest-8 dietary supplement by people who purchased the product from pharmacies for their FGID symptoms. Methods: This pharmacy-based observational study included a convenience sample recruited by flyers at 2 pharmacies upon purchase of Digest-8 dietary supplement to assess symptoms, satisfaction, tolerability, and side-effects through 7 weekly voluntary surveys completed by consenting participants. Results: Twenty-two participants completed an initial survey and a collective total of 59 follow-up surveys. Analysis of follow-up surveys compared to baseline provided pilot data on symptom improvement, satisfaction, tolerability, and low side effect profile. Conclusion: Preliminary findings of the study warrant a follow-up prospective randomized clinical trial to address the study limitations.

The efficacy of zuranolone versus placebo in postpartum depression and major depressive disorder: a systematic review and meta-analysis.

BACKGROUND: Zuranolone, an oral version of allopregnanolone and neurosteroid, is a novel drug for the treatment of major depressive disorder (MDD) and postpartum depression (PPD). AIM: The purpose of this systematic review and meta-analysis was to assess the efficacy of zuranolone in the treatment of MDD and PPD. METHOD: A systematic search was conducted using EBSCOhost to simultaneously search Academic Search Premier, APA PsycArticles, APA PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL Ultimate, and MEDLINE with Full Text. Two independent reviewers screened the articles and completed a full-text review using Covidence. The quality of each study was assessed using the Cochrane Risk of Bias tool for randomized trials (RoB 2). A meta-analysis was then conducted using Review Manager (RevMan v5.4) software. RESULTS: The initial search yielded 127 results, with 6 articles fitting our inclusion and exclusion criteria. All 6 studies, comprising 1707 participants, had an overall low risk of bias. There was a significant decrease in HAM-D scores for MDD at 15 days versus placebo (MD - 2.40, 95% CI - 3.07 to - 1.63; p < .001). When pooling data for PDD, there was an overall significant decrease in HAM-D scores at 15 days versus placebo (MD - 4.06, 95% CI - 4.25 to - 3.87; p < .001). CONCLUSION: The results suggest that zuranolone can improve symptoms of PPD at 15 days; however, results were not clinically significant for MDD. Future research is needed to evaluate the long-term efficacy of zuranolone in PPD and the treatment efficacy in MDD.

Vacuum-induced tamponade for managing postpartum hemorrhage: a systematic review.

OBJECTIVE: Postpartum hemorrhage is a leading cause of maternal mortality and morbidity around the globe. The novel low-suction vacuum hemorrhage device (VHD) provides an alternative treatment option for cases of postpartum hemorrhage when first-line uterotonic agents fail. This systematic review aims to review current data evaluating the overall efficacy and safety of VHDs in treating postpartum hemorrhage. METHODS: We searched CINAHL Ultimate, Academic Search Premier, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE with Full Text, and PubMed and reference lists of retrieved studies for eligible studies that included outcomes of effectiveness, efficacy, or safety. Two independent reviewers used Covidence.org to screen Titles and Abstracts for 69 studies of which six were included in the analysis. Secondary outcomes measured across studies included time to bleeding control, total device deployment time, and adverse effects. RESULTS: Six nonrandomized trials (N = 1018 participants) included studies conducted in Indonesia, the United States, Switzerland, and Canada. The VHDs were found to have 90% effectiveness in achieving bleeding control across the studies. For most patients, this was achieved in <5 min and required a total device deployment time of 3 h. Reported adverse events were not considered life-threatening, including endometritis in 11 patients and red blood cell transfusions in 38% of patients. CONCLUSION: VHDs have the potential to be used as a rapidly effective means for mechanical intervention of postpartum hemorrhage. The efficacy and safety of VHDs must be further studied at the randomized controlled trial level to determine their clinical usage.

Evaluation of a Palliative Care Longitudinal Curriculum for Medical Students Using the Context-Input-Process-Product Model.

Palliative care (PC) longitudinal curricula are increasingly being recognized as important in Undergraduate Medical Education (UME). They are however, not yet commonplace, and where they do exist may be implemented without a systematic, prospective approach to curriculum evaluation. This paper describes an implementation of a new longitudinal curriculum at the Perelman School of Medicine (PSOM) at the University of Pennsylvania. We used the Context Input Process Product (CIPP) model, a holistic evaluation model, to assess the local environment, design the curriculum, guide the improvement process, and evaluate outcomes. Comprehensive models such as CIPP provide a more robust approach to curriculum evaluation than outcomes-only models and may be of use to other programs who are implementing new curricula or improving upon existing programs.

High-Fidelity Bleeding Control Simulation Scenario During Medical Student Orientation Improves Students' Self-Reported Ability to Identify and Treat Life-Threatening Bleeding with 3-year Follow-up.

OBJECTIVE: Increasingly, medical schools integrate clinical skills into early didactic coursework. The Stop the Bleed® Campaign emphasizes prehospital hemorrhage control to reduce preventable deaths; however, this course overlooks team interactions. We assessed the impact of high-fidelity simulation during medical student orientation on identification and treatment of life-threatening hemorrhage in a team setting. DESIGN: In this mixed method, prospective pre-, post-, and follow-up survey analysis assessing student knowledge and attitudes, student teams encountered a standardized patient in a prehospital environment with pulsatile bleeding from an extremity wound. Individual students completed surveys assessing previous experience, willingness and ability to assist bleeding person(s), and knowledge and attitudes about tourniquets. Postscenario, faculty preceptors made qualitative observations on teamwork. SETTING: Medical student orientation at a tertiary care academic medical center with long-term follow-up. PARTICIPANTS: Medical students (N = 150). RESULTS: Ninety students (60%) completed both pre- and postsimulation questionnaires. Sixteen (17%) students had previous tourniquet training experience although none had applied a tourniquet outside of training. Postsimulation, students reported increased likelihood of providing treatment until additional help arrived (p = 0.035), improved ability to identify life-threatening hemorrhage (p < 0.001), and more favorable opinions about tourniquet use (p < 0.001) and potential for limb-salvage (p = 0.018). Long-term follow-up respondents (n = 34, 23%) reported increased ability to identify life-threatening hemorrhage (p = 0.010) and universal willingness to intervene until additional help arrived. Follow-up survey responses elicited themes in hemorrhage control including recognition of the importance of continuous pressure, appropriate use of tourniquets, a desire for repeated team training, and the recognition of clerkship rotations as an optimal setting for skill reinforcement. Preceptors noted variable team responses but uniformly endorsed the exercise. CONCLUSIONS: High-fidelity bleeding simulation during medical student orientation improved students' knowledge and attitudes about treating life-threatening hemorrhage and served as an introduction to team-based emergency care. Future studies should further explore team training and hemorrhage control education.

Preschool anxiety disorders: comprehensive assessment of clinical, demographic, temperamental, familial, and life stress correlates.

This study examined correlates of preschoolers' anxiety disorders using a comprehensive, multimethod design. Participants included a community sample of 541 three-year-old children, of whom 106 (19.6%) met criteria for at least 1 anxiety disorder. Child and parental psychopathology and life stress were assessed with clinical interviews. Child temperament and parenting behavior were assessed with laboratory observations. Mothers and fathers reported on their parenting styles. Compared to preschoolers with no anxiety disorder, preschoolers with an anxiety disorder were more likely to meet criteria for comorbid depressive and oppositional defiant disorders and to exhibit greater temperamental behavioral inhibition and lower positive affectivity, and more sleep problems. Children with anxiety disorders also experienced more stressful life events in the previous 6 months, and their mothers had a higher rate of current anxiety disorders. Compared to children with other anxiety disorders, children with only specific phobia exhibited a somewhat different pattern of associations than children with other anxiety disorders. Overall, the findings suggest that many of the correlates observed in older youth with anxiety disorders are also observed in preschoolers.