Background: Clinician burnout in hospice and palliative care (HPC) has potentially widespread negative consequences including increased clinical errors, decreased professionalism, decreased staff retention, and decreased empathy. Reading non-medical literature has been associated with increased empathy, but no studies on the effect of reading on burnout have previously been conducted. We wished to assess reading patterns of practicing HPC clinicians and determine associations between non-medical reading and burnout.Methods: Sixteen-item electronic survey regarding reading practices, exposure to non-medical literature, fatigue, quality of life, and burnout symptoms was administered to members of the American Academy of Hospice and Palliative Medicine. Burnout measures of emotional exhaustion and depersonalization were assessed by the validated 2-item Maslach Burnout Inventory. Data were analyzed using descriptive statistics and multivariate regression.Results: Seven hundred nine members responded (15.2% response rate), of which 129 (18.2%) met the criteria for burnout, with 117 (16.6%) meeting the criteria for high emotional exhaustion and 45 (6.3%) meeting the criteria for high depersonalization. On univariate analysis, burnout was associated with age, reading habits, and fatigue, but not years in practice. On multivariable logistic regression consistent readers had decreased odds of overall burnout compared to inconsistent readers (OR 0.61; 95% CI, 0.39-0.97, P=0.036). This was true across the depersonalization (OR 0.58; 95% CI, 0.36-0.93, P=0.025), but not the emotional exhaustion domain. Conclusions:Reading non-medical literature on a consistent basis may be associated with a significantly decreased likelihood of burnout, specifically across the depersonalization domain.

Sivakumar SS, Namath AG, Tuxhorn IE, Lewis SJ, Galán RF. Decreased heart rate and enhanced sinus arrhythmia during interictal sleep demonstrate autonomic imbalance in generalized epilepsy. J Neurophysiol 115: 1988 -1999. First published February 17, 2016 doi:10.1152/jn.01120.2015.-We hypothesized that epilepsy affects the activity of the autonomic nervous system even in the absence of seizures, which should manifest as differences in heart rate variability (HRV) and cardiac cycle. To test this hypothesis, we investigated ECG traces of 91 children and adolescents with generalized epilepsy and 25 neurologically normal controls during 30 min of stage 2 sleep with interictal or normal EEG. Mean heart rate (HR) and high-frequency HRV corresponding to respiratory sinus arrhythmia (RSA) were quantified and compared. Blood pressure (BP) measurements from physical exams of all subjects were also collected and analyzed. RSA was on average significantly stronger in patients with epilepsy, whereas their mean HR was significantly lower after adjusting for age, body mass index, and sex, consistent with increased parasympathetic tone in these patients. In contrast, diastolic (and systolic) BP at rest was not significantly different, indicating that the sympathetic tone is similar. Remarkably, five additional subjects, initially diagnosed as neurologically normal but with enhanced RSA and lower HR, eventually developed epilepsy, suggesting that increased parasympathetic tone precedes the onset of epilepsy in children. ECG waveforms in epilepsy also displayed significantly longer TP intervals (ventricular diastole) relative to the RR interval. The relative TP interval correlated positively with RSA and negatively with HR, suggesting that these parameters are linked through a common mechanism, which we discuss. Altogether, our results provide evidence for imbalanced autonomic function in generalized epilepsy, which may be a key contributing factor to sudden unexpected death in epilepsy.SUDEP; heart rate variability; cardiac cycle; parasympathetic tone; children EPILEPTIC SEIZURES ARE KNOWN to have profound effects on autonomic function (Wyllie 2015). To quantify these effects, many studies have focused on heart rate (HR) (Behbahani et al.

Objective This study estimates the association of a first trimester finding of subchorionic hematoma (SCH) with third trimester adverse pregnancy outcomes in women with twin pregnancies. Study Design Retrospective cohort study of twin pregnancies prior to 14 weeks at a single institution from 2005 to 2019, all of whom had a first trimester ultrasound. We excluded monoamniotic twins, fetal anomalies, history of fetal reduction or spontaneous reduction, and twin-to-twin transfusion syndrome. Ultrasound data were reviewed, and we compared pregnancy outcomes after 24 weeks in women with and without a SCH at their initial ultrasound 60/7 to 136/7 weeks. Regression analysis was used to control for any differences in baseline characteristics. Results A total of 760 women with twin pregnancies met inclusion criteria for the study, 68 (8.9%) of whom had a SCH. Women with SCH were more likely to have vaginal bleeding and had their initial ultrasound at earlier gestational ages. On univariate analysis, SCH was not significantly associated with gestational age at delivery, preterm birth, birthweight of either twin, low birthweight percentiles of either twin, fetal demise, or preeclampsia. SCH was associated with placental abruption on univariate analysis, but not after controlling for vaginal bleeding and gestational age at the time of the initial ultrasound (adjusted odds ratio: 2.00, 95% confidence interval: 0.63–6.42). Among women with SCH, SCH size was not associated with adverse pregnancy outcomes. Conclusion In women with twin pregnancies, the finding of a first trimester SCH is not associated with adverse pregnancy outcomes >24 weeks.

For women with a prior CD for arrest of descent, VBAC success rates are high. This suggests that arrest of descent is mostly dependent on factors unique to each pregnancy and not due to an inadequate pelvis or recurring conditions. Women with a prior CD for arrest of descent should not be discouraged from attempting TOLAC in a subsequent pregnancy due to concerns about the likelihood of success.

The major challenge in applying pharmacogenomics to everyday clinical practice in heart failure (HF) is based on (1) a lack of robust clinical evidence for the differential utilization of neurohormonal antagonists in the management of HF in different subgroups, (2) inconsistent results regarding appropriate subgroups that may potentially benefit from an alternative strategy based on pharmacogenomic analyses, and (3) a lack of clinical trials that focused on testing gene-guided treatment in HF. To date, all pharmacogenomic analyses in HF have been conducted as post hoc retrospective analyses of clinical trial data or of observational patient series studies. This is in direct contrast with the guideline-directed HF therapies that have demonstrated their safety and efficacy in the absence of pharmacogenomic guidance. Therefore, the future of clinical applications of pharmacogenomic testing will largely depend on our ability to incorporate gene-drug interactions into the prescribing process, requiring that preemptive and cost-effective testing be paired with decision-support tools in a value-based care approach.

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Previous work from our lab has demonstrated how the connectivity of brain circuits constrains the repertoire of activity patterns that those circuits can display. Specifically, we have shown that the principal components of spontaneous neural activity are uniquely determined by the underlying circuit connections, and that although the principal components do not uniquely resolve the circuit structure, they do reveal important features about it. Expanding upon this framework on a larger scale of neural dynamics, we have analyzed EEG data recorded with the standard 10–20 electrode system from 41 neurologically normal children and adolescents during stage 2, non-REM sleep. We show that the principal components of EEG spindles, or sigma waves (10–16 Hz), reveal non-propagating, standing waves in the form of spherical harmonics. We mathematically demonstrate that standing EEG waves exist when the spatial covariance and the Laplacian operator on the head's surface commute. This in turn implies that the covariance between two EEG channels decreases as the inverse of their relative distance; a relationship that we corroborate with empirical data. Using volume conduction theory, we then demonstrate that superficial current sources are more synchronized at larger distances, and determine the characteristic length of large-scale neural synchronization as 1.31 times the head radius, on average. Moreover, consistent with the hypothesis that EEG spindles are driven by thalamo-cortical rather than cortico-cortical loops, we also show that 8 additional patients with hypoplasia or complete agenesis of the corpus callosum, i.e., with deficient or no connectivity between cortical hemispheres, similarly exhibit standing EEG waves in the form of spherical harmonics. We conclude that spherical harmonics are a hallmark of spontaneous, large-scale synchronization of neural activity in the brain, which are associated with unconscious, light sleep. The analogy with spherical harmonics in quantum mechanics suggests that the variances (eigenvalues) of the principal components follow a Boltzmann distribution, or equivalently, that standing waves are in a sort of “thermodynamic” equilibrium during non-REM sleep. By extension, we speculate that consciousness emerges as the brain dynamics deviate from such equilibrium.