Neuronal and axonal degeneration results in irreversible neurological disability in multiple sclerosis (MS) patients. A number of adaptive or neuroprotective mechanisms are thought to repress neurodegeneration and neurological disability in MS patients. To investigate possible neuroprotective pathways in the cerebral cortex of MS patients, we compared gene transcripts in cortices of six control and six MS patients. Out of 67 transcripts increased in MS cortex nine were related to the signalling mediated by the neurotrophin ciliary neurotrophic factor (CNTF). Therefore, we quantified and localized transcriptional (RT-PCR, in situ hybridization) and translational (western, immunohistochemistry) products of CNTF-related genes. CNTF-receptor complex members, CNTFRalpha, LIFRbeta and GP130, were increased in MS cortical neurons. CNTF was increased and also expressed by neurons. Phosphorylated STAT3 and the anti-apoptotic molecule, Bcl2, known down stream products of CNTF signalling were also increased in MS cortical neurons. We hypothesize that in response to the chronic insults or stress of the pathogenesis of multiple sclerosis, cortical neurons up regulate a CNTF-mediated neuroprotective signalling pathway. Induction of CNTF signalling and the anti-apoptotic molecule, Bcl2, thus represents a compensatory response to disease pathogenesis and a potential therapeutic target in MS patients.

The novel coronavirus disease (COVID-19) has exposed critical supply shortages both in the United States and worldwide, including those in intensive care unit (ICU) and hospital bed supply, hospital staff, and mechanical ventilators. Many of those who are critically ill have required days to weeks of supportive invasive mechanical ventilation (IMV) as part of their treatment. Previous estimates set the U.S. availability of mechanical ventilators at approximately 62,000 full-featured ventilators, with 98,000 non–full-featured devices (including noninvasive devices). Given the limited availability of this resource both in the United States and in low- and middle-income countries, we provide a framework to approach the shortage of IMV resources. Here we discuss evidence and possibilities to reduce overall IMV needs, discuss strategies to maximize the availability of IMV devices designed for invasive ventilation, discuss the underlying methods in the literature to create and fashion new sources of potential ventilation that are available to hospitals and front-line providers, and discuss the staffing needs necessary to support IMV efforts. The pandemic has already pushed cities like New York and Boston well beyond previous ICU capacity in its first wave. As hot spots continue to develop around the country and the globe, it is evident that issues may arise ahead regarding the efficient and equitable use of resources. This unique challenge may continue to stretch resources and require care beyond previously set capacities and boundaries. The approaches presented here provide a review of the known evidence and strategies for those at the front line who are facing this challenge.

BACKGROUND: Heterogeneity of existing physician burnout studies impairs analyses of longitudinal trends, geographic distribution, and organizational factors impacting physician burnout. The Department of Veterans Affairs (VA) is one of the largest integrated healthcare systems in the USA, offering a unique opportunity to study burnout across VA sites and time. OBJECTIVE: To characterize longitudinal burnout trends of VA physicians and assess organizational characteristics and geographic distribution associated with physician burnout. DESIGN: Longitudinal study of the VA All Employee Survey during 2013-2017. PARTICIPANTS: Self-identified physicians practicing in one of nine clinical service areas at 140 VA sites nationwide. MAIN MEASURES: We identified burnout using a validated definition adapted from the Maslach Burnout Inventory and characterized burnout trends for physicians in different clinical service areas. We used clustering analysis to categorize sites based on their burnout rates over time, and compared organizational characteristics and geographic distribution of high, medium, and low burnout categories. KEY RESULTS: We identified 40,382 physician responses from 140 VA sites. Mean burnout rates across all physicians ranged from 34.3% in 2013 to a high of 39.0% in 2014. Primary care physicians had the highest burnout. High burnout sites were more likely to be rural and non-teaching, have lower complexity (i.e., offer fewer advanced clinical services), and have fewer unique patients per site. CONCLUSIONS: VA physician burnout was lower than previously described in many non-VA studies and was relatively stable over time. These findings may be due to unique characteristics of the VA practice environment. Nonetheless, with over a third of VA physicians reporting burnout, organizational interventions are needed. Primary care physicians and those practicing at small, rural sites have higher rates of burnout and may warrant more focused attention. Our results can guide targeted interventions to promote VA physician well-being and inform efforts to address burnout in diverse clinical settings.

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Background Burnout is a maladaptive response to work-related stress that is associated with negative consequences for patients, clinicians, and the health care system. Critical care nurses are at especially high risk for burnout. Previous studies of burnout have used survey methods that simultaneously measure risk factors and outcomes of burnout, potentially introducing common method bias. Objectives To evaluate the frequency of burnout and individual and organizational characteristics associated with burnout among critical care nurses across a national integrated health care system using data from an annual survey and methods that avoid common method bias. Methods A 2017 survey of 2352 critical care nurses from 94 sites. Site-level workplace climate was assessed using 2016 survey data from 2191 critical care nurses. Results Overall, one-third of nurses reported burnout, which varied significantly across sites. In multilevel analysis, workplace climate was the strongest predictor of burnout (odds ratio [OR], 2.20; 95% CI, 1.50-3.22). Other significant variables were overall hospital quality (OR, 1.44; 95% CI, 1.05-1.99), urban location (OR, 1.93; 95% CI, 1.09-3.42), and nurse tenure (OR, 2.11; 95% CI, 1.44-3.10). In secondary multivariable analyses, workplace climate subthemes of perceptions of workload and staffing, supervisors and senior leadership, culture of teamwork, and patient experience were each significantly associated with burnout. Conclusions Drivers of burnout are varied, yet interventions frequently target only the individual. Results of this study suggest that in efforts to reduce burnout, emphasis should be placed on improving local workplace climate.

Introduction: In recent years, undergraduate and graduate medical education has been rightfully emphasizing education in quality improvement and patient safety (QIPS). However, the best methods for teaching the foundational principles of QIPS and associated skills are unknown. Methods: In collaboration with the Institute for Healthcare Improvement Open School, we developed an approachable simulation for teams of health care trainees at any level and any discipline. The simulation is based on the investigation of a case regarding a psychiatric patient admitted to a fictional hospital for medical treatment who has eloped. In teams, participants investigate the incident by collecting data and using basic QI principles to brainstorm and design interventions. Participants are guided through this paper-based simulation by QI facilitators who have working knowledge of basic QI principles and techniques. Results: The simulation has been successfully used with hundreds of medical students and other health professional trainees. While working in teams, participants gained exposure to patient-safety incident reporting and investigation, process mapping, plan-do-study-act cycles, run charts, intervention design, and interactions with hospital administrators. Surveyed participants reported that they had learned QI principles, gained confidence in their ability to do QI work, and increased their likelihood of leading a QI initiative in the future. Discussion: Simulation has become a standard way to teach many clinical topics in undergraduate and graduate medical education, and QIPS should be no exception. This simulation has been shown to be effective in increasing understanding of and interest in QIPS.

Background Critical care nurses have a burnout rate among the highest of any nursing field. Nurse burnout may impact care quality. Few studies have considered how temporal patterns may influence outcomes. Objective To test a longitudinal model of burnout clusters and associations with patient and clinician outcomes. Methods An observational study analyzed data from annual employee surveys and administrative data on patient outcomes at 111 Veterans Health Administration intensive care units from 2013 through 2017. Site-level burnout rates among critical care nurses were calculated from survey responses about emotional exhaustion and depersonalization. Latent trajectory analysis was applied to identify clusters of facilities with similar burnout patterns over 5 years. Regression analysis was used to analyze patient and employee outcomes by burnout cluster and organizational context measures. Outcomes of interest included patient outcomes (30-day standardized mortality rate and observed minus expected length of stay) for 2016 and 2017 and clinician outcomes (intention to leave and employee satisfaction) from 2013 through 2017. Results Longitudinal analysis revealed 3 burnout clusters among the 111 sites: low (n = 37), medium (n = 68), and high (n = 6) burnout. Compared with sites in the low-burnout cluster, those in the high-burnout cluster had longer patient stays, higher employee turnover intention, and lower employee satisfaction in bivariate models but not in multivariate models. Conclusions In this multiyear, multisite study, critical care nurse burnout was associated with key clinician and patient outcomes. Efforts to address burnout among nurses may improve patient and employee outcomes.

Introduction: We created a standardized workshop to engage residents in quality improvement (QI) using the root cause analysis model. The workshop allows for a robust learning experience while providing solutions derived from clinicians to address important local problems. No prerequisite knowledge or experience is required. Methods: The workshop is facilitated by one or more moderators, ideally with experience in QI. An interdisciplinary group of residents, medical students, nurses, and other attendees comprise an audience which actively engages in workshop activities. Facilitators follow a scripted model to teach important patient safety concepts with frequent break-outs for hands-on application of QI tools. During the workshop, participants create a process map and fishbone diagram, as well as develop and critically evaluate novel interventions. Results: Over the course of one academic year, the workshop has been implemented 17 times with roughly 25 internal medicine residents in attendance at each workshop. In addition, the workshop was run online for 126 participants with varied exposure to QI techniques. Forty percent of these participants completed a survey indicating that over 89% learned something new, 87% felt they could apply the material to their work, and 95% would recommend the workshop to a colleague. Discussion: This 60-minute workshop can provide hands-on QI experience in a standardized format to achieve the dual objectives of teaching QI to clinicians and allowing them to generate innovations. The module can be used for internal case development and trainee participation, but prepared cases are provided for facilitators without the resources for local case development.