Peng, Lillian

Abstract Purpose Research suggests that burnout can begin early in medical school, yet burnout among preclerkship students remains underexplored. This study aimed to characterize burnout signs, sources, coping strategies, and potential interventions among preclerkship students at one U.S. medical school. Method The authors conducted a qualitative study of preclerkship students at Mayo Clinic Alix School of Medicine (MCASOM) in June 2019. Participants completed 2 Maslach Burnout Inventory (MBI) items (measuring frequency of emotional exhaustion and depersonalization) and 2 free-text questions on burnout before participating in 1 of 3 semistructured focus groups. Focus group questions were derived from a literature review on medical student burnout with input from the MCASOM Student Life and Wellness Committee. Group discussions were recorded, transcribed, coded inductively, and analyzed iteratively (along with free-text comments) using a general inductive approach from a constructivist perspective. Results Eighteen of 111 eligible students (16%) participated, with 5/18 (28%) reporting weekly emotional exhaustion and/or depersonalization on MBI items. Analysis of focus group transcripts showed that most students had experienced burnout symptoms during their first or second year, corresponding with school-related stressors and manifesting in cognitive-emotional, physical, and verbal-behavioral ways. Students identified systemic, institutional, and individual burnout drivers and discussed how these drivers interacted (e.g., high standards of excellence at the system level interacted with anxiety and maladaptive thinking at the individual level, creating pressure to always do more). Students used various coping strategies (e.g., self-care, peer support, reframing, and compartmentalization) but emphasized limitations of these strategies and recommended interventions directed toward systemic and institutional burnout drivers. Conclusions This study offers insights into burnout signs and sources among preclerkship medical students that can inform future large-scale studies. Results suggest that burnout emerges from dynamic interactions among systemic, institutional, and individual factors and may benefit from multipronged interventions.

Background: Left ventricular outflow tract (LVOT) obstruction is an important determinant in management of hypertrophic cardiomyopathy (HCM). Valsalva maneuver and amyl nitrite are used in clinical practice during resting echocardiography to induce latent obstruction (LVOT gradient <30 mmHg at rest, ≥30 mmHg with maneuver). With a nationwide shortage of amyl nitrite in 2019, we implemented a “repetitive squat-to-stand” maneuver to provoke LVOT obstruction during echocardiography. Methods: Patients with known or suspected HCM without resting obstruction who underwent repetitive squat-to-stand maneuver during echocardiography between February and September 2019 were included. Maximal instantaneous gradients were recorded. Provocable gradients were compared utilizing a two-sided t-test. Amyl nitrite was not available during the study period. Results: Squat-to-stand assessments were available in 125 patients without resting obstruction (age 58 ± 15 years, 67% male); 114 also performed Valsalva maneuver. 47 of 125 patients (37.6%) demonstrated provocable obstruction. 46 (36.8%) demonstrated latent obstruction provoked by squat-to-stand, which was severe (gradient ≥50 mmHg) in 29 (23.2%). Of the 46 patients, 19 demonstrated latent obstruction only with squat-to-stand but not with Valsalva, 13 of which demonstrated severe obstruction. Among patients with latent obstruction who performed both Valsalva and squat-to-stand maneuver (n=41), squat-to-stand resulted in a higher gradient than Valsalva maneuver (p<0.0001, Figure). Conclusion: Repetitive squat-to-stand maneuver is a clinically useful adjunct to the traditional echocardiographic exam in HCM. This maneuver appears to be more sensitive than the Valsalva maneuver for identifying severe dynamic LVOT obstruction. Use of repetitive squat-to-stand warrants further study in comparison to amyl nitrite, particularly regarding cost savings and diagnostic performance.

Objective The aim of the study was to compare vaginal wound healing after exosome injection in a porcine mesh exposure model with (1) single versus multiple dose regimens and (2) acute versus subacute exposure. Methods Six 80-kg Yorkshire-crossed swine each had 2 polypropylene meshes implanted to create the vaginal mesh exposure model. Animals were divided into 3 groups based on number and timing of exosome injection: (1) single purified exosome product (PEP) injection (acute-single), (2) weekly PEP injections (acute-weekly, 4 total injections), and (3) delayed single injection (subacute-single). Acute and subacute injections occurred 1 and 8 weeks after mesh implantation, respectively. EdU, a thymidine analog, was given twice weekly after the first injection to track tissue regeneration. Euthanasia and tissue analysis occurred 4 weeks after the first injection. ImageJ was used to quantify epithelial thickness, cellular proliferation, and capillary density. Statistical analysis was performed using analysis of variance and post hoc Tukey test. Results Acute-single PEP injection tissues mirrored pilot study results, validating replication of protocol. Within the acute groups, weekly dosing resulted in 1.5× higher epithelial thickness (nonsignificant), 1.8× higher epithelial proliferation ( P < 0.05), and 1.5× higher regenerated capillary density ( P < 0.05) compared with single injection. Regarding chronicity of the exposure, the subacute group showed 1.7× higher epithelial proliferation (nonsignificant) and similar capillary density and epithelial thickness as compared with the acute group. Conclusions Exosome redosing resulted in significantly greater epithelial proliferation with significantly higher regenerated capillary density, leading to a trend toward thicker epithelium. Subacute exposure exhibited similar regeneration to acute exposure despite a delayed injection timeline. These results contribute to a growing body of preclinical research demonstrating utility of exosomes in pelvic floor disorders.

Abstract Background Left ventricular outflow tract (LVOT) obstruction is an important determinant of the management of hypertrophic cardiomyopathy (HCM). With a nationwide shortage of amyl nitrite in 2019, we implemented a ‘repetitive squat-to-stand’ manoeuvre to provoke LVOT obstruction during echocardiography. Case summary A 64-year-old female was referred with symptomatic HCM refractory to pharmacologic therapy. Transthoracic echocardiography showed minor LVOT obstruction with conventional imaging at rest and during Valsalva manoeuvre, but severe obstruction was confirmed with the repetitive squat-to-stand manoeuvre. Alcohol septal ablation via the first septal perforator was performed with subsequent resolution of symptoms. Discussion Due to the dynamic nature of LVOT obstruction, a series of provocative manoeuvres including Valsalva manoeuvre, inhalation of amyl nitrite, and exercise are often necessary to maximally augment ventricular obstruction. The recent unavailability of amyl nitrite during a nationwide shortage prompted the implementation of a protocol of repetitive squat-to-stand manoeuvre in our echocardiography laboratory. Rising from the squatting position decreases preload and afterload, both of which augment dynamic LVOT obstruction. Repetition of squatting and standing appears to enhance the sensitivity of the manoeuvre, particularly when exertional symptoms are reproduced. In this case, repetitive squat-to-stand manoeuvre led to the identification of severe LVOT obstruction which may not have been diagnosed otherwise, alteration of treatment to septal reduction therapy, and subsequent resolution of symptoms.