Issue: Burnout in graduate medical education is pervasive and has a deleterious impact on career satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have often addressed isolated contributors to burnout; however, a more comprehensive framework for conceptualizing wellness is needed. Evidence: In this article the authors propose Maslow's hierarchy of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential framework for addressing wellness initiatives. There are numerous contributors to burnout among physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic approach, considering both the trainees personal and professional needs, is recommended. Maslow's Needs can be adapted to create such a framework in graduate medical education. The authors review current evidence to support this model. Implications: This work surveys current interventions to mitigate burnout and organizes them into a scaffold that can be used by residency programs interested in a complete framework to supporting wellness.

Objective: To provide an early global assessment of the impact of government stringency measures on the rate of growth in deaths from COVID-19. We hypothesized that the overall stringency of a government’s interventions and the speed of implementation would affect the growth and level of deaths related to COVID-19 in that country. Design: Observational study based on an original database of global governmental responses to the COVID-19 pandemic. Daily data was collected on a range of containment and closure policies for 170 countries from January 1, 2020 until May 27, 2020 by a team of researchers at Oxford University, UK. These data were combined into an aggregate stringency index (SI) score for each country on each day (range: 0-100). Regression was used to show correlations between the speed and strength of government stringency and deaths related to COVID-19 with a number of controls for time and country-specific demographic, health system, and economic characteristics. Interventions: Nine non-pharmaceutical interventions such as school and work closures, restrictions on international and domestic travel, public gathering bans, public information campaigns, as well as testing and contact tracing policies. Main outcomes measures: The primary outcome was deaths related to COVID-19, measured both in terms of maximum daily deaths and growth rate of daily deaths. Results: For each day of delay to reach an SI 40, the average daily growth rate in deaths was 0.087 percentage points higher (0.056 to 0.118, P<0.001). In turn, each additional point on the SI was associated with a 0.080 percentage point lower average daily growth rate (−0.121 to −0.039, P<.001). These daily differences in growth rates lead to large cumulative differences in total deaths. For example, a week delay in enacting policy measures to SI 40 would lead to 1.7 times as many deaths overall. Conclusions: A lower degree of government stringency and slower response times were associated with more deaths from COVID-19. These findings highlight the importance of non-pharmaceutical responses to COVID-19 as more robust testing, treatment, and vaccination measures are developed.

There remains diagnostic uncertainty regarding the sensitivity of reverse transcription polymerase chain reaction in detection of SARS-CoV-2 from nasopharyngeal specimens. We present a case where two nasopharyngeal specimens were negative, followed by a positive sputum sample. Serial testing for COVID-19 is indicated in patients with high pretest probability of disease.

Asplenic patients are at increased risk for sepsis and fulminant infection. Sepsis in these patients is typically secondary to encapsulated bacteria, with Streptococcus pneumoniae being the most frequent pathogen. Rare complications of severe sepsis include purpura fulminans and bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome). We present the case of a 36-year-old woman, healthy except for splenectomy years prior for idiopathic thrombocytopenic purpura treatment, who presented with fever. Upon presentation to our hospital, three hours after symptoms onset, she had purpura fulminans and shock. Despite timely antimicrobials and maximal resuscitative efforts, her disease progressed and she expired 12 hours after symptoms onset. Autopsy revealed bilateral adrenal hemorrhage; acute adrenal crisis likely contributed to her refractory shock. Prior to her presentation, she had not received guideline-based post-splenectomy care. Sepsis in asplenic patients can be fulminant and rapidly fatal. Streptococcus pneumoniae remains the most frequent cause, despite decreasing rates in recent years related to widespread pneumococcal vaccination. Guideline-based vaccinations and "pill-in-pocket" therapy can be life-saving for asplenic patients. Purpura fulminans represents an extreme manifestation of disseminated intravascular coagulation, is more common in asplenic patients, and portends a poor prognosis. Waterhouse-Friderichsen syndrome can be seen concurrently with purpura fulminans and further portends a poor prognosis; pre-mortem diagnosis requires a high index of suspicion.

Clostridium bifermentans is a rare pathogen in humans. A fatal case of fulminant endometritis with toxic shock and capillary leak secondary to C. bifermentans infection in a young woman is described, and compared to all 13 previously described cases of C. bifermentans infection.

Background: A significant proportion of human communication is nonverbal. Although the fields of business and psychology have significant literature on effectively using body language in a variety of situations, there is limited literature on effective body language for medical educators. Aim: To provide 12 tips to highlight effective body language strategies and techniques for medical educators. Method: The tips provided are based on our experiences and reflections as clinician-educators and the available literature. Results: The 12 tips presented offer specific strategies to engage learners, balance learner participation, and bring energy and passion to teaching. Conclusions: Medical educators seeking to maximize their effectiveness would benefit from an understanding of how body language affects a learning environment and how body language techniques can be used to engage audiences, maintain attention, control challenging learners, and convey passion for a topic. Understanding and using body language effectively is an important instructional skill.