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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-signs-new-contract-with-cepiec-china-for-distribution-of-open-access-books-20210319",title:"IntechOpen Signs New Contract with CEPIEC, China for Distribution of Open Access Books"},{slug:"150-million-downloads-and-counting-20210316",title:"150 Million Downloads and Counting"},{slug:"intechopen-secures-indefinite-content-preservation-with-clockss-20210309",title:"IntechOpen Secures Indefinite Content Preservation with CLOCKSS"},{slug:"intechopen-expands-to-all-global-amazon-channels-with-full-catalog-of-books-20210308",title:"IntechOpen Expands to All Global Amazon Channels with Full Catalog of Books"},{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"}]},book:{item:{type:"book",id:"7961",leadTitle:null,fullTitle:"Induced Abortion and Spontaneous Early Pregnancy Loss - Focus on Management",title:"Induced Abortion and Spontaneous Early Pregnancy Loss",subtitle:"Focus on Management",reviewType:"peer-reviewed",abstract:"This book is focused on the protection of female reproductive health. Artificial pregnancy termination is known to be associated with an increased risk of infertility, spontaneous pregnancy loss, and other gestational pathologies. Since family planning is a system for the prevention of unwanted pregnancy, the current situation of the spread of induced abortion in different parts of the world is analyzed. Early pregnancy loss is a wide-ranging problem in medicine and habitual abortion is a real tragedy for women in their childbearing years. The different pathogenetic scenarios of spontaneous pregnancy termination are described and the possible interventions for prevention contributing to beneficial outcomes are discussed.",isbn:"978-1-78985-388-9",printIsbn:"978-1-78985-387-2",pdfIsbn:"978-1-78984-439-9",doi:"10.5772/intechopen.77791",price:119,priceEur:129,priceUsd:155,slug:"induced-abortion-and-spontaneous-early-pregnancy-loss-focus-on-management",numberOfPages:112,isOpenForSubmission:!1,isInWos:null,hash:"02cfa65d8d630b8cacd78aafa3f2f42e",bookSignature:"Igor Lakhno",publishedDate:"April 22nd 2020",coverURL:"https://cdn.intechopen.com/books/images_new/7961.jpg",numberOfDownloads:2141,numberOfWosCitations:0,numberOfCrossrefCitations:1,numberOfDimensionsCitations:2,hasAltmetrics:1,numberOfTotalCitations:3,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"January 23rd 2019",dateEndSecondStepPublish:"March 12th 2019",dateEndThirdStepPublish:"May 11th 2019",dateEndFourthStepPublish:"July 30th 2019",dateEndFifthStepPublish:"September 28th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,editors:[{id:"255757",title:"Dr.",name:"Igor",middleName:"Victorovich",surname:"Lakhno",slug:"igor-lakhno",fullName:"Igor Lakhno",profilePictureURL:"https://mts.intechopen.com/storage/users/255757/images/system/255757.jpg",biography:"Lakhno Igor Victorovich was born in 1971 in Kharkiv (Ukraine). \nMD – 1994, Kharkiv National Medical Univesity.\nOb&Gyn; – 1997, master courses in Kharkiv Medical Academy of Postgraduate Education.\nPhD – 1999, Kharkiv National Medical Univesity.\nDSc – 2019, PL Shupik National Academy of Postgraduate Education \nLakhno Igor has been graduated from an international training courses on reproductive medicine and family planning held in Debrecen University (Hungary) in 1997. Since 1998 Lakhno Igor has worked as an associate professor of the department of obstetrics and gynecology of VN Karazin National University and an associate professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education. Since June 2019 he’s a professor of the department of obstetrics and gynecology of VN Karazin National University and a professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education . He’s an author of about 200 printed works and there are 17 of them in Scopus or Web of Science databases. Lakhno Igor is a rewiever of Journal of Obstetrics and Gynaecology (Taylor and Francis), Informatics in Medicine Unlocked (Elsevier), The Journal of Obstetrics and Gynecology Research (Wiley), Endocrine, Metabolic & Immune Disorders-Drug Targets (Bentham Open), The Open Biomedical Engineering Journal (Bentham Open), etc. He’s defended a dissertation for DSc degree \\'Pre-eclampsia: prediction, prevention and treatment”. Lakhno Igor has participated as a speaker in several international conferences and congresses (International Conference on Biological Oscillations April 10th-14th 2016, Lancaster, UK, The 9th conference of the European Study Group on Cardiovascular Oscillations). His main scientific interests: obstetrics, women’s health, fetal medicine, cardiovascular medicine.",institutionString:"V.N. Karazin Kharkiv National University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Kharkiv Medical Academy of Postgraduate Education",institutionURL:null,country:{name:"Ukraine"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"189",title:"Obstetrics and Gynecology",slug:"obstetrics-and-gynecology"}],chapters:[{id:"67037",title:"Provoked Abortion",doi:"10.5772/intechopen.86270",slug:"provoked-abortion",totalDownloads:339,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Affonso Renato Meira",downloadPdfUrl:"/chapter/pdf-download/67037",previewPdfUrl:"/chapter/pdf-preview/67037",authors:[{id:"217073",title:"Emeritus Prof.",name:"Affonso Renato",surname:"Meira",slug:"affonso-renato-meira",fullName:"Affonso Renato Meira"}],corrections:null},{id:"68634",title:"Is Induced Abortion a Part of Family Planning in China?",doi:"10.5772/intechopen.86342",slug:"is-induced-abortion-a-part-of-family-planning-in-china-",totalDownloads:367,totalCrossrefCites:1,totalDimensionsCites:1,signatures:"Jinlin Liu, Yvon Englert and Wei-Hong Zhang",downloadPdfUrl:"/chapter/pdf-download/68634",previewPdfUrl:"/chapter/pdf-preview/68634",authors:[null],corrections:null},{id:"69245",title:"East-West Divide in Abortion Behaviour in the EU Countries Since 1990: Ongoing or Vanished Differentiation?",doi:"10.5772/intechopen.88819",slug:"east-west-divide-in-abortion-behaviour-in-the-eu-countries-since-1990-ongoing-or-vanished-differenti",totalDownloads:228,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Jiřina Kocourková",downloadPdfUrl:"/chapter/pdf-download/69245",previewPdfUrl:"/chapter/pdf-preview/69245",authors:[null],corrections:null},{id:"67850",title:"Implantation and the Fetal Health",doi:"10.5772/intechopen.87016",slug:"implantation-and-the-fetal-health",totalDownloads:354,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Aleksandar Ljubic, Dzihan Abazovic, Dusica Ljubic, Andrea Pirkovic and Andjela Perovic",downloadPdfUrl:"/chapter/pdf-download/67850",previewPdfUrl:"/chapter/pdf-preview/67850",authors:[null],corrections:null},{id:"67845",title:"Abortions in First Trimester Pregnancy, Management, Treatment",doi:"10.5772/intechopen.86194",slug:"abortions-in-first-trimester-pregnancy-management-treatment",totalDownloads:438,totalCrossrefCites:0,totalDimensionsCites:1,signatures:"Panagiotis Tsikouras, Theodora Deftereou, Xanthoula Anthoulaki, Anastasia Bothou, Anna Chalkidou, Fotini Gaitatzi, Ioannis Tsirkas, Arsou Chalil Bourazan, Eirini Bampageorgaka, George Stanulov, Elefterios Chatzimichael, Spyridon Michalopoulos, Panagiotis Petsidis, Georgios Iatrakis, Stefanos Zervoudis, Maria Lambropoulou, Werner Rath and Georgios Galazios",downloadPdfUrl:"/chapter/pdf-download/67845",previewPdfUrl:"/chapter/pdf-preview/67845",authors:[null],corrections:null},{id:"67430",title:"Interruption of Pregnancy in Women with the Uterine Scar: Potential Risks",doi:"10.5772/intechopen.86282",slug:"interruption-of-pregnancy-in-women-with-the-uterine-scar-potential-risks",totalDownloads:415,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Galina Dikke and Vladimir Ostromenskiy",downloadPdfUrl:"/chapter/pdf-download/67430",previewPdfUrl:"/chapter/pdf-preview/67430",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},relatedBooks:[{type:"book",id:"6191",title:"Selected Topics in Breastfeeding",subtitle:null,isOpenForSubmission:!1,hash:"3334b831761ffa52e78de6fc681e33b3",slug:"selected-topics-in-breastfeeding",bookSignature:"R. 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\r\n\tOver time, e-learning has evolved and changed the landscape of learning. Due to emerging learning technologies, e-learning became very diverse in its forms and applications in education and training. As a result, blended learning and ODL (open and distance learning/online distance learning) are increasingly being used in formal, non-formal and informal education programs across the globe. To facilitate continuous improvements, flexibility, and accessibility in e-learning, it is essential to understand the challenges and opportunities by exploring current theories, policies, and practices.
\r\n\r\n\tThis edited book is aiming to compile works of educators, developers, and practitioners from various disciplines to highlight significant elements of e-learning. This book will serve as a critical resource for administrators, educators, instructional designers, academic developers, researchers, and students.
\r\n\r\n\tPossible topics include, but are not limited to:
\r\n\t• Concept, Nature, and Types of E-Learning
\r\n\t• Strategies for E-Learning
\r\n\t• Synchronous and Asynchronous E-Learning
\r\n\t• Digital Learning
\r\n\t• Blended Learning
\r\n\t• Open and Distance Learning
\r\n\t• Online Distance Learning
\r\n\t• Mobile Learning
\r\n\t• Digital Divide and E-Learning
\r\n\t• Digital Native and Immigrants in E-Learning
\r\n\t• E-Learning Platforms
\r\n\t• Free E-Learning Platforms
\r\n\t• Virtual Learning Environment (VLE) and E-Learning
\r\n\t• Facilitating Learning in E-Learning
\r\n\t• Designing Experiential Learning in VLE
\r\n\t• E-Learning and Challenges of MOOCs
\r\n\t• Customized, Self-paced, and On-demand Learning
\r\n\t• Personal and Professional Development through E-Learning
\r\n\t• Staff Development and E-Learning
\r\n\t• Continuous Professional Development and E-Learning
\r\n\t• Organizational Culture and E-Learning
\r\n\t• Collaborative Learning and E-Learning
\r\n\t• Work-based Learning and E-Learning
\r\n\t• Workplace Learning and E-Learning
\r\n\t• Digital Culture and E-Learning
\r\n\t• Cultural Dimensions and E-Learning
\r\n\t• Culture, Interaction, and E-Learning
\r\n\t• E-Learning, Widening Participation and Social Justice
\r\n\t• Teaching and Learning Styles in E-Learning
\r\n\t• Quality Assurance in E-Learning
\r\n\t• E-Learning and Assessment
\r\n\t• Social Responsibility, Higher Education and E-Learning
\r\n\t• Virtual Universities and E-Learning
\r\n\t• Promoting Learning and Empowering Learners through E-Learning
\r\n\t• Challenges and Opportunities of E-Learning
\r\n\t• Ethical, Legal, Pedagogical and Design Aspects of E-Learning
\r\n\t• Social Constructivism and E-Learning
\r\n\t• Social Networks and E-Learning
\r\n\t• Inclusive Education and E-Learning
\r\n\t• Case Studies of E-Learning Programmes including Religious Education
\r\n\t• Learning about E-Learning from Individuals’ Experiences
\r\n\t• Leadership and Management in E-Learning
\r\n\t• E-Learning Management Systems
\r\n\t• Prospects of E-Learning
Micropumps are the essential active components of fluid transport systems in microfluidics. They can manipulate small volumetric fluids on spatial scales, from several to a hundred microns [1-3]. Nowadays, they have been widely used in many scientific and technical fields of microfluidics, such as biological/chemical analysis and assays [4-7], liquid drug reagent injection/delivery [8-9], and microelectronic chip cooling [10].
With the rapid development of microfluidic technologies, great attention has been paid recently to miniature micropumps with compact design for microfluidic analysis and assays. Miniature micropumps can be easily integrated into microfluidic systems and enable users to achieve low-cost portable pumping devices such as disposable insulin infusion pumps. Miniaturization of pumping systems can simplify the operation of sample introduction and transport in the microfluidic platform with less manual intervention. Meanwhile, miniaturization can greatly reduce the quantities of sample reagents and achieve microfluidic analysis or assays efficiently.
Recently, electroosmotic flow (EOF) pumps [11-12] have received extensive attention because of their ability to drive a wide range of liquid fluids and generate high pumping pressures or flow rates with continuous pulse-free flows. Besides, the EOF pumps can exhibit precise control of small volumetric fluids in microfluidic systems under finely controlled electric fields. Compared with mechanical micropumps, EOF pumps do not require moving mechanical parts inside, which can be easily integrated into pumping platforms to achieve the miniaturization of microfluidic systems. Notably, by changing the strength and direction of the electric field through the pump channels, the EOF pumps can conveniently offer bidirectional fluid flows for microfluidic systems.
The pumping flows in EOF pumps are driven by the mechanism of electroosmotic flow phenomenon [13-15]. When in contact with an uncharged liquid fluid (e.g., deionized water, aqueous solution), channel wall surfaces of PDMS, glass, PMMA, or Si can carry electrostatic charges, forming an electrical double layer nearby. The electrical double layer has a compact layer (containing immobile ions) on the channel surface and a diffuse layer (containing mobile ions) in the liquid fluid. Once an electric field is applied through the pump channel, the mobile ions in the diffuse layer move under the electric field force. As a result of the viscous effect, the moving ions will drag their surrounding fluid molecules to the same speed, forming electroosmotic flow in the pump channel. In short, the electroosmotic pumping performance of EOF pumps is fundamentally dependent on the material property of the pump channel wall and electrical field applied to the pump electrodes. The fabrication of pump channels and electrode plays a vital role in cost control of the EOF pumps. The material and fabrication of the pump channel and electrode are also important considerations in the selection of EOF pumps for microfluidic applications.
Recently, the scientific and technical research of EOF pumping in microfluidics has often focused on the pump channel material, pump electrode, and their fabrication techniques. In this chapter, we will mainly present the research progress of EOF pumps in these aspects and briefly introduce new and recent applications of EOF pumps in microfluidics.
Generally, EOF pumps can roughly be divided into direct EOF pumps, porous membrane EOF pumps, and packed porous media EOF pumps, according to the type of EOF-generating pump channels.
Direct electroosmotic flow (EOF) pumps utilize open pump channels to drive fluids inside. The pumping pressure or flow rate can be increased via enlarging the number of pump channels. Direct EOF pumps are extremely suitable for the introduction delivery of sample reagents containing cells, biomolecules, and larger particles.
Basically, the common direct EOF pumps are fabricated by capillaries (e.g., PMMA, fused silica capillaries), which are named open-capillary EOF pumps [16-20]. The open-capillary EOF pumps, compared with others, are simple, cheap, and easy to fabricate, because the capillaries are popular on the market. However, the capillary cannot offer high pumping pressure or flow rate for microfluidic systems. In the open-capillary EOF pump, inert solid-metal-based thin wires are often used to fabricate the pump electrodes. Normally, the outer diameter of thin wires is much larger than the inner diameter of the capillary channel. To generate electric field through the capillary channel, the thin wire electrodes have to be inserted and fastened into two fluid reservoirs connected with both ends of the capillary. The open-capillary EOF pumps are widely used as sample introduction devices to drive liquid reagents into microfluidic chip platforms.
The direct EOF pumps can also be constructed by open channels. These pumps can be described as direct open-channel EOF pumps [20-24], which are usually used to perform on-chip integratable control of sample reagents in microfluidic chip systems. The open channels in these pumps are usually fabricated with photolithographic microfabrication technologies. Figure 1 shows a widely used direct EOF pump using a PDMS microchannel as an open pump channel. Two inert solid-metal wires (platinum or gold) are inserted into both inlet and outlet fluid reservoirs of the PDMS microchannel as the pump electrodes. The PDMS microchannel in this pump can be fabricated with the standard soft lithography technology, which will facilitate the integration of this EOF pump microfluidic systems. To obtain high pumping pressure or flow-rate fluid flows, the direct open-channel EOF pumps can be usually designed and fabricated with a large number of open pump channels in parallel.
Open-channel EOF pump with metal wire electrodes.
Porous membrane EOF pumps [25-28] utilize a piece of porous membrane to construct sub-microscale or nanoscale pump channels within. They are miniaturized and highly integrated microfluidic pumping devices. Compared with the direct EOF pumps, the porous membrane EOF pumps under action of a large number of micro-/nanopump channels can offer high pumping pressure or flow-rate flows. The porous membranes are frequently made of glass, silica, alumina, or organic polymer (PC or PET) using the high-temperature sintering technique or etching technologies like chemical track etching, physical etching, and soft lithography. The drawback of the porous membrane EOF pump is that the sub-micro- or nanoscale pump channels in the pump cannot be used to transport cell, biochemical macromolecules, or large particle in aqueous suspensions.
Figure 2 shows a popular porous membrane EOF pump with mesh microelectrodes. In this EOF pump, the porous membrane is located between the inlet and outlet fluid reservoirs and vertically fastened to the macrofluid channel wall by both supporting frames. Two pieces of mesh microelectrodes are attached onto both sides of the membrane to reduce voltage drop and generate a high electric field through the pump channels. The pump channels embedded in the porous membrane are relatively short (from tens to several hundreds of μm). Hence, an electric field with high strength can be obtained when a low voltage is applied. In order to reduce fluid flow resistance, the micro-/nanopump channels embedded in membrane are often designed and fabricated straight from one side of the porous membrane to the other.
Porous membrane EOF pump with mesh microelectrodes.
Packed porous media EOF pumps [29-32], highly miniaturized and integrated microfluidic pumps, can drive high-pressure or flow-rate fluids. Similar to the porous membrane EOF pumps, the packed porous media EOF pumps have a large number of sub-micro- or nanopump channels inside. The sub-micro-/nanopump channels are usually prepared by packing sub-micro-/nanodielectric particles or columns into a mini-/microfluidic channel. These dielectric particles or columns can be made of fused silica, alumina, or organic polymer.
Figure 3 presents a typical example of packed porous media EOF pump with metal wire electrodes. In this EOF pump, a short mini-/microfluidic channel is used to build the pumping region with two pieces of porous membranes on both sides. The packed particles are held in place inside the fluid channel. Two metal wire electrodes are separately inserted into both inlet and outlet fluid reservoirs, paralleling to the fluid channel. Because the particles are randomly distributed inside the fluid channel, the fluid flow resistance in the pump will rise with pumping, thus leading to the reduction of pumping pressure or flow rate. To produce high flow rates or high pumping pressures, the EOF pump can be designed with a large number of parallel sub-micro-/nanopump channels. Alternatively, sub-micro-/nanodielectric columns can be introduced and packed into this pump (shown in Figure 3) to construct parallel sub-micro-/nanopump channels. For convenient fabrication purpose, the packed columns should be short in length compared with the fluid channel.
Packed porous media EOF pump with metal wire electrodes.
Electrodes, the key components of EOF pumps, can be used to induce the driving electric field through the pump channels with applied voltage. In EOF pumps, the material and fabrication of the electrodes are vital factors in pump performance and cost control. Basically, there are two electrode types. One is contact electrode exposed to the fluid and the other is noncontact electrode separated from the fluid. This section will show detailed description of them.
Contact electrodes mainly made of solid metals are the most widely used electrodes in EOF pumps. The solid-metal-based contact electrodes are often divided into three groups, which are metal wire electrodes, membranous microelectrodes, and mesh microelectrodes.
Metal wire electrodes [33-36] are inserted into the inlet/outlet reservoirs of the pump channels in EOF pumps, as shown in Figure 13. These metal wire electrodes are the simplest type for EOF pumps, which can be bought easily. However, they are not suitable for the integration or miniaturization of the pumping devices in microfluidic systems. Due to the smaller size of metal wires as shown in Figure 3, the metal wire electrodes are not capable of generating a roughly uniform electric field throughout the whole pump channels with applied voltage. Therefore, the pump cannot offer steady flows with a uniform velocity field inside the channel.
Membranous microelectrode used in open-channel EOF pump.
Membranous microelectrodes [37-40] are often fabricated under the pump channel using sputtering or deposition techniques, as shown in Figure 4. They can be well miniaturized and integrated into the on-chip pumping system. However, it is important to note that the membranous microelectrodes have to be fabricated separately with the pump microchannels, and they should be accurately aligned with the pump microchannels during bonding. The fabrication of these membranous microelectrodes is complex, expensive, and time-consuming.
Figure 5 presents the fabrication of the membranous microelectrodes together with the pump channels for the open-channel EOF pumps. The membranous microelectrodes are fabricated onto a glass substrate through techniques of sputtering and standard soft lithography (Figure 5 (a)), and the PDMS pump microchannel can be prepared by soft lithography technique (Figure 5 (b)). After fabrication, the PDMS pump microchannel is irreversibly bonded with the glass substrate. Since the membranous microelectrodes are located under the pump channel, the EOF pump cannot obtain a parallel electric field through the pump channel or drive uniform pumping flows. To achieve an almost uniformly distributed flow, the pump microchannel needs to be designed with a relatively low high-aspect-ratio section.
Fabrication of open-channel EOF pump with membranous microelectrodes and PDMS-based pumping microchannel.
Similarly, mesh microelectrodes [41-43] are miniature and integratable ones for EOF pumps, as shown in Figure 2. They are very suitable for the porous media EOF pumps, which will strengthen the miniaturization and integration of the EOF pumps into microfluidic systems. In EOF pumps, the mesh microelectrodes are usually placed and fastened on both ends of the porous pump channels. During assembly, meshes of each electrode have to be aligned with the sub-micro-/nanopump channels. Different with the membranous microelectrodes, the mesh microelectrodes can induce a roughly uniform electric field in the pump channels. They can easily offer high flows at relatively low voltages. However, they do have the same characteristics that are extremely complex and expensive in fabrication.
The contact electrodes exposed to the fluid usually give rise to a serious problem of electrolysis during pumping. Bubbles or other electrolytic products can occur at the electrode surfaces, entering the pump channels and blocking the EOFs. What’s more, the joule heat will be generated in the fluid. All bring a sharp decrease in electroosmotic mobility and flow rate. Even worse, the short circuit of high-voltage supply equipment happens sometimes. The use of inert solid-metal platinum (Pt) and gold (Au) electrodes can largely reduce the electrolysis in EOF pumps. The abovementioned problems can be eliminated if the solid-metal electrodes are separated from the aqueous reagents in the pump channels.
Noncontact electrodes have been developed to prevent the above problems. These noncontact electrodes often utilize nonmetal materials (e.g., polymer gel, silica, polyaniline, PDMS) as membrane layers to separate the solid-metal electrodes from the EOF pumping fluid. The membrane layers are capable of allowing ion charges to pass through but stopping water molecules, and thus bubbles and by-products from electrolysis at the electrode surfaces can be prevented from entering the EOF pump channels in these micropumps.
Gel-type salt-bridge microelectrode used in open-channel EOF pump.
Gel-type salt-bridge electrode, a widely used noncontact electrode in the field of electrochemistry, has been successfully fabricated for EOF pumps with bubble-free formation [22, 33]. Figure 6 shows a typical bubble-free EOF pump with this gel-type salt-bridge electrode. As shown in Figure 6, this EOF pump employs a thin gel region to protect the solid-metal wire electrode from the fluid. The wire electrode is immersed in the electrode reservoir filled with a conductive aqueous solution. When a high voltage is applied to the pump, the electrolysis can still emerge inside the pump. But, bubbles can only be generated at the wire electrode surfaces in both electrode reservoirs, having no effect on the fluid flows in the pump channels. In this pump, both of the two gel regions are located in the electrode reservoirs between the metal wire electrodes and the parallel pump channels. The polymer gel, a sensitive polymer material, can be used for the microscale gel regions with the normal photolithography technique. During photolithographic fabrication, the mask for both two gel regions always has to be aligned costly and accurately. As a result, the fabrication of these gel-type salt-bridge electrodes requires a complex process. Another potential problem for this electrode is that the gel region can be easily collapsed due to the poor compatibility of gel material to the electrode reservoir wall. In the worst cases, electrolysis and bubbles will also be generated in the pump channels.
Other noncontact microelectrodes, such as fused silica capillary microelectrodes [31, 44], polyaniline-wrapped aminated graphene microelectrodes [45], and Ag/Ag2O microelectrodes [46], have been successfully fabricated to work as noncontact electrodes for bubble-free EOF pumps. In fabrication, three noncontact microelectrodes can be made from the chemical synthesis or assembly method in the laboratory. Compared with the gel-type salt-bridge microelectrodes, the three microelectrodes are robust in long-time running. However, the fabrication of this kind of electrodes is also a very complex, time-consuming, and expensive process. Now, the first challenge is to develop a new noncontact electrode with a simpler and cheaper fabrication technique.
Handy liquid-metal microelectrode used in open-channel EOF pump.
Injecting wettable liquid metal into microchannels to make noncontact electrodes should be a simpler and cheaper method for bubble-free EOF pumps. Figure 7 shows a handy liquid-metal (GaInSn)-based EOF pump fabricated in a PDMS microfluidic chip [47]. In this pump, the liquid metal is a kind of metal alloy (GaInSn), which can be easily injected into microchannels by a simple syringe. The melting point of this liquid metal is only 10.6 °C below room temperature. As shown in Figure 7, two pairs of liquid-metal electrodes are fabricated parallel to each other and vertical to the pump channel in the same horizontal plane of the microfluidic chip. These two pairs of electrodes are also designed symmetrically to both sides of the pump channel. To induce high electric field strength in the pump channel when a relatively low voltage is applied, the electrodes are placed very close to but always not in contact with the pump channel. In this pump, the PDMS gaps are designed to be ≤ 40 μm between the liquid-metal electrode channels and the pump channel. For the convenience of liquid-metal injection, the liquid-metal electrode microchannels are all designed in the ohm shape.
Figure 8 depicts the typical fabrication of the liquid-metal noncontact electrodes for the open-channel EOF pump. Compared with membranous or mesh microelectrodes (shown in Figure 5), the liquid-metal electrode channels can be easily made just in one step together with the pump channel using the same fabrication technique. Furthermore, the liquid-metal electrodes can also be easily designed and fabricated in any shape and any location in the EOF pump. Using liquid-metal-filled microchannels as noncontact electrodes can provide an efficient approach to the miniaturization and integration of EOF pumps in microfluidic systems.
Fabrication of handy liquid-metal microelectrode for open-channel EOF pump.
EOF pumps can offer a simple and cost-effective way to generate adequate pumping pressures and flow rates for microfluidic systems. They have been widely and successfully used in many areas of microfluidics. In this part, we will briefly introduce applications of EOF pumps in microfluidics. Based on the category of application areas, this section will be divided into 1) microfluidic delivery and actuation and 2) microelectronic thermal management.
Due to the simplicity of pumping components, EOF pumps have been widely used in microfluidic delivery of pure liquids or aqueous solutions. As a micrototal analysis pumping tool, the EOF pump is commonly fabricated to be disposable devices with a compact design. The online reduction of sample reagent quantities should be desirable. For microinjection delivery, in particular, the EOF pump is usually required to offer high flows. Preferentially, open-capillary EOF pumps [16-20] are used to perform the introduction of sample reagents into a microfluidic analysis or assay system. The open capillary has the ability to deliver a wide range of sample reagents such as pure liquid drug reagents and aqueous solutions containing cells, particles, or biochemical macromolecules. The porous media EOF pumps [25-32] can also be used to drive pure liquid sample reagents for the injection purpose. For on-chip microfluidic delivery, open-channel EOF pumps [20-24] are the most popular pumping devices. The reason is that the open pump channels and the pump electrodes can be easily and conveniently integrated into the microfluidic chip together with other functional components.
In most microfluidic systems, efficient mixing of sample reagents is extremely essential for improving the throughput of microfluidic assays and analysis. Many active mixing methods [48] using external actuation forces to perturb the sample reagents to enhance their diffusion have been recently developed to achieve a high mixing performance. Most of the external actuation forces are generated by mechanical moving, stirring, or vibrating. Owing to the fast electrical operation, the EOF pump has also been widely used to perform highly efficient active mixing in microfluidics. The EOF-actuated mixing utilizes electroosmotic driving forces to induce oscillatory, turbulent, or chaotic flows in the sample reagents, while a periodic electric field is applied simultaneously [49]. Several typical open-channel configurations, such as T-shaped, Y-shaped, and multi-shaped configurations, have been developed for the EOF-actuated mixing [50-56]. The use of EOF pump does not require mechanical moving components and hence brings cheaper and more reliable microfluidic mixers. Besides, the EOF pump can also be used as a microactuator for focusing and separation of droplets, particles, or cells in microfluidic systems [57-58].
With the rapid development of MEMS technologies, the design of a miniature electronic chip with more and more functional components has become an essential demand in recent years. Consequently, power consumption is increased to maintain operation which generates great heat flux. Air-forced cooling cannot remove such high heat flux from the hot chip. Micropumping that drives liquid fluids through microchannels is an efficient approach to perform heat dissipation of electronic components [10-12].
EOF pumps have been considered in microchannel-based liquid cooling for electronic chips owing to their low power consumption and high pumping pressure. EOF pumps can work without any noise during liquid coolant pumping. Recently, a porous media-based EOF pump [59] has been successfully utilized for liquid cooling of microelectronic chips. In this microchannel liquid cooling system, the pump works as an external device to drive water coolant to force thermal dissipation of the hot region in the microelectronic chip. To reduce the thermal resistance, the microchannels filled with liquid coolant are tightly attached to the hot surface of electronic chip. Since the microchannels have high surface-volume ratio available for thermal dissipation, the EOF pump is capable of removing the heat generation efficiently.
This chapter has briefly reported recent research progress of EOF pumps with emphasis on channel materials, electrodes, and their fabrication and summarized pump applications in microfluidics.
EOF pumping is commonly used in many microfluidic devices. Nowadays, it has become an increasingly popular tool to manipulate such liquid sample reagents with electric fields. The number of microfluidic applications is growing fast, and certain EOF pumping devices, like porous membrane EOF pumps (Osmotex), have been already commercially available. However, the popular use of EOF pumps in microfluidics may be limited due to the lack of high-performance pumps with cost-effective characteristics.
The EOF pump continues to be improved, which shows stable performance, rapid operation, and compact design. EOF pumps with noncontact electrodes have generated robust pumping flows without bubble formation, but there is still a lot of work to be done for improving these pumps. Further research is required to understand the basic driving mechanism of gel, silica, or PDMS-based noncontact electrodes. Research on new material design and fabrication is also an urgent need for noncontact electrodes with low-cost and simple process. Another option of liquid metal, instead of solid metal and conductive aqueous solution in electrode reservoirs of noncontact electrodes, should be an alternative solution for the water electrolysis at the solid-metal electrode surfaces.
EOF pumps do not require mechanical moving components, and they can offer excellent miniaturization potential in integrated microfluidic applications. With applied electric fields, EOF pumps are capable of performing fine control of fluids fast. In the near future, the EOF pump should be an important element in promising implantable medical devices such as drug transport or infusion pumps.
This work is financially supported by the National Natural Science Foundation of China (Grant No. 51276189).
A pandemic, by definition, is an epidemic of an infectious disease that has progressed across a large region, for instance multiple continents, affecting a substantial number of people [1]. COVID-19 is caused by an infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus strain, initially isolated from individuals with pneumonia and a constellation of acute respiratory signs/symptoms signs and symptoms in Wuhan, China in December 2019 [2]. Signs and symptoms include: fever (71%), cough (80%), fatigue (62%), muscle aches (61%), headache (46%) and shortness of breath (43%) in addition to loss of taste or smell (32%) [2]. Approximately 93% of patients encountered a triad of signs/symptoms including fever, cough and shortness of breath [3].
Initially, COVID-19 was identified in the United States in January 2020 and in March 2020, the World Health Organization (WHO) affirmed COVID-19 as a pandemic [3]. About one year after the initial identification, approximately 92.7 million individuals have been diagnosed as having COVID-19 worldwide [4]. As of January 2021, approximately 2 million individuals have succumbed to COVID-19 worldwide [4]. Prior to the COVID-19 pandemic, the 2009 Influenza A (H1N1) pandemic infected approximately 1.4 billion individuals worldwide and killed approximately 575,000 of said individuals [5]. The 2014 Ebola Virus Disease (EVD) pandemic infected approximately 28,656 and killed approximately 11,325 of said individuals [6]. In contrast, these figures pertaining to previous noteworthy pandemics that were ultimately restrained, illustrate that the present pandemic is unparalleled, particularly pertaining to mortality.
The pandemic incited a considerable response regarding cautionary and counteractive measures by both state and federal administrations to address an uptick in incidence including legislation like the Coronavirus Aid, Relief and Economic Security (CARES) Act and the Coronavirus Preparedness and Response Supplemental Appropriations Act [7]. At $2 trillion and $8.3 billion respectively, they were to help expand assessment for COVID-19, vaccine research and PPI procurement [7]. This legislation, particularly the CARES Act, allocated monetary reimbursement to the American public and provided supplemental unemployment payments subsequent to imposed quarantines throughout the country. Aside from legislation, partnerships among constituents of the Department of Health and Human Services (HHS) including: Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Biomedical Advances Research and Development Authority (BARDA) and the Department of Defense (DoD) donned Operation Warp Speed in May 2020, in a concerted attempt to develop 300 million doses of efficacious FDA approved vaccines available by January 2021 [1]. As of January 2021, the FDA has approved two vaccines for emergency use to battle the pandemic: co-developed Pfizer-BioNTech and Moderna [8]. Additionally, Operation Warp Speed has been integral in promoting the use of alternative therapeutics against COVID-19 like FDA-approved REGN-COV2, a combination of monoclonal antibodies casirivimab and imdevimab [1].
Several studies have assessed the association among the COVID-19 pandemic, the pervasiveness of adverse psychosocial stressors encountered by trainees and the detrimental effects on the trainee’s well-being regarding GME. Resultantly, these studies indicate that it is imperative to perpetuate the transfiguration of procedures and policies through the Accreditation Council for Graduate Medical Education (ACGME) and subsequent GME constituents of respective residency training programs, as a means to address the negative impact the COVID-19 pandemic has had on post-doctoral training. Prior to the COVID-19 pandemic, there were a plethora of studies that examined physician well-being and welfare including the prevalence of physical and emotional exhaustion that exacerbates burnout, using reliable psychological assessments like the Maslach Burnout Inventory. Nonetheless, the predominance of said studies disregard the post-doctoral trainee population, particularly throughout a pandemic that poses personal and professional challenges to a previously susceptible practitioner population.
A website search engine was used to assist in the selection of an assortment of studies examining the negative implications the COVID-19 pandemic has had on post-doctoral training pertaining to the prevalence of physician burnout. Scholarly sources such as the National Library of Medicine, particularly the National Institutes of Health, including peer-reviewed literature catalogs like PubMed were used. Keywords used were burnout related to intern, resident, residency, fellow and COVID-19. Additionally, the keywords welfare and well-being were used in relation to the previous specifiers pertaining to post-doctoral trainees. Inclusion criteria included: studies about physician burnout including at least one of its primary symptoms (emotional exhaustion, depersonalization or decrease in personal satisfaction), studies composed using the English language, studies that illustrate empirical results using reliable instruments to measure instances of burnout like the Maslach Burnout Inventory, more specifically the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP) and studies that examined a patient population primarily comprised of post-doctoral trainees (i.e. residents and/or fellows). Exclusion criteria included: studies composed using a non-English language, studies possessing no preset criteria pertaining to physician burnout, studies that disregard the examination of burnout related to residents and/or fellows.
Burnout was a term originally defined by psychologist Herbert Freudenberger in a 1974 article titled, “Staff Burnout”, essentially discussing job dissatisfaction precipitated by work-related stress [9]. Physician burnout is defined as a syndrome related to the healthcare profession involving emotional exhaustion, depersonalization or decrease in personal satisfaction [9]. In May 2019, the 11th revision of the International Classification of Diseases (ICD-11) included a more detailed definition of burnout, characterizing it as a chronic work-related syndrome that can be assimilated into the healthcare profession. This definition of burnout incorporates three different domains including: feelings of energy depletion or emotional exhaustion, increased mental distance from one’s job or feelings of cynicism or negativism about one’s job and reduced professional efficacy [10]. Additionally, the WHO designated burnout not as disorder, rather a phenomenon. Physician burnout correlates to lower patient satisfaction, higher rates of medical errors and malpractice, higher physician turnover and predisposition to substance abuse, addiction and suicide [11]. Presently, the epidemic of physician burnout in the United States is being appreciably addressed in the setting of post-doctoral education to deter the adverse consequences that contribute to the conveyance of substandard healthcare that quite often originates as a resident/fellow and propagates into one’s practice as an attending physician (Figure 1).
The 3 domains of physician burnout as adapted from west et al. [
Prior to the COVID-19 pandemic, physician burnout among post-doctoral trainees was becoming immensely problematic with an alarming increase in the prevalence and pervasiveness of this phenomenon. A 2018 excerpt in the Journal of the American Medical Association (JAMA) illustrated this alarming increase in physician burnout through two studies. One of the studies surveyed about 3,600 second-year residents and illustrated that approximately 45% of the residents encountered burnout whereas approximately 15% of said surveyed residents regretted practicing medicine [12]. Also, this study indicated a higher prevalence of burnout among physician trainees versus non-healthcare personnel (28.4%). Per the second study included in the 2018 JAMA excerpt, 182 articles spanning 1991–2018 surveyed approximately 100,000 trainees in 45 countries in regard to burnout. The prevalence of burnout varied from 0%–81% including emotional exhaustion, depersonalization or negativism, reduced professional efficacy or a combination of all three domains [12]. In contrast, Monsalve-Reyes et al. (2018) demonstrated that a lower prevalence of burnout existed among about 1110 primary care nurses versus their resident trainee counterparts [13]. These examinations exemplify that although burnout is a phenomenon that is able to be encountered by any laboring individual, it is evident that the physician trainees suffer from a higher prevalence of burnout, even in comparison to other individuals involved in healthcare.
Analogous to the COVID-19 pandemic, previous pandemics including the 2009 Influenza A (H1N1) pandemic and the 2014 Ebola Virus Disease (EVD) pandemic, exemplify that an emotional burden exists pertaining to not merely alterations in an individual’s behavior, rather predilection to mood disorders. This is consequential of medically managing symptomatic patients infected by a deadly disease and encountering deceased individuals of said deadly disease including the bereavement of deceased individuals in your support system. A 2017 excerpt that examined observers of the Ebola pandemic illustrated that 39% experienced difficulty concentrating on errands, 33% experienced difficulty sleeping subsequent to worry and 5–10% experienced feelings of worthlessness, diminished decisiveness or loss of confidence in one’s self [14].
Conversely, this excerpt emphasized the significance of a sensation coined “post-traumatic growth”, commonly referred to as PTG. This is defined as a positive change in one’s behavior as a result of struggle regarding a major life crisis or trauma [14]. PTG is described as an augmentation in different domains including an increase in appreciation for one’s existence and others in addition to an improved sense of closeness and cohesion in interpersonal relationships that is conducive to an individual’s ability to contest adversity [15]. This is in opposition to remaining in a disparaging rotation of maladaptive behavior that is common in mood disorders including post-traumatic stress disorder (PTSD). Also, encountering trauma or substantial distress promotes reprioritization of an individual’s commitments through incorporating a revision in their spirituality or sense of self [15]. Therefore, additional studies are merited to examine physician burnout and post-traumatic growth pertaining to adaptive behaviors as opposed to maladaptive behaviors that are routinely recognized in traumatic experiences, particularly amidst a pandemic (Figures 2 and 3).
The 4 precipitating factors of post-traumatic growth (PTG) as adapted from Godbold et al. [
The 5 domains of post-traumatic growth (PTG) as adapted from CT et al. [
Presumably, the COVID-19 pandemic has presented inimitable challenges to the delivery of healthcare, particularly by post-doctoral trainees in residency and fellowship programs. Post-doctoral trainees are predominantly on the forefront of healthcare to acquire an unmediated, practical proficiency in the practice of medicine in addition to addressing the increasing demand for appropriate healthcare. The COVID-19 pandemic has certainly stimulated an increase in the demand of healthcare as substantiated by the cumulative COVID-19-associated hospitalization rate of 364 hospitalization per 100,000 population through January 2021 in contrast to the hospitalization rate of 4.6 per 100,000 population at the beginning of March 2020, prior to the pandemic [18]. The COVID-19 pandemic has undoubtedly exacerbated the preexisting problem of physician burnout, particularly pertaining to post-doctoral trainees. Several studies have examined the presence of behavioral health ailments like mood disorders including depression, anxiety or stress and diminished satisfaction in their corresponding specialties, corresponding to their particular exposure to COVID-19 versus non-COVID-19 patients. Physician trainees exposed to COVID-19 patients encountered higher prevalence rates of mood disorders like depression (28%), anxiety (22%) and overall stress (29%) compared to their non-COVID-19 exposed peers (26%, 15% and 19% correspondingly) and the ordinary populace (12%, 11% and 11% correspondingly), as illustrated by comparable scoring using the Beck Depression Inventory, Beck Anxiety Inventory and the State–Trait Anxiety Inventory [18]. Exposure to COVID-19 patients increased the prevalence of burnout in physician trainees (46%) compared to 33% in non-COVID-19 patient exposure, as illustrated by examination of physical/emotional exhaustion, interpersonal disengagement (depersonalization) and professional satisfaction, using the Stanford Professional Fulfillment Index (PFI) [19]. Exposure to COVID-19 patients did not contribute to the low professional satisfaction scores pertaining to clinical concerns (25.2% vs. 25.9%) [19].
Aside from an increased prevalence of behavioral health ailments like depression, anxiety or stress and diminished satisfaction in their corresponding specialties, the COVID-19 pandemic has impaired the trainee’s ability to achieve a balance between professional and personal responsibilities. Physician trainees were queried about common psychosocial stressors, if applicable, including monetary concerns, childcare and eldercare. Additional queries included ability to take time off and interference regarding a trainee’s personal responsibilities. Exposure to COVID-19 patients increased the prevalence of stress related to childcare (62%) versus trainees not exposed to COVID-19 patients (39%), an increased prevalence of inability to take time off (74%) versus trainees not exposed to COVID-19 patients (48%) and interference in personal responsibilities (68%) versus 55% in non-exposed trainees [20]. In comparison, exposure to COVID-19 patients did not contribute to an increase in prevalence of monetary concerns (67% for each cohort) or eldercare (82% for each cohort) [20].
Considerable reformation of ACGME/GME policies and procedures pertaining the adverse clinical settings created by the COVID-19 pandemic and physician burnout have been implemented to mitigate the disadvantages and detriments of physician burnout. The ACGME assigned six core competencies to assure competency-based assessment and specialty-specified milestones include: patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice and medical knowledge [21]. Historically, these competencies were created to assist not merely in ACGME accreditation of 12,500 corresponding residency and fellowship programs to assure appropriate training of approximately 140,000 trainees, rather to assure that trainees are prepared to address the increasing demands imposed on the healthcare system [21]. This has become increasingly imperative as a result of the COVID-19 pandemic.
Consequential of the increase in demand of healthcare propagated by the COVID-19 pandemic, the ACGME has reiterated the importance of prioritizing the response to the COVID-19 pandemic versus previous GME protocols except appropriate work-hour restraints and resident oversight by attending physicians [22]. This has adversely affected the compulsory volume of patients evaluated by trainees in the inpatient and outpatient settings, including the cancelation of elective procedures. Unfortunately, this has adversely affected proficiency in the practice of medicine derived from pragmatic experience, particularly in specialties that are constructed around procedures. Additionally, trainees have encountered instances of reassignment to assist in the delivery of COVID-19 related medical management, often outside the realm of one’s specialty of study and concurrently in the pervasive presence of a shortage of personal protective equipment (PPE) [22]. Although this allows for diverseness in experiential education, the uncertainty of resident rotations including electives and reassignment to the forefront of the pandemic lessens experiences in a trainee’s respective specialties. The archetypical medical lectures and symposiums have undeniably been susceptible to the COVID-19 pandemic because of the present CDC’s suggestions to abandon in-person instruction. Therefore, transitioning post-doctoral training to adhere to the requirements for distance learning has required innovative implementation to diminish the disruption to medical education delivery and sense of comradery that comes from socialization.
The response of the ACGME and related GME programs has been rapid and robust to avoid an abrupt deterioration in the educational experiences of post-doctoral training that is of the utmost importance to develop adept practitioners. This response has been aimed at numerous stages of medical education, extending from forgoing ACGME activities regarding accreditation of training programs to the preferment of telemedicine and virtual video conferencing to continue instructive endeavors [21]. Regardless of the stage of response, the commonality among said responses subsists in adequately addressing the preservation of the trainee’s educational experience derived from the appropriate medical management of patients using an attentive albeit cautious approach. Remarkably, this approach has had the inherent ability to be altered in relation to the uncertainty to the COVID-19 pandemic.
In an attempt to assure proper patient care and mitigate institutional challenges imposed by the COVID-19 pandemic, the ACGME delayed the direct surveyal of sites including accreditation and clinical learning environment review (CLER) [22]. The ACGME has deferred the assessment of a post-doctoral trainee’s proficiency to the program director and Clinical Competency Committee (CCC) because of the adversely affected compulsory volume of patients evaluated in inpatient and outpatient settings in addition to the reassignment of trainees to assist in the medical management of COVID-19 patients [21]. Likewise, the ACGME deferred the determination of a trainees capability to practice medicine unsupervised, indicated through completion of their residency training program, because of rotation resignment [21]. The ACGME and corresponding GME programs have increasingly implemented telemedicine including the redefining of “direct supervision” as the supervising physician and/or patient not being physically present with the trainee, consequential of concurrent patient care by the supervising physician and trainee through telecommunication [23]. The transition of post-doctoral training from in-person education to telecommunication for educational instruction has required innovative implementation to diminish the disruption to medical education delivery and sense of comradery that comes from socialization. Irrespective of the integral role of telecommunication in patient encounters or in-person conferences, adherence to 80 hours of clinical and education work per week, the maximum of every third day call and the minimum of one day per seven days free of clinical duties approximated over four weeks, including the reception of appropriate training regarding PPE, is compulsory to preserve proper work-hour restraints and oversight [23].
The transfiguration of GME policies and procedures in the setting of adverse clinical conditions imposed by the present pandemic has concentrated on trainee well-being to contest physician burnout. The ACGME has created coalitions with the National Academy of Medicine (NAM) to create the ‘Action Collaborative on Clinician Well-Being and Resilience’ in addition to promotion of their ‘AWARE’ program to promote well-being, mitigate the adverse effects of psychosocial stressors encountered in training and prevent burnout by-and-large [21]. Particular to the COVID-19 pandemic, the ‘Well-Being in the Time of COVID-19’ guidebook contains responses to illness and death due to COVID-19 by incorporating six strategies to promote well-being including: optimizing a challenging working and learning environment, promoting connectedness, building skills and mindsets, providing virtual resources for well-being support, identifying and assisting residents and fellows in distress and delivering coordinated crisis planning and management [24].
Numerous institutions have implemented Stanford’s WellMD Initiative to disseminate positive transformations at the GME level. Created in 2015, this initiative discusses a culture of wellness including behaviors, attitudes and values that promote self-care, organizational responsibility regarding value of time and energy in clinical practice and personal resilience regarding behaviors and attitudes that contribute to personal well-being [25]. Initiatives like the aforementioned have advocated for added examinations of different interventions to diminish the extensiveness of burnout in the healthcare setting. A 2017 study by Busireddy et al. illustrated that a reasonable decrease in ACGME duty hours improved emotional exhaustion and burnout, evident by 42% lower odds of the percentage of residents reporting high levels of emotional exhaustion (OR = 0.59; 95% confidence interval 0.45–0.79; P < 0.001) [26]. A 2019 study by Spinelli et al. illustrated that interventions predicated on mindfulness possessed moderate effect on anxiety (Hedge’s g = 0.47), depression (0.41), psychological distress (0.46) and stress (0.52) [27]. Small to moderate effects were present for burnout (0.26) and well-being (0.32) [27]. Therefore, there is substantiating evidence that cognitive and behavioral interventions on personal and institutional levels ideally lessen the severity of trainee burnout. An abundance of GME programs have adopted the application of wellness interventions into their curricula like St. Luke’s University Health Network lifestyle medicine. Lifestyle medicine integrates positive transformation in an individual’s nutrition, physical activity and coping mechanisms to lessen the precipitating and perpetuating factors that worsen physician burnout (Figure 4).
The Stanford wellness framework as adapted from Stanford medicine et al. [
The ACGME and corresponding GME programs have afforded analogous post-doctoral trainees an ability to retreat from the pervasiveness of adverse psychosocial implications the COVID-19 pandemic has inflicted on this susceptible practitioner population. Through policies that promote enhanced well-being and an increased emphasis on behavioral interventions that endorse resilience, precipitated behavioral health ailments including depression and anxiety, diminished satisfaction and an impaired ability to achieve balance between professional and personal responsibilities have been dissuaded. Likewise, cautionary and counteractive measures have been endorsed by both state and federal administrations through enacted legislation, assuring that there has been a dynamic response to deter inconducive clinical settings regarding medical education. Additional examinations are essential to assess the advancement and application of present ACGME/GME approaches that address post-doctoral trainee burnout, irrespective of the avail present-day approaches have had on administrative and clinical levels. Notably, added examinations are essential to assess the awareness and implementation of resiliency training targeting the medical school and medical student population prior to their progression into post-doctoral trainees. Seeing as the consequences of the COVID-19 pandemic are continuous and noticeably apparent through the lapse of time, supplementary study is necessary in the presence of an unresolved pandemic.
The authors declare no conflict of interest.
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