Job Satisfaction among Resident Doctors of a Tertiary Care Hospital in South Delhi.

Background: Doctors' job satisfaction is crucial to the health service to ensure commitment, effective training, service provision, and retention. Job satisfaction matters to doctors for their happiness, fulfilment, service to patients, and duty to employers. The quality of performance in the health sector to a large extent depends on whether healthcare providers are job-satisfied or dissatisfied. Objectives: This study assessed the level and factors determining job satisfaction among resident doctors in a federal tertiary institution. Material and Methods: A cross-sectional study was conducted among the resident doctors of a government tertiary care hospital. Data were collected using a self-reported questionnaire consisting of 49 items under seven domains of job satisfaction, where higher values indicated a higher level of satisfaction. The average scores of items were computed to construct factor scores for each individual. A Chi-square test was applied. Results: The proportion of job satisfaction among resident doctors was found to be 80.9%. On adjustment, the odds of being satisfied were found to be higher in the older age groups, among males, and doctors posted in clinical departments. Conclusion: Most respondents in this study were satisfied with their jobs with minorities satisfied with their monetary and infrastructure facilities. There is a need to address these issues to enhance healthcare quality, especially in the public sector.

Childlessness among Muthuvan Tribes of Tamil Nadu, India: An Exploratory Study.

INTRODUCTION: Childlessness is a global concern and it has serious demographic, social, and health implications. The declining Muthuvan child population may reduce their population on the whole. OBJECTIVE: The study explored the prevalence of childlessness and its underlying reasons in the Muthuvan tribes of Tamil Nadu. SUBJECTS AND METHODS: The study applied the mixed-method design, and the snowball technique was adopted to identify eight Muthuvan hamlets. Descriptive and thematic analysis was done for the collected quantitative and qualitative information. RESULTS: The study found the prevalence of childlessness among Muthuvan couples as 30.65%. The underlying reasons were their cultural practices of confinement during menstruation and restriction on engaging in productive work and family care, which gave them the idea of regular intake of oral contraceptive pills and lessen their desire to have children. CONCLUSION: The study concludes that the comfort of their daily life has taken over more important than the consequences of objects used for comfort, to their health and future generations.

Is there any perceptiveness about the mode of transmission of human immunodeficiency virus/acquired immune deficiency syndrome? An analysis among the adolescent tribal students in Tamil Nadu.

BACKGROUND: Cognizance about human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) among the community is still lacking. Seldom studies done in tribal area and to indentify the awareness about HIV/AIDS among the adolescent tribal students in Jawadhu hills of Tamil Nadu, with the objectives includes on social, demographical, and knowledge about HIV/AIDS were taken. For primary data, survey method and secondary data from various literatures gathered. MATERIALS AND METHODS: Schedule tribe adolescent students, between the age groups of 13-21 years, from 8th to 12th standard, exclusively from Vellore and Tiruvannamalai educational districts, were taken, by applying STRATA method. RESULTS: A total of 938 students from various tribal schools participated. Amongst them, 507 (54%) were males and 431 (46%) were females. Half of the respondents (50%) agreed that blood transfusion, intravenous drug use, and sharing infected needles are the major modes of transmission. Nearly 35% agreed that HIV/AIDS is transmitted by hugging, tattooing, dirty hands, breastfeeding, kissing on cheeks, shaving at the barber shop, shaking hands with AIDS patients, homosexuality and are food and waterborne. CONCLUSIONS: Formal HIV/AIDS education should be mandatory in their curriculum, where teachers get an opportunity to deliver the scientific information about HIV/AIDS. To acquire better knowledge about HIV/AIDS, sex education should be included in the mainstream of curriculum with the assistance of educational consultants, professional social workers, and also local non-governmental organizations to conduct further mindfulness camps about the HIV/AIDS.

Frontofacial surgery in children and adolescents: techniques, indications, outcomes.

The techniques of frontofacial surgery are most valuable in the clinical management of complex craniofacial deformity to achieve a range of functional and aesthetic gains in children from infancy to maturity. A variety of complex craniofacial osteotomies that can be used to separate the orbits from the skull base have been described. In addition, the combination of circumorbital release and pterygomaxillary disjunction allows advancement of the orbitomaxillary segment for powerful clinical benefit. For the purpose of this article, the principal frontofacial strategies include the monobloc frontofacial advancement by distraction (MBD), frontofacial bipartition advancement by distraction (BpD), orbital box osteotomy (FFBx), and frontofacial bipartition (FFBp). These techniques are broadly used for two purposes: to allow for the translocation of one or both orbits to correct orbitofacial disproportion (hypertelorism, vertical orbital dystopia, or a combination of both), or to advance the orbitomaxillary segment for orbital volume expansion and protection of the eye in syndromes featuring severe exorbitism (oculo-orbital disproportion). Here we describe aspects of our experience of frontofacial surgery in the Craniofacial Centre at Great Ormond Street Hospital for Children, London, with reference to the principles underpinning frontofacial surgical techniques, their challenges, and their impact on function and aesthetics.

A clinical analysis of Dupuytren's disease of the thumb.

Although Dupuytren's disease of the thumb was first described in 1833, the literature on this subject is limited to a few anatomical and clinical studies. This study examined the pattern of cords of Dupuytren's disease in 260 thumbs in 181 consecutive patients with evidence of disease relating to the thumb attending an out-patient clinic over a period of 36 months. Discrepancies in the literature are discussed in the light of the findings of this more detailed analysis and a simple but practical pictorial system for recording disease severity and detailing progression over time is presented.

Expression of FGFR-2 and FGFR-3 in the normal human fetal orbit.

AIMS: To demonstrate the expression patterns of two fibroblast growth factor receptors (FGFR-2 and FGFR-3) in the normal human fetal orbit. METHODS: 6 microm orbital slide sections were prepared from 12 week old human fetal material obtained within established ethical guidelines. Radioactive in situ hybridisation techniques were used to demonstrate the expression patterns of FGFR-2 and FGFR-3 within these sections. Only one foetus had appropriate orbital sections taken. RESULTS: FGFR-2 was expressed within the extraocular muscles (EOMs) and the optic nerve sheath and to a lesser degree within the orbital periosteal margins and the cranial sutures. FGFR-3 was expressed a lot within the periosteal margins and cranial sutures but not within either the EOMs or the optic nerve sheath. CONCLUSIONS: FGFR-2 and FGFR-3 are differentially expressed within different orbital components. FGFR-2 gene mutations may be responsible for craniosynostotic syndromes such as Crouzon, Pfeiffer, and Apert, while those in the FGFR-3 gene may cause isolated unicoronal synostosis. EOMs may be histologically abnormal in cases of Apert, Pfeiffer, and Crouzon syndromes but not isolated unicoronal synostosis. The pattern of expression of FGFR-2 in the normal human fetal orbit may explain some of the EOM histological findings seen in some cases of Apert, Pfeiffer, and Crouzon syndromes.

Tripier's innervated myocutaneous flap 1889.

A translation of Tripier's publication in 1889 is presented. This paper includes description of two bipedicled myocutaneous flaps based on the orbicularis oculi muscle and designed as 'bucket-handles'. The author intended that these flaps be a transfer of innervated and functioning muscle and designed the flaps with full awareness of the need to maintain the original muscle length and nerve supply to retain function. This paper was, perhaps, the first description of an innervated myocutaneous flap. A third and new variant of the Tripier flap is described and illustrated.

Circulating aldosterone levels are unexpectedly low in children with acute meningococcal disease.

The incidence of meningococcal disease in childhood has risen over the past decade. Mortality remains high for those who develop septic shock and purpura fulminans. Poor perfusion, hypotension, and loss of intravascular circulating volume may be expected to influence both mineralocorticoid and glucocorticoid secretion. The aim of the study was to define adrenocortical hormone status at presentation. Sixty children admitted to the pediatric intensive care unit were studied. Children were divided into two groups: group A (n = 31), with meningococcal sepsis, mean age 4.4 yr (range 0.5-14.4), predicted risk of mortality mean 32.3% (range 0.5-99.3%); and group B (n = 29), with other diagnoses (post major surgery and with severe respiratory infections), mean age 4.1 yr (range 0.3-16.3), predicted risk of mortality mean 9.4% (range 0.2-83%). The groups were not significantly different for age. Plasma levels of aldosterone and cortisol were determined by RIA. The mean plasma aldosterone concentration on admission in group A was 427.5 +/- 88.1 pg/ml, with 96.7% of values within the normal range for age for healthy children and were significantly lower than group B mean, 1489.2 +/- 244.2 pg/ml (P < 0.0001), with 59.3% of values above the normal range. In group A there was no correlation with plasma concentrations of sodium, potassium, or volume of colloid infused in the previous 8 h. In group A mean serum cortisol mean values were 799.5 +/- 75.9 nmol/liter and in group B cortisol levels were 703.4 +/- 78.6 nmol/liter (P = n.s.). We conclude that children with meningococcal disease present with lower plasma aldosterone concentrations than other patients in the pediatric intensive care unit, for which there is no clear explanation. Further work is needed to elucidate the mechanisms underlying this finding and to examine its clinical implications.

The fascial planes of the temple and face: an en-bloc anatomical study and a plea for consistency.

Many investigators have detailed the soft tissue anatomy of the face. Despite the broad reference base, confusion remains about the consistent nature of the fascial anatomy of the craniofacial soft tissue envelope in relation to the muscular, neurovascular and specialised structures. This confusion is compounded by the lack of consistent terminology. This study presents a coherent account of the fascial planes of the temple and midface. Ten fresh cadaveric facial halves were dissected, in a level-by-level approach, to display the fascial anatomy of the midface and temporal region. The contralateral 10 facial halves were coronally sectioned through the zygomatic arch at a consistent point anterior to the tragus. These sections were histologically prepared to demonstrate the fascial anatomy en-bloc with the skeletal and specialised soft tissues. Three generic subcutaneous fascial layers consistently characterise the face and temporal regions, and remain in continuity across the zygomatic arch. These three layers are the superficial musculo-aponeurotic system (SMAS), the innominate fascia, and the muscular fasciae. The many inconsistent names previously given to these layers reflect their regional specialisation in the temple, zygomatic area, and midface. Appreciation of the consistency of these layers, which are in continuity with the layers of the scalp, greatly facilitates an understanding of applied craniofacial soft tissue anatomy.

Does the use of a specialised paediatric retrieval service result in the loss of vital stabilisation skills among referring hospital staff?

AIMS: To compare the proportion of airway and vascular access procedures performed by referring hospital staff on critically ill children in two discrete time periods, before and after widespread use of a specialised paediatric retrieval service. METHODS: Transport data were obtained from retrieval logs of all children for whom a paediatric retrieval team was launched in each of two time periods (October 1993 to September 1994; and October 2000 to September 2001). RESULTS: The overall intubation rate was similar in the first and second time periods (83.9% v 79.1%). However, 31/51 (61%) retrieved children were intubated by referring hospital staff in 1993-94, compared to 227/269 (84%) in 2000-01. Referring hospital staff gained central venous access in 11% v 18% and arterial access in 22% v 19% of retrieved children in the first and second time periods respectively. This was in spite of a significant reduction in the proportion of children on whom these procedures were performed. CONCLUSION: Referring hospital staff are performing a greater proportion of initial airway and vascular access procedures undertaken in the stabilisation of sick children retrieved by a specialised paediatric retrieval team. The provision of this service has not resulted in the loss of vital skills at the local hospital.

Severe and unrecognised: pertussis in UK infants.

AIMS: To diagnose pertussis using culture, polymerase chain reaction, and serology, in children admitted to intensive care units (PICUs) and some paediatric wards in London, and in their household contacts to determine the source of infection. METHODS: Infants <5 months old admitted to London PICUs between 1998 and 2000 with respiratory failure, apnoea and/or bradycardia, or acute life threatening episodes (ALTE), and children <15 years admitted to paediatric wards at St Mary's and St George's Hospitals between 1999 and 2000 with lower respiratory tract infection, apnoea, or ALTE were studied. RESULTS: Sixty seven per cent of eligible children (142/212) were recruited; 23% (33/142) had pertussis, 19.8% (25/126) on the PICU and 50% (8/16) on wards. Two died. Only 4% (6/142) were culture positive. Pertussis was clinically suspected on admission in 28% of infants (7/25) on the PICU and 75% (6/8) on the wards. Infants on PICU with pertussis coughed for longer, had apnoeas and whooped more often, and a higher lymphocyte count than infants without pertussis. Pertussis and respiratory syncytial virus (RSV) co-infection was frequent (11/33, 33%). Pertussis was confirmed in 22/33 (67%) of those who were first to become ill in the family. For 14/33 children the source of infection was a parent; for 9/33 the source of pertussis was an older fully vaccinated child in the household. CONCLUSIONS: Severe pertussis is under diagnosed. An RSV diagnosis does not exclude pertussis. Future changes to the UK vaccination programme should aim to reduce pertussis transmission to young infants by their parents and older siblings.

ISABEL: a web-based differential diagnostic aid for paediatrics: results from an initial performance evaluation.

AIMS: To test the clinical accuracy of a web based differential diagnostic tool (ISABEL) for a set of case histories collected during a two stage evaluation. SETTING: acute paediatric units in two teaching and two district general hospitals in the southeast of England. MATERIALS: sets of summary clinical features from both stages, and the diagnoses expected for these features from stage I (hypothetical cases provided by participating clinicians in August 2000) and final diagnoses for cases in stage II (children presenting to participating acute paediatric units between October and December 2000). MAIN OUTCOME MEASURE: presence of the expected or final diagnosis in the ISABEL output list. RESULTS: A total of 99 hypothetical cases from stage I and 100 real life cases from stage II were included in the study. Cases from stage II covered a range of paediatric specialties (n = 14) and final diagnoses (n = 55). ISABEL displayed the diagnosis expected by the clinician in 90/99 hypothetical cases (91%). In stage II evaluation, ISABEL displayed the final diagnosis in 83/87 real cases (95%). CONCLUSION: ISABEL showed acceptable clinical accuracy in producing the final diagnosis for a variety of real as well as hypothetical case scenarios.

Geometry of the human common carotid artery. A vessel cast study of 86 specimens.

The carotid artery is of special interest for the pathologist because of its frequent depositions, and for the fluidmechanician because of its complex flow properties. However, there is a distinct lack in current knowledge of its geometry. Therefore, a vessel cast study was undertaken. At post mortem, the arteries are excised and filled with a special resin at the proper transmural pressure. Eighty-six vessel casts of the carotid artery were performed, and some etiological factors of atherosclerosis, such as age, sex and disease, were collected. The following selected geometric parameters of these vessel casts were measured in this study: the diameters of the main branches of carotid bifurcation (common, internal and external arteries), and the angles between internal, external and common carotid arteries. The averaged geometric parameters and their variability over 86 vessel casts of the carotid artery were investigated. Furthermore, the relationship between these measured parameters and the etiological factors age, sex and disease was analyzed. The geometric parameters varied considerably, presumably contributing to a corresponding variability in the local hemodynamic and distribution of the atherosclerotic lesions.

Atherosclerosis and flow in carotid arteries with authentic geometries.

The influence of blood flow on the depositions and development of atherosclerotic lesions have been observed and described since the 19th century. Observations have shown that depositions correlate with regions of low wall shear stress. However, the exact correlations between depositions, vessel geometry and flow parameters are not yet known. The purpose of this study was the quantification of atherosclerosis risk factors in carotid bifurcation. This artery has attracted particular interest because lesions are often found in this bifurcation. Post mortem, the arteries are excised and vessel casts are produced. Afterwards, the arteries are analyzed morphometrically. The vessel casts are used for the assessment of some geometrical parameters. 31 carotid bifurcations were analyzed in this study. Eight vessel casts were digitized and rendered three-dimensional mathematical models of the arteries. These data were imported by the computational fluid dynamics program FLUENT. Further, the blood flow was reconstructed in a computer model based on the individual vessel geometry. The flow parameters, such as velocity, pressure and wall shear stress were computed. At the same time the geometrical parameters and wall alterations are known. This permits the comparison of the anatomical shape and its flow with the distribution and level of the wall alterations.

Thumb function without the abductor pollicis longus and extensor pollicis brevis.

Two patients are reported in which one thumb has lost the abductor pollicis longus and extensor pollicis brevis tendons. This is an uncommon injury in isolation, and these cases provide an opportunity to assess the functional importance of these musculotendinous units.

Noninvasive measurement of cardiac output in critically ill children.

This study was performed to evaluate the hemodynamic status of children admitted to the intensive care unit, using suprasternal and transesophageal Doppler ultrasound, and to establish a suitable noninvasive technique to monitor trends in cardiac output in critically ill children. Twenty children were studied over a period of 6 months. The median age was 32.5 months and weight 14.5 kg. Minute distance (MD), which is a linear cardiac output parameter, was assessed. Seven simultaneous pairs of measurements of MD were made using transesophageal Doppler (TED) and suprasternal Doppler (SSD) by the same operator. Following a fluid challenge, seven repeat pairs of measurements were made. The mean percentage changes for MD by TED and SSD were 21.84 (SD 9.97) and 5.75 (SD 7.32). The average coefficients of variation for measurements of MD by TED and SSD were 2.34% and 15.98%, respectively. The mean difference in percentage change between MD, measured by TED and SSD, was 27.59 with a 95% confidence interval and wide limits of agreement. The repeatability of TED measurements was good, but the measurements by SSD were wide and erratic with poor reproducibility. Our study shows that TED is easy to use, reliable, and very useful for monitoring hemodynamic changes in critically ill children.

From genotype to phenotype: the differential expression of FGF, FGFR, and TGFbeta genes characterizes human cranioskeletal development and reflects clinical presentation in FGFR syndromes.

Mutations in the fibroblast growth factor receptor (FGFR) genes 1, 2, and 3 are causal in a number of craniofacial dysostosis syndromes featuring craniosynostosis with basicranial and midfacial deformity. Great clinical variability is displayed in the pathologic phenotypes encountered. To investigate the influence of developmental genetics on clinical diversity in these syndromes, the expression of several genes implicated in their pathology was studied at sequential stages of normal human embryo-fetal cranial base and facial ossification (n = 6). At 8 weeks of gestation, FGFR1, FGFR2, and FGFR3 are equally expressed throughout the predifferentiated mesenchyme of the cranium, the endochondral skull base, and midfacial mesenchyme. Both clinically significant isoforms of FGFR2, IgIIIa/c and IgIIIa/b, are coexpressed in maxillary and basicranial ossification. By 10 to 13 weeks, FGFR1 and FGFR2 are broadly expressed in epithelia, osteogenic, and chondrogenic cell lineages. FGFR3, however, is maximally expressed in dental epithelia and proliferating chondrocytes of the skull base, but poorly expressed in the osteogenic tissues of the midface. FGF2 and FGF4, but not FGF7, and TGFbeta1 and TGFbeta3 are expressed throughout both osteogenic and chondrogenic tissues in early human craniofacial skeletogenesis. Maximal FGFR expression in the skull base proposes a pivotal role for syndromic growth dysplasia at this site. Paucity of FGFR3 expression in human midfacial development correlates with the relatively benign human mutant FGFR3 midfacial phenotypes. The regulation of FGFR expression in human craniofacial skeletogenesis against background excess ligand and selected cofactors may therefore play a profound role in the pathologic craniofacial development of children bearing FGFR mutations.