Burnout among doctors in residency training in a tertiary hospital.

The mental health of doctors is an issue of growing concern all over the world as it frequently interplays with their professional trainings and responsibilities. This study was done to determine the pattern and correlates of burnout among 204 doctors undergoing residency training. Eligible participants were interviewed using designed questionnaire, General Health Questionnaire (GHQ-12) and Maslach Burnout Inventory (MBI). The mean age of participants was 33.44±4.50. Ninety-three (45.6%) respondents reported burnout in the dimension of emotional exhaustion (EE), 118 (57.8%) in the dimension of depersonalization (D), and 126 (61.8%) in the dimension of reduced personal accomplishment (RPA). Factors that were significantly associated with all the dimensions of burnout were perceived heavy workload and presence of emotional distress (based on GHQ score of ≥3). The perception of call duty as being not stressful was negatively predictive of burnout in the emotional exhaustion subscale (odds ratio [OR]=0.52; 95%confidence interval [CI]=0.29-0.97; p=0.03), while emotional distress was a positive predictor (OR=6.97; 95%CI=3.28-14.81; p<0.001]. Absence of doctor-to-doctor conflict negatively predicted burnout in the depersonalization subscale (OR=0.36; 95%CI=0.17-0.76); p<0.01), while older age (OR=0.66; 95%CI=0.47-0.95; p=0.03) and adequate support from the management (OR=0.45; 95%CI=0.22-0.90; p=0.02) constituted negative predictors of burnout in the reduced personal accomplishment subscale. Burnout is highly prevalent among resident doctors. Evolvement of comprehensive mental health services, training supports, conflict de-escalation/resolution mechanisms, and periodic assessment are indicated to mitigate work related distress with burn out among resident doctors, while improving their productivity.

Factors associated with anxiety disorders among HIV-positive attendees of an HIV clinic in Lagos, Nigeria.

Anxiety disorders (ADs) occurring in people living with HIV/AIDS (PLWHA) are often poorly identified in spite of the untold consequences that may result if not diagnosed and treated promptly. This study aimed to describe factors associated with ADs among PLWHA. Three hundred participants were administered sociodemographic/clinical profile questionnaires, and diagnoses of ADs were made using Schedule for Clinical Assessment in Neuropsychiatry (SCAN) based on International Classification of Diseases, 10th edition (ICD-10) criteria. In this study, 65 (21.7%) participants were diagnosed with ADs. A lack of family support, unemployment, younger mean age and being unmarried (P < 0.05) were factors associated with ADs in PLWHA; however, lack of family support (odds ratio [OR] = 0.458, 95% confidence interval [CI] = 0.254-0.827, P = 0.010), being unmarried (OR = 1.930, 95% CI = 1.046-3.560, P = 0.035) and unemployment (OR = 0.495, 95% CI = 0.264-0.926, P = 0.028) were the only factors that remained significant following logistic regression analysis. Prompt identification with active management of ADs and their associated factors among PLWHA are advocated. Further research on the risk factors for ADs is also warranted.

Description of a chronic heart failure service model and review of pharmacotherapy in a district general hospital in comparison to Scottish Intercollegiate Guideline Network (SIGN) guidelines.

BACKGROUND: The Scottish Intercollegiate Guidelines Network (SIGN) guideline 95 on the management of chronic heart failure (CHF) was published in February 2007, superseding SIGN guideline 35 of February 1999. The guideline promotes evidence based management of CHE. AIMS: To describe an existing service model and to review our level of concordance with SIGN guidelines. METHODS: We describe a model of a CHF service based in a district general hospital (DGH) in Scotland. We conducted a retrospective review on consecutive new referrals between August and November 2002, and a prospective review of new attendances between September 2005 and January 2006. RESULTS: In 2002 and 2005/6, 49 and 45 patients were reviewed respectively, with 26 and 28 patients showing left ventricular systolic dysfunction on echocardiography. Median ages of patients were 81 and 79 years respectively. Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin II Receptor Blocker (AIIRB) therapy was in use in 23 (88.5%) and 24 (85.7%) patients respectively. The use of beta-blockers, digoxin and spironolactone was shown to have improved between both reviews. CONCLUSIONS: We have been able to demonstrate an improving level of concordance with SIGN guidelines in a district general hospital (DGH) heart failure service model run by care of the elderly physicians and supported by specialist nurses.

An audit of antibiotics usage and their effect on MRSA infection or colonisation following percutaneous endoscopic gastrostomy in a district general hospital.

Percutaneous endoscopic gastrostomy (PEG) has become a widely practised procedure to maintain long-term nutrition in patients with a variety of medical conditions. Incidence of infection and the usage of prophylactic antibiotic continue to remain an area of debate. Guidelines in gastroenterology on antibiotic prophylaxis published by the British Society of Gastroenterology recommend the use of prophylactic antibiotic prior to placement of PEG tube (1). There has been an alarming rise in the incidence of MRSA, which has jumped from a reported 2% in 1992 to about 42% in 2001 in England & Wales. Use of antibiotic may lead to emergence of MRSA in debilitated patients requiring PEG feeding. This audit addresses some of the problems encountered in a small district general hospital.

Prophylactic amnioinfusion for oligohydramnios: a reevaluation.

OBJECTIVE: To compare the effects of prophylactic amnioinfusion to standard care plus indicated therapeutic amnioinfusion (for variable decelerations) in term patients with oligohydramnios. METHODS: One hundred sixteen term gestations with oligohydramnios (amniotic fluid index less than 5.0 cm) were randomly assigned to receive prophylactic saline amnioinfusion (600-mL bolus followed by 3 mL/minute) or standard obstetric care (control). Control patients who subsequently developed moderate or severe variable decelerations received therapeutic amnioinfusion. RESULTS: There was no significant difference in overall cesarean delivery (21 versus 17%; P = .68), cesarean delivery for fetal distress (7 versus 10%; P = .83), or umbilical gas values between the prophylactic amnioinfusion group (N = 56) and control group (N = 60), respectively. The rate of intrapartum fever was significantly increased among the prophylactic amnioinfusion patients (23 versus 7%; P = .02), although the duration of intrauterine monitoring (8.8 versus 6.5 hours; P = .06) and time from ruptured membranes to delivery (12.3 versus 14.3 hours; P = .51) were not different. Only 22% of the controls developed moderate or severe variable decelerations in the first stage of labor and received therapeutic amnioinfusion. Thus, in approximately four of five term patients with oligohydramnios, neither prophylactic nor therapeutic amnioinfusion would be indicated. CONCLUSIONS: Compared to indicated amnioinfusion, prophylactic amnioinfusion did not improve perinatal outcome. Amnioinfusion should be reserved for term laboring patients with variable fetal heart rate decelerations, rather than all patients with oligohydramnios.

Prophylactic amnioinfusion for meconium-stained amniotic fluid.

OBJECTIVE: Previous studies have demonstrated reduced perinatal morbidity in patients receiving amnioinfusion for meconium-stained amniotic fluid compared with control patients receiving no amnioinfusion. Because amnioinfusion for variable fetal heart rate decelerations has become accepted care, we sought to determine the benefit of prophylactic amnioinfusion for meconium compared with standard care, incorporating therapeutic amnioinfusion for variable decelerations. STUDY DESIGN: Ninety-three term patients with moderate to heavy meconium and no variable fetal heart rate decelerations were randomized to immediate prophylactic amnioinfusion (600 ml saline solution bolus followed by 3 ml/min) or to standard care (including therapeutic amnioinfusion for variable decelerations developing later). All babies had DeLee suctioning on delivery of the head. Laryngeal cords were visualized and tracheal suctioning performed when meconium was seen below the cords. Statistical comparisons were performed using Student t test, Fisher's exact test, or chi 2 analysis. RESULTS: There were no significant differences in the incidence of operative delivery, fetal distress, or meconium below the cords or in newborn Apgar scores and umbilical artery gas values between the amnioinfusion (n = 43) and control (n = 50) patients. There were four cases of meconium aspiration, three in the amnioinfusion group, one in the standard care group. The rate of endometritis-chorioamnionitis was higher (p = 0.3) in the amnioinfusion (16%) than in the control group (8%), although time from ruptured membranes to delivery (8.5 hours vs 7.3 hours) and duration of intrauterine monitoring (6.1 hours vs 5.3 hours) were not different. CONCLUSIONS: Although amnioinfusion does dilute amniotic meconium, prophylactic amnioinfusion for meconium in the absence of variable decelerations remains controversial. Prophylactic amnioinfusion in term pregnancies did not improve perinatal outcome and increased the risk for chorioamnionitis-endometritis. Together with recent reports, the current data suggest that the benefit of amnioinfusion for meconium-stained amniotic fluid is a result of the alleviation of variable fetal heart rate decelerations rather than meconium dilution.

Assessments of fetal swallowed volume: tracer disappearance versus esophageal flow.

OBJECTIVE: We sought to compare fetal swallowed volume determinations simultaneously by two techniques--amniotic fluid (AF) tracer disappearance and esophageal flow probe measurements. METHODS: Six ovine fetuses (129 +/- 1 days) were chronically prepared with a thoracic esophageal flow probe and vascular and two AF catheters. 125I-labeled albumin was injected into the AF cavity, and samples were withdrawn at timed intervals for 8 hours. The AF volume was calculated by time-0 extrapolation of the semilog of 125I disappearance. Tracer-determined swallowed volume was calculated as the product of AF volume and the slope of isotope disappearance. Flow probe measurement of swallowed volume was determined by computer integration of calibrated flow probe velocity recordings. RESULTS: The AF volume averaged 805 +/- 168 mL. The isotope disappearance rate from the AF was 2.8 +/- 0.4%/hour. Average tracer-determined swallowed volume (547 +/- 113 mL/day) was greater than flow probe volume (366 +/- 81 mL/day), although these values were not significantly different. However, when corrected for estimated swallowed lung fluid, tracer-determined volume was significantly greater than flow probe volume (P < .05). CONCLUSION: Ovine fetal swallowed volume determinations by AF tracer techniques are greater than those determined by esophageal flow probe measurements.

Fetal endocrine and renal responses to in utero ventilation and umbilical cord occlusion.

OBJECTIVE: Fetal to neonatal transition involves a myriad of endocrine and renal adaptive changes triggered by multiple simultaneous stimuli. We examined the extent to which ventilation and umbilical cord occlusion have an impact on the many endocrine and renal function changes in fetal sheep at 133 +/- 1 day of gestation. STUDY DESIGN: Nine fetuses were chronically prepared with an endotracheal tube, vascular and bladder catheters, and an inflatable umbilical cord occluder. After a 2-hour control period fetuses were treated with commercially prepared surfactant and ventilated with 100% oxygen. One hour after the onset of stable ventilation the umbilical cord was occluded and the animals were monitored for 3-hours. RESULTS: In response to ventilation fetal arterial PO2 increased (18 +/- 1 to 86 +/- 29 mm Hg) and remained significantly above control values after cord occlusion. Fetal arterial pH, hematocrit, and mean arterial pressure and heart rate did not change during the study. Ventilation alone evoked significant increases in epinephrine and norepinephrine concentrations. Renal responses to ventilation included significant decreases in urine flow rate, fractional sodium excretion, and fractional water excretion. Neither ventilation nor cord occlusion resulted in significant changes in plasma concentrations of atrial natriuretic factor, arginine vasopressin, and angiotensin II or in glomerular filtration rate, urine osmolality, free water, and osmolar clearances. CONCLUSIONS: (1) Mechanical ventilation and oxygenation alone increase circulating fetal catecholamine levels. (2) The addition of umbilical cord ligation has minimal impact on fetal endocrine and renal adaptive responses.