Síndrome de burnout en médicos de Terapias Intensivas de General Roca y Cipolletti / Burnout syndrome in doctors of Intensive Therapies General Roca and Cipolletti

Objetivo: Conocer la existencia del síndrome de burnout en médicos intensivistas de General Roca y Cipolletti, y correlacionarlo con factores de estrés laboral. Diseño: Encuesta a los médicos intensivistas de adultos, pediátricos y neonatólogos, de General Roca y Cipolletti, utilizando el Maslach Burnout Inventory Manual (MBI), la encuesta hospitalaria de estrés/satisfacción laboral (HCJSSQ) y una autoevaluación del nivel de estrés/satisfacción. Se identificaron los profesionales que están por encima de la mediana en agotamiento emocional y despersonalización, y por debajo en realización personal. La presencia de las tres dimensiones definió la existencia del síndrome. Se correlacionaron las encuestas con el coeficiente de Pearson, vinculando el burnout con los factores que provocan estrés. Resultados: Respondieron 52 intensivistas (92% del total); 12 presentaron burnout (21,4%), en su mayoría, mujeres (58,33%). Cinco (41,7%) de ellos consideraron al estrés intenso; 6 (50%), moderado y uno (8,33%), leve. Casi el 60% de los afectados no reconoció su existencia. Los intensivistas de instituciones públicas, de terapias pediátricas/neonatoló- gicas y de Cipolletti manifestaron más afectación. Los factores que provocan estrés fueron: falta de tiempo, mayor complejidad tecnológica, necesidad de cubrir guardias y dar malas noticias, amenaza de litigio, restricciones institucionales, conflictos con el equipo de trabajo, falta de autonomía, exceso de responsabilidad y sensación de no hacer bien la tarea. Un factor de satisfacción fue el trabajo en equipo. Conclusión: Se evidenció el rol institucional en la prevención, el reconocimiento y el empleo de estrategias de abordaje orientadas al afectado y a mejorar el clima organizacional, las condiciones laborales, la comunicación y el trabajo en equipo.(AU)

Objective: To establish the occurrence of burnout syndrome in critical care physicians from General Roca and Ciplolletti, and correlate it with factors found in work-related stress. Design: A survey involving all adult, pediatric and neonatal critical care physicians in General Roca and Cipolletti. The Maslach Burnout Inventory Manual (MBI) questionnaire, the Hospital Consultants Job Stress & Satisfaction questionnaire (HCJSSQ) and an auto-evaluation of stress and satisfaction levels were used. The investigation identified professionals of above-average emotional exhaustion and depersonalisation, and below-average personal achievement. The presence of these three indicators defined the existence of the syndrome. The questionnaires were correlated using the Pearson coefficient to link burnout with factors causing stress. Results: Fifty-two critical care physicians responded to the survey (92% of the target group): 12 presented burnout (21.4%), the majority being women (58.33%). Five (41.7%) of them considered their stress to be "severe", 6 (50%) "moderate" and 1 (8.33%) "mild". Almost 60% of those affected were unaware of its presence. Critical care physicians working in public institutions, in pediatric/neonatal care and in Cipolletti were the most affected. Correlating stress-inducing factors: lack of time, high levels of technological complexity, need to cover ER/A&E and deliver bad news, threat of litigation, institutional restrictions, conflicts within a team, lack of autonomy, excess responsibility and the feeling of underperforming. Teamwork was a factor in deriving satisfaction. Conclusion: The role played by the institution was identified as a factor in the prevention and recognition, and the use of hands-on strategies aimed at the sufferer and at improving the organisational climate, working conditions, communication and teamwork(AU)

Prolonged neurological burden in severe lithium intoxication.

A 53-year-old woman was brought to the Emergency Department for a persistent state of stupor, tremors, fever and oliguria. The patient had been under treatment for depression. The electrocardiogram showed a wider QRS complex; laboratory tests were as follows: urea 110 mg/dL, creatinine 3 mg/dL, sodium 135 mEq/L, potassium 4.5 mEq/L, and lithium 8.0 mEq/L. Renal replacement was initiated to normalize plasma lithium levels; both stupor and speech impairment persisted for several days after dialysis. Complete recovery was achieved several days afterwards.

Relation of fetal growth to maternal responses to oral glucose tolerance test throughout gestation.

Fetal growth is dependent on transplacental supply of fuels. We aimed to assess the effect of serial changes in maternal glucose tolerance and insulin secretion with advancing pregnancy on maternal-fetal outcomes. Sixty-nine healthy pregnant women were studied over the course of gestation for glucose tolerance, by oral glucose tolerance test (OGTT), and hemoglobin A(1c) (HbA(1c)), fetal intrauterine growth (by ultrasound) and pregnancy outcome. Seven women had an abnormal OGTT in the third trimester developing gestational diabetes mellitus (GDM), but none of the 12 mothers of large babies (> 3.9 kg) had GDM: the former had the highest post-load glycemic increment, despite an apparently 'normal' insulin secretory response, the latter showed the lowest post-load glucose increase in the face of the lowest insulinemic response. Neonatal body weight correlated with maternal gestational weight gain, placental weight, third trimester ratio of incremental plasma insulin and glucose integrated areas under the curve and first and second trimester HbA(1c) levels. Fetal growth indices (femur length, biparietal diameter and abdominal circumference) were correlated with both HbA(1c) and 2h OGTT. Fetal growth rate is confirmed as being associated with maternal glycemic equilibrium, but one of the main determinants of high infant birthweight seems to be an enhanced maternal insulin sensitivity, accompanied by remarkable gestational weight gain.

[Low-flow anesthesia: isoflurane increment kinetics as a function of the rotatory circuit volume]. / Narcosi a "bassi flussi": cinetica di incremento dell'isoflurano in funzione del volume del circuito rotatorio.

OBJECTIVE: Study of the increment of isoflurane volume concentration in two rotatory circuits having different capacity during low flow narcosis. DESIGN: Descriptive comparison of different halogenate concentration in circuits connected to two patient groups and evaluation of the significance of the observed differences. SETTING: Surgery theatres of a district Public Hospital. PATIENTS: 16 female patients included in the same age, weight and body surface group, showing neither obstructive nor restrictive lung diseases. According to the surgical treatment used (abdominal or major gynecological surgery) the patients were then divided into two groups of 8 each. MEASUREMENTS AND MAIN RESULTS: After opening the halogenate nebulizer, dry measurement of the isoflurane concentration detected for 30 minutes in the inspiratory and expiratory circuit segment by means of monitors at pre-determined intervals, before abdominal or major gynecological surgery. Simultaneous measurement of isoflurane uptake by means of indirect methods (heart frequency, average arterial pressure, use of muscle relaxing agents). The analysis of the measured values showed higher isoflurane concentrations and a faster percent increase in the small circuit than in the big one (resp. 0.9% vs 0.71% in the inspiratory segment and 0.59% vs 0.4% in the expiratory one, with p < 0.005 and I.C. = 99.00%). CONCLUSIONS: This study demonstrates how the different kinetics of the isoflurane increment in the rotatory circuit is mainly related to the circuit volume. To eliminate the problems due to the "low compliance" of the small circuit (collection of toxic gases) and to the "high compliance" of the big circuit rotatory (awareness), circuits with varying volume might be introduced.

[Prophylactic use of cefotetan in gynecologic surgery]. / Profilassi con cefotetan in chirurgia ginecologica.

The efficacy of prophylactic treatment with systemic antibiotics in laparotomic gynecologic surgery is well established. Lately, short-term schemes have been preferred in surgical prophylaxis for different reasons. First of all, experimental data demonstrated that the efficacy of an antibiotic is maximal when it reaches active tissue concentrations at the time of bacterial contamination. In addition with the availability of new, long-acting antibiotics, a long period of time around the operations was possibly covered. The effectiveness of a single preoperative 2 gm dose of Cefotetan was compared with a traditional treatment of 3 gm daily of Cefazolin for one week following surgery in 86 women undergoing laparotomic gynecologic surgery for benign pathology. Our results confirm that preoperative treatment with Cefotetan is able to prevent infectious disease such as 3 gm of Cefazolin per day for one week. Thus, Cefotetan can be used for this type of prophylaxis considering its broad spectrum of action and pharmacokinetic properties.

Evolution of antimicrobial prophylaxis in obstetric surgery.

Problems concerning antimicrobial prophylaxis in obstetric surgery are reviewed from the first experiences with multiple-dose treatments to the new short-term prophylaxis. With the purpose to evaluate the effectiveness of a short-term scheme, a controlled population of 134 obstetric patients was treated with a double dose of 2 g i.m. of cefotetan. Clinically important infectious complications were not observed.

[Effects of low-dose oral contraceptives on sugar metabolism]. / Effetti dei contraccettivi orali a basse dosi sul metabolismo glucidico.

The effects on carbohydrate metabolism by four low-dose oral contraceptives were evaluated in four low-dose oral contraceptives were evaluated-66 young women randomly divided in four groups. In the various preparations there were a different dosage of estrogen (ethinylestradiol) together different doses and types of progestogen (desogestrel, gestodene, cyproterone acetate). After six months of treatment, in all groups a slight increase of glycemic and insulinemic responses during OGTT was observed; the significance was achieved with the preparation containing cyproterone acetate alone. Glycated hemoglobin did not change. Our results suggest that these new low-dose oral contraceptives induced negligible metabolic side effects.

Metabolic effects of three new low-dose pills: a six-month experience.

We evaluated the effects on glucose and lipid metabolism in 57 healthy volunteers randomly assigned to one of three low-dose oral contraceptives: two monophasic (desogestrel + ethinylestradiol, EE, and cyproterone acetate + EE) and one triphasic (gestodene + EE) contraceptives. Glucose and insulin responses during OGTT were slightly affected by the cyproterone pill. The insulin area/glucose area ratio and HbA1c level were unchanged in all women. No preparation affected total and LDL-cholesterol levels. Triglycerides rose in all groups, while HDL-CH did only in women taking the two monophasic pills. The three low-dose pills assessed in this study have negligible effects on glucose and lipid metabolism.

PIP: In a study of low-dose oral contraceptives, it was found that the low dosage caused insignificant effects on glucose and lipid metabolism. 57 women of good health were studied and divided into 3 groups determined by the preparation given: monophasic desogestrel, monophasic cyproterone acetate, and triphasic gestodene. There was no family history of diabetes mellitus nor was there hyperlipoproteinemia in any of the women. Among the 3 groups, there were negligible differences concerning glucose and insulin levels and lipid profiles. This held true at both the beginning and concluding stages of the study. In all of the women, the insulin area/glucose area ratio was unaffected. Lipid metabolism and hyperglycemia have been linked to heart disease, and other reports have shown glucose and lipid abnormalities produced in women taking the 2 most popular progestins, norgestrel and norethindrone. Thus, the minor effects on carbohydrate and lipid metabolism found in these tests are significant.

Clinical and metabolic study of a new pill containing 20 mcg ethinylestradiol plus 0.150 mg desogestrel.

The clinical and metabolic effects of a short-term treatment with a combination contraceptive pill containing 0.150 mg desogestrel and 20 mcg ethinylestradiol were evaluated in a group of 17 healthy women. In spite of the low estrogen content, the pill exerted a good cycle control and the incidence of irregular bleedings was low. The minor side effects commonly associated with oral contraceptive (OC) use rarely occurred, and an improvement of premenstrual symptoms was reported during pill intake. As for the different biochemical parameters tested, the formulation induced a significant increase of fibrinopeptide A (FPA) plasma levels. However, the resulting increase of peptide was lower than that induced by pills containing 30 mcg ethinylestradiol. No significant modifications of plasma total cholesterol (T-CH) and low-density lipoprotein cholesterol (LDL-CH) were observed, while triglycerides (TG), high-density lipoprotein cholesterol (HDL-CH) concentrations and the HDL-CH/LDL-CH ratio significantly increased. A significant increase of apolipoproteins AI (Apo AI) and apolipoproteins AII (Apo AII) concentrations was also observed. Moreover, the pill did not alter fasting insulin and glucose levels and their response to an oral glucose tolerance test (OGTT). It may be concluded that this new formulation can be considered acceptable for clinical use, mainly in consideration of the minor or no changes in the biochemical parameters regarded as risk factors for venous and arterial diseases.

PIP: The clinical and metabolic effects of short-term treatment with an oral contraceptive (OC) containing 0.150 mg desogestrel and 20 mcg ethinyl estradiol were evaluated in 17 healthy subjects 19-37 years of age. Despite its low estrogen content, the OC exerted good menstrual cycle control and the incidence of irregular bleeding was low. Side effects often associated with OC use, such as weight gain or changes in blood pressure, did not occur. Moreover, there was improvement of premenstrual symptoms during pill use. The formulation induced a significant increase of fibrinopeptide A plasma levels, although the resulting peptide increase was lower than that induced by OCs containing 30 mcg ethinyl estradiol. No significant alterations of plasma total cholesterol and low-density lipoprotein cholesterol (LDL-C) were recorded, but triglyceride concentrations, high-density lipoprotein cholesterol (HDL-C), and the HDL-C/LDL-C ratio significantly increased. Also observed was a significant increase in concentrations of apolipoproteins AI and AII. Finally, the OC did not alter fasting insulin and glucose levels or their response to an oral glucose tolerance test. These find ngs refute the belief that doses lower than 30 mcg of ethinyl estradiol are inadequate for maintaining satisfactory contraceptive efficacy and good cycle control. The advantages of using a lower estrogen dose were evident both in terms of the low incidence of side effects and the lack of effects on the coagulation system. The present results suggest that this OC formulation could further minimize the thrombogenic effects of low-dose OCs. In addition, this formulation retains the effects on lipid metabolism of OCs containing desogestrel.

Parathyroid function and pituitary-gonadal axis in male uremics; effects of dietary treatment and of maintenance hemodialysis.

Parathyroid and pituitary-gonadal secretions were studied in 18 male uremics following a low protein diet supplemented with essential amino acids and ketoanalogues (SD), and in 8 subjects on maintenance hemodialysis (MHD). SD corrected high serum PTH and low serum testosterone (sT) levels, while pituitary hormones (LH, FSH, PRL) were elevated and did not change. Patients on MHD had very high siPTH, PRL and LH levels, while sT was markedly low. These data suggest that PTH is a prominent cause of sexual dysfunction in male uremics, since SD can restore sT secretion by correcting PTH levels, without improving pituitary dysfunctions. In dialyzed patients secondary hyperparathyroidism worsens and is an important cause of low sT secretion, but also a severe hyperprolactinemia develops, which may further impair gonadal function.