Suicide in anaesthetists: a systematic review.

Evidence suggests that healthcare professionals are at an increased risk of dying by suicide, with anaesthetists at particularly high risk. However, much of the data on which this is based are historical. With a focus on the epidemiology and methods used, we conducted a systematic review of evidence regarding suicide and suicidal behaviour among anaesthetists to provide a more contemporary summary. The systematic review process was adapted from a previous similar study in veterinary surgeons and was consistent with recommended guidance. We identified 54 articles published in or after 1990 that had anaesthetist-specific data and met the inclusion criteria. Seven of these reported epidemiological data, of which four were published after 2000. Although none of the more recent studies reported standardised mortality rates specific to suicide in anaesthetists, the proportion of anaesthetists dying by suicide was increased with respect to comparator groups, which is consistent with previous findings. Eleven studies that included information on suicidal behaviour reported suicidal ideation in 3.2-25% of individuals (six studies) and suicide attempts in 0.5-2% (four studies). Studies reporting methods of suicide highlighted the use of anaesthetic drugs, particularly propofol, supporting the suggestion that the increased risk of suicide in anaesthetists may be related to the availability of the means. We discuss our findings in relation to other recently published data and guidance concerning mental health problems in anaesthetists.

Guidelines on suicide amongst anaesthetists 2019.

Anaesthetists are thought to be at increased risk of suicide amongst the medical profession. The aims of the following guidelines are: increase awareness of suicide and associated vulnerabilities, risk factors and precipitants; to emphasise safe ways to respond to individuals in distress, both for them and for colleagues working alongside them; and to support individuals, departments and organisations in coping with a suicide.

A national survey of out-of-hours working and fatigue in consultants in anaesthesia and paediatric intensive care in the UK and Ireland.

The tragic death of an anaesthetic trainee driving home after a series of night shifts prompted a national survey of fatigue in trainee anaesthetists. This indicated that fatigue was widespread, with significant impact on trainees' health and well-being. Consultants deliver an increasing proportion of patient care resulting in long periods of continuous daytime duty and overnight on-call work, so we wished to investigate their experience of out-of-hours working and the causes and impact of work-related fatigue. We conducted a national survey of consultant anaesthetists and paediatric intensivists in the UK and Ireland between 25 June and 6 August 2018. The response rate was 46% (94% of hospitals were represented): 84% of respondents (95%CI 83.1-84.9%) contribute to a night on-call rota with 32% (30.9-33.1%) working 1:8 or more frequently. Sleep disturbance on-call is common: 47% (45.6-48.4%) typically receive two to three phone calls overnight, and 48% (46.6-49.4%) take 30 min or more to fall back to sleep. Only 15% (14.0-16.0%) reported always achieving 11 h of rest between their on-call and their next clinical duty, as stipulated by the European Working Time Directive. Moreover, 24% (22.8-25.2%) stated that there is no departmental arrangement for covering scheduled clinical duties following a night on-call if they have been in the hospital overnight. Overall, 91% (90.3-91.7%) reported work-related fatigue with over half reporting a moderate or significantly negative impact on health, well-being and home life. We discuss potential explanations for these results and ways to mitigate the effects of fatigue among consultants.

Suicide amongst anaesthetists - an Association of Anaesthetists survey.

Following a 2-3-month period of publicity, anaesthetists were invited to participate in an online survey that was administered by a third party company on behalf of the Association of Anaesthetists and ran between 3 September and 31 October 2018. Anaesthetists working in the UK or Ireland were asked about the presence or absence of welfare/support structures or resources in their workplace in the case of mental illness, addiction and/or suicide. Anaesthetists working anywhere in the world were also asked for their experiences of a colleague's suicide, defined as a colleague's taking his or her own life - whether intentional or not - while practising as an anaesthetist in the UK or Ireland, in the same department and at the same time as the respondent. Respondents were also asked about experiences of other suicides not meeting this definition. A total of 3638 responses were received. Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads, within their Trust or department. A total of 1916 cases of suicide meeting the survey's definition were reported by 1397 respondents, although the actual number of discrete cases is unknown because of likely multiple reporting of the same cases. A third of respondents who reported a suicide had experience of more than one case. Most reports were of suicide in the last 10 years, and most reported cases involved anaesthetic drugs. Deficiencies were noted in the support available and in the way the deaths were handled, although examples of good support were also described. A further 1715 respondents reported suicides that did not meet the primary definition. Overall, 92% of respondents reporting suicide experienced it through work, and 41% outside of work (total > 100% as some reported both). Although unable to provide estimates of suicide rates, or numerical associations between the features of the deaths, this survey highlights the considerable emotional and mental burden of suicide on anaesthetists.

Guidelines for the peri-operative care of people with dementia: Guidelines from the Association of Anaesthetists.

Ageing populations have greater incidences of dementia. People with dementia present for emergency and, increasingly, elective surgery, but are poorly served by the lack of available guidance on their peri-operative management, particularly relating to pharmacological, medico-legal, environmental and attitudinal considerations. These guidelines seek to deliver such guidance, by providing information for peri-operative care providers about dementia pathophysiology, specific difficulties anaesthetising patients with dementia, medication interactions, organisational and medico-legal factors, pre-, intra- and postoperative care considerations, training, sources of further information and care quality improvement tools.

People, systems and safety: resilience and excellence in healthcare practice.

This article outlines recent developments in safety science. It describes the progression of three 'ages' of safety, namely the 'age of technology', the 'age of human factors' and the 'age of safety management'. Safety science outside healthcare is moving from an approach focused on the analysis and management of error ('Safety-1') to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring ('Safety-2'). A key factor in the understanding of safety within organisations relates to the distinction between 'work as imagined' and 'work as done'. 'Work as imagined' assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the 'sharp end' of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include 'appreciative inquiry', 'positive deviance' and excellence reporting.

A national survey of the effects of fatigue on trainees in anaesthesia in the UK.

Long daytime and overnight shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. The Working Time Regulations (1998) implemented the European Working Time Directive into UK law, and in August 2009 it was applied to junior doctors, reducing the maximum hours worked from an average of 56 per week to 48. Despite this, there is evidence that problems with inadequate rest and fatigue persist. There is no official guidance regarding provision of a minimum standard of rest facilities for doctors in the National Health Service, and the way in which rest is achieved by trainee anaesthetists during their on-call shift depends on rota staffing and workload. We conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK. We achieved a response rate of 59% (2231/3772 responses), with data from 100% of NHS trusts. Fatigue remains prevalent among junior anaesthetists, with reports that it has effects on physical health (73.6% [95%CI 71.8-75.5]), psychological wellbeing (71.2% [69.2-73.1]) and personal relationships (67.9% [65.9-70.0]). The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% (55.0-59.1) stating they had experienced an accident or near-miss when travelling home from night shifts. We discuss potential explanations for the results, and present a plan to address the issues raised by this survey, aiming to change the culture around fatigue for the better.

AAGBI: Consent for anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland.

Previous guidelines on consent for anaesthesia were issued by the Association of Anaesthetists of Great Britain and Ireland in 1999 and revised in 2006. The following guidelines have been produced in response to the changing ethical and legal background against which anaesthetists, and also intensivists and pain specialists, currently work, while retaining the key principles of respect for patients' autonomy and the need to provide adequate information. The main points of difference between the relevant legal frameworks in England and Wales and Scotland, Northern Ireland and the Republic of Ireland are also highlighted.

Coulter counter-based evaluation of sperm volume to assess sperm viability of bull semen and application to X/Y sperm sorting.

The Coulter Counter Hypo-Osmotic Swelling test (CC-HOS) was developed to provide insight into the membrane integrity (relative volume shift Vr) of sperm necessary for fertilization, and to identify the optimum buffer needed for the X/Y chromosome sorting process. Using the CC-HOS test on neat bovine semen, the mean relative volume shift Vr for July and August was 1.20 and 1.14, respectively, whereas mean Vr values ranged from 1.32 to 1.41 during September to November. There was an inverse relationship between Vr magnitude and environmental temperature; we inferred that this enhanced sperm viability during autumn relative to summer. A method was developed to measure the dynamics of volume change of sperm in the buffer (pH 6.5) used for the X/Y chromosome sorting process. When exposed to the buffer (4 mM K+, 153 mM Na+, 140 mM Cl(-)), sperm from Bull C had a mean modal volume of 22.8+/-0.2 fL during a 0-300 s time interval, which did not significantly vary from sperm volumes (21.88+/-0.66 fL for Bull A and 22.46+/-0.38 fL for Bull B) noted in isotonic Isoton II solution. However, when exposed to lower ionic concentrations (2 mM K+, 62 mM Na+, 47 mM Cl-), the mean volume of Bull C sperm increased to 29.2+/-1.5 fL and exhibited slower rates toward stabilized volumes relative to higher ionic concentration buffers. Utilization of volume swelling measurements for measuring the impact of ion concentrations in X/Y chromosome sorting process buffers illustrated the importance of its application for emerging sperm-based biotechnologies.

Morphological apsects of the coronary artery in the neonates.

Knowledge of the morphometric quantities of the coronary arteries in neonates is an increasingly vital component in the management of congenital and acquired heart disease. Because of the considerable heterogeneity of coronary vasculature, what is considered atypical and aberrant or insignificant anatomy is often unclear. The purpose of our present study is to define the normal anatomy of neonates. This was done by focusing on segment analysis of the coronary arteries, which was used to obtain accurate definitions of the length and diameter of the coronary network. The lengths, widths and numbers of collateral branches of the coronary arteries of neonates were measured. The coronary vessels of 50 neonate hearts were visualised post mortem by injection of the coronary arteries with opaque X-ray dye for the imaging study. Black ink cast and silver impregnation specimens were also studied. The longest segment of the circumflex branches of the left coronary arteries was the first, the lengths measuring 7188.5 +/- 839.6 microm and the diameters 850 +/- 90.8 mum. The lengths of segments II, III and IV were 5780 +/- 1182.7 microm, 5397.5 +/- 2070.2 microm and 6932.8 +/- 2236.5 microm and the diameters were 680 +/- 90.8 microm, 510 +/- 90.8 microm and 408 +/- 77.58 microm respectively. The longest segment of the anterior interventricular branches of the left coronary arteries was the first, with lengths of 10151.4 +/- 1298.6 microm and diameters of 1141.9 +/- 82.1 microm. The lengths of segments II, III and IV were 8208.5 +/- 1222.3 microm, 3278.5 +/- 602.4 microm and 5370 +/- 1657.6 mum and the diameters were 971 +/- 82.1 microm, 801.42 +/- 82.1 microm and 631.4 +/- 82.1 microm respectively. The lateral branches were increased in number in the fourth segment. Its diameters ranged from 157.8 +/- 31.7 microm to 655.7 +/- 99.7 microm. The main branch of the right coronary artery was short at the base of the heart. In the newborn the lateral branches of the right coronary artery were short, scattered and curved. Analysis of the data suggests a new anatomical system for classifying the vasculature of the coronary arteries in neonates.

Early effects of continuous low-dosage all-norgestrel administered alone or with estrogen.

Twenty-six postmenopausal women participated in a double-blind trial involving treatment according to a Latin square design with either (i) dl-norgestrel alone (0.075 mg/day) continuously for two cycles, (ii) estradiol-17 beta alone (1 mg on 25 of 28 days) for two cycles, or (iii) the combined hormones for six cycles. A placebo control cycle followed each hormonal treatment. Plasma triglycerides decreased by an average 22% during treatment with either dl-norgestrel alone (123 +/- 11 vs. 160 +/- 10 mg/dl, n = 25, P < 0.005) or combination therapy (126 +/- 11 vs. 162 +/- 11, n = 25, P < 0.005) as compared with control. Plasma total cholesterol fell by 5% during two cycles of treatment with either dl-norgestrel alone (229 +/- 11 vs. 242 +/- 10 mg/dl, n = 25, P < 0.02) or combination therapy (233 +/- 11 vs. 246 +/- 10, n = 25, P < 0.05) versus placebo. During the fifth and sixth cycles of combination therapy 94% of cycles were free of flushing (vs. 31% for control, P < 0.01), 64% of cycles were free of spotting not requiring protection (control 75%), 96% of cycles were free of vaginal bleeding (control 100%), endometrial biopsy showed inactive endometrium in nine of the 10 subjects re-biopsied, fasting blood pyruvate decreased by 20% (P < 0.05) and diastolic blood pressure fell by 4% compared with control (P < 0.05), whereas glucose tolerance was unchanged. There was a significant reduction in vasomotor flushing beginning with the third to fourth cycles of combination therapy.

Prolonged effects of a novel, low-dosage continuous progestin-cyclic estrogen replacement program in postmenopausal women.

OBJECTIVE: Our objective was to ascertain long-term tolerability and effects of a novel, low-dosage continuous progestin-cyclic estrogen regimen on vasomotor flushing, vaginal bleeding patterns, bone density, and plasma lipoprotein lipids. STUDY DESIGN: Eighteen postmenopausal women with climacteric symptoms received low doses of dl-norgestrel (0.075 mg/day) continuously and 17 beta-estradiol (1 mg/day) intermittently (25 of 28 days) for 3 years. The results were compared with baseline values. RESULTS: The hormonal regimen was well tolerated. Vaginal bleeding, vaginal spotting, and vasomotor flushing occurred in only 0.4%, 4.2%, and 7.7% of cycles, respectively. Bone density was stable. Mean fasting plasma total cholesterol concentration fell 19%, low-density lipoprotein cholesterol 23%, high-density lipoprotein cholesterol 13%, and triglycerides 31% (p less than 0.01) over the 3-year period, while the ratios of low-density lipoprotein cholesterol/high-density lipoprotein cholesterol and total cholesterol/high-density lipoprotein cholesterol decreased by 14% and 10%, respectively. CONCLUSION: Long-term compliance with female hormonal replacement is feasible once vaginal bleeding is essentially eliminated, allowing for potentially better prophylaxis against coronary heart disease, osteoporosis, endometrial cancer, and stroke.

A strategy for introducing diagnostic reasoning: hypothesis testing using a simulation approach.

The ability to generate a number of hypotheses, so all possibilities in a situation are recognized, is a vital component in arriving at a correct nursing diagnosis. Students need learning experiences in this aspect of the diagnostic reasoning process. The authors discuss the four phase simulation method of teaching, which provides a useful model for developing beginning skills in hypothesis generation.

Antisperm antibodies and circulating immune complexes of vasectomized men with and without coronary events.

We compared antisperm antibody and circulating immune complex (CIC) levels in serum samples from 101 vasectomized and 101 normal age-matched nonvasectomized men; 31 of each group had histories of coronary heart disease (CHD). Vasectomy and CHD status were treated as categorical independent variables in the two-way analysis of variance. Elevations of both systolic and diastolic blood pressures were significantly associated with age and body mass index but not vasectomy. Antisperm antibodies (immobilizing and agglutinating) were significantly associated with vasectomy (P less than or equal to .001); the incidences were similar in men with and without CHD. The CICs were significantly associated with vasectomy in a Staphylococcus aureus (FcSa) CIC assay (P less than or equal to .001) and a Raji cell CIC assay (P less than or equal to .05). A third CIC assay, the Clq binding assay, did not reveal a difference between any subgroups. Generally, CICs occurred more frequently in the CHD group by the FcSa assay and particularly the Raji cell assay (P less than or equal to .001). In summary, vasectomized men had a higher incidence and higher levels of circulating antisperm autoantibodies and CICs than did age-matched controls.

Contraceptive Steroids, age, and the cardiovascular system.

There is evidence that women who use oral contraceptives may be at slightly greater risk of cardiovascular complications as their age increased beyond 35 years. Popular opinion has held that these risks were largely estrogen-related. At the same time, however, postmenopausal women taking natural estrogen alone or in association with minimal amounts of progestogen have not exhibited these increased risk when compared with untreated control subjects. New clinical data indicate that there is a progestogen dose-related decrease in high-density lipoprotein cholesterol. There is also some evidence that relates progestogen dosage to morbidity rates from circulatory disease. Therefore the smallest dose of both estrogen and progestogen consistent with contraceptive efficacy and reasonable cycle control must be sought for all steroid combinations. This applies particularly to oral contraception for the woman beyond 35 years of age.

PIP: Evidence suggests that cardiovascular complications may develop in oral contraceptive (OC) users as their age increases beyond 35 years. This paper reviews the risks, clinical problems, and possible solutions for women who require estrogens or estrogens/progestogens after age 35. Tietze and Lewit pointed out the increasing risks associated with pregnancy and increasing age. Nonsmoking OC users aged 15-29 were found to have a mortality rate between 0.6-1.6/100,000 woman years, increasing to 9 and 17.7 in the 35-39 and 40-44 age groups respectively. A combination of smoking and pill use increases the risks in the latter 2 groups to 31.3 and 60.9 respectively. The Royal College of General Practitioners (RCGP) study published mortality data in 1977 based on 56 OC users and 43 controls. Major causes of death among the users were circulatory with a relative risk (RR) of 4.7 over the controls. The RR rose to 9.7 when OC use lasted more than 5 years. A 1981 RCGP report of the mortality data of 156 "ever users" and 93 controls again showed circulatory complications as the major problem, with an overall RR of 4.2. Overall mortality rate from all causes was 87.7 in the OC group and 64.4 in the controls; relative overall risk was 1.4. In March 1981, Vessey et al., of the Oxford Family Planning Association Study, reported that of the 81 deaths reviewed, OC users showed a mortality rate of 12.3/100,000 woman/years compared to 29.9 in the RCGP report. Other studies showed no increased risk of OC use for certain cardiovascular diseases (Walnut Creek Contraceptive Drug Study, Nachtigall et al., Hammon et al.). The most significant complication of OC use is the increased risk of circulatory diseases; smoking and age are 2 of the most consistent and significant contributing risk factors. Surgical sterilization is the safest and most practical approach for the more mature woman who needs contraception. Others may use IUDs and other barrier method with therapeutic abortion as backup. Older women who need steroid contraceptives should be checked for existing risk factors, advised to stop smoking, followed closely, and given the lowest progestin dose. In postmenopausal women, the addition of progestogen may reduce the risk of developing endometrial carcinoma.

Pharmacokinetics of ethynyloestradiol in women for different populations.

The pharmacokinetics of a dose of 50 microgram ethynyloestradiol administered orally was studied in fourteen centres. Absorption was rapid and the highest serum concentrations of total ethynyloestradiol were found in most subjects at 1 h and by 24 h concentrations were less than 250 pg/ml. Calculation of the half-lives for absorption, distribution and elimination showed wide variations between subjects, the half-life of elimination varying from 2.5 h to more than 30 h. Bioavailability as measured by the area under the serum ethynyloestradiol concentration-time curve also showed more than a ten-fold variation. Intra-centre differences in the various parameters measured were as large as the inter-centre differences.

Pituitary function testing in amenorrhea-galactorrhea-hyperprolactinemia.

Fifteen patients, age 16 to 55, presented with amenorrhea-galactorrhea-hyperprolactinemia. Pituitary function was evaluated by bolus injections of insulin, luteinizing hormone-releasing hormone (LHRH), and thyrotropin-releasing hormone (TRH) in 13 and by LHRH and TRH in 2. Responses to growth hormone (GH), thyroid-stimulating hormone (TSH), cortisol (F), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin were measured. GH, TSH, and F responses were normal in most cases. LH responses were decreased (P less than 0.025) in patients with abnormal sellar tomography, whereas FSH responses tended to decrease with elevated prolactin levels. Prolactin responses were absent in five of the seven cases which could be evaluated. The clinical value of such testing appears to be limited to an individualized basis, although some prognosis of ovulatory response to bromocriptine therapy may be obtained from the gonadotropin response.

Rate of metabolism of norethisterone in women from different populations.

The rate of metabolism of orally administered norethisterone was compared in fourteen centres by measuring plasma levels of the steroid by radioimmunoassay at varying times after oral administration of a 1 mg dose. The inter-centre differences were of the same order as the intra-centre differences. Variations in metabolism appeared not to be due to variations in body size.