The challenge of Burnout in Public Medical Teachers in Pakistan: A mixed methods study.

BACKGROUND AND OBJECTIVES: Burnout is common in healthcare workers and affects multiple domains of functioning. The objective of this study was to assess burnout in medical teachers in a large public medical university in Lahore, Pakistan and explore the factors behind it. METHODS: Using an explanatory sequential mixed methods design, we first sent out the abbreviated Maslach Burnout Inventory (aMBI) to all teaching faculty of basic and clinical science at King Edward Medical University (KEMU) Lahore. Descriptive analysis was performed on the 203 respondents who returned the survey. Of those who scored higher on the aMBI, 10 respondents (8 clinical science faculty and two basic science faculty) were selected for detailed semi-structured interviews exploring possible reasons for burnout. Thematic analysis of interview transcripts was performed using Interpretive Phenomenological Analysis. Triangulation and member checking was used for validation. RESULTS: About 38.9% of respondents scored high on the Emotional Exhaustion subscale and 31.5% scored high on the Depersonalization subscale. There were statistically significant differences on the mean Emotional Exhaustion scores (p <0.001) between Basic and Clinical Sciences Departments with respondents from the Clinical Departments having higher scores (7.84 ± 4.32). Four main themes and multiple sub-themes emerged around burnout after qualitative analysis of the data. These included 1. Work-related factors 2. Family and social factors including challenges related specifically to women 3. Feelings and emotions and 4. Personal Qualities. CONCLUSION: A significant proportion of medical faculty experiences burnout related to their professional and personal responsibilities. The reasons are varied. Policy planners and University/College administrators must acknowledge the negative effects of burnout on medical teachers and take steps to ameliorate it in the interests of improving medical education and training.

Role of Oxytocin in the Pathogenesis and Modulation of Borderline Personality Disorder: A Review.

Borderline personality disorder (BPD) is a serious psychiatric condition characterized by dysfunctional relations, abnormal social behavior, and high morbidity. Many studies have implicated abnormal oxytocinergic system as a causative factor of behavioral dysregulation in BPD patients. The objective of this review is to provide a comprehensive analysis of the association of oxytocin with the pathogenesis of BPD and its possible role as a therapeutic agent. Our review indicates that a combination of genetic and environmental factors causes BPD patients to have lower baseline levels of oxytocin, leading to increased activation of the amygdala. This results in defective cognition of social stimuli, leading to abnormal behaviors like affective instability, unresolved attachment, and emotional dysregulation. Clinical trials conducted on BPD patients using intranasal oxytocin have shown both prosocial and trust-lowering effects. The effects of oxytocin depend upon various patient characteristics like the history of childhood trauma and the nature of attachment. Even though evidence of oxytocin's role in modulating behavior in BPD patients already exists, further studies are required to more clearly elaborate on this role to fully explore oxytocin's potential as a therapeutic agent.

Between a Rock and a Hard Place - Gender Dysphoria and Comorbid Depression in a Young, Low-Income, Pakistani Transgender Man.

Gender dysphoria (GD) describes an incongruence between a person's assigned and expressed gender and the distress associated with it. The management of GD ideally involves a team of healthcare professionals, including psychiatrists, endocrinologists, and surgeons, and may include one or more of the following - psychotherapy, hormone therapy, and gender reassignment surgeries. While Pakistan still has a sizeable population of the traditional 'khwaja siras' or 'hijras,' many young transgender Pakistanis are now adopting global transgender identities and seeking sex-reassignment procedures from a state-run healthcare system, which still heavily discriminates against them. In spite of the passage of a new law protecting the fundamental human rights of transgendered Pakistanis, they continue to be oppressed and deprived of education, employment, and healthcare. This case report describes one such young transman from a low-income Pakistani household, who, owing to the legal red tape, family pressure, religious disapproval, and hefty hospital expenses, is left with only two options - to undergo unsafe, unstandardized procedures at the hands of quacks or live the rest of his life trapped in the wrong body. There is a dire need for a wide-scale awareness campaign to educate and sensitize the general public about transgender rights. Medical students must also be exposed to transgender patients during their medical school training in order to familiarize them with the special medical needs of transgender individuals.

Smart phones and medical students: Pleasant distraction or dangerous addiction?

Smart phones are central to communication in the current century. We administered a survey to determine the impact of excessive smart phone use on academic performance, interpersonal relationships and mental health in medical students. During the study, 700 medical students from King Edward Medical University, Lahore, Pakistan, were administered a questionnaire which recorded information about demographics, academic performance, interpersonal relationships and psychological problems. Out of 630 respondents, 255(40.5%) were males and 375(59.5%) were females with a mean age of 21.1}1.8 years. Results showed smart phone use during class lectures was associated with significant reduction in academic performance and problems with interpersonal relationships. Medical students bullied via smart phones were likely to bully others. Excessive use of smart phones was associated with students preferring to communicate emotions through texting rather than verbal communication. Various psychological problems were found prevalent in excessive users of smart phones.

Burnout and quality of life in nurses of a tertiary care hospital in Pakistan.

OBJECTIVE: To determine the relationship of burnout and quality of life among nurses of different departments at a tertiary care hospital. METHODS: The observational, cross-sectional study was conducted at Mayo Hospital, Lahore, from November 2013 to May2014, and comprised nurses recruited by convenience sampling. Maslach Burnout Inventory was used to assess burnout and World Health Organisation Quality of life instrument's BREF version was used to assess quality of life of the subjects. Data was analysed using SPSS 16. RESULTS: Of the 106 nurses with a mean age of 35.5±7 years, 83(79%) were experiencing severe burnout and a low quality of life. Nurses of Surgery and Obstetrics/Gynaecology departments who worked longer hours on the night shift scored higher on burnout and lower on quality of life. CONCLUSIONS: Burnout in nurses was very common because of increasing workload and can negatively affect their quality of life leading to compromised patient care.

Pathophysiological Role of HERV-W in Schizophrenia.

Schizophrenia is a neuropsychiatric disorder of complex etiology. Human endogenous retroviruses (HERVs) have been presented as possible candidates explaining the connections between the genetic, infectious, neurodevelopmental, and neuroinflammatory aspects of schizophrenia, with the human endogenous retrovirus type W family (HERV-W) showing the greatest evidence of association. Studies have identified retroviral nucleotide sequences, envelope and capsid proteins, and elevated transcription of HERV-W elements in CSF, blood, and brain samples from individuals with schizophrenia. The HERV-W elements can trigger the immune system in a variety of ways. HERV genetic elements may be activated by various prenatal maternal infections, leading to neuroinflammation and genetic abnormalities, altering the development of the brain, and eventually culminating in the development of schizophrenia. This review presents a concise synthesis of available evidence and theoretical speculation regarding the role of HERV-W in schizophrenia. The need for further investigation is highlighted before any conclusions can be stated with confidence.

The Pittsburgh Sleep Quality Index: validation of the Urdu translation.

OBJECTIVE: To translate and validate the Pittsburgh Sleep Quality Index (PSQI), a standardized self-administered questionnaire for the assessment of subjective sleep quality into the Urdu language. STUDY DESIGN: Validation study. PLACE AND DURATION OF STUDY: Mayo Hospital, Lahore, from March to April 2012. METHODOLOGY: The PSQI was translated into Urdu following standard guidelines. The final Urdu version (PSQI-U) was administered to 200 healthy volunteers comprising medical students, nursing staff and doctors. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation of component scores with global score was assessed by calculating Spearman correlation coefficient. Correlation between global PSQI-U scores at baseline with global scores for each PSQI-U and PSQI-E at 4-week interval was evaluated by calculating Spearman correlation coefficient. Moreover, scores on individual items of the scale at baseline were compared with respective scores after 4-week by t-test. RESULTS: One hundred and eighty five (185) participants completed the PSQI-U at baseline. The Cronbach alpha for PSQI-U was 0.56. Scores on individual components of the PSQI-U and composite scores were all highly correlated with each other (all p-values < 0.01). Composite scores for PSQI-U at baseline and PSQI-E at 4-week interval were also highly correlated with each other (Spearman correlation coefficient 0.74, p-value < 0.01) indicating good linguistic interchangeability. Composite scores for PSQI-U at baseline and at 4-week interval were positively correlated with each other (Spearman correlation coefficient 0.70, p < 0.01) indicating good test-retest reliability. CONCLUSION: The PSQI-U is a valid and reliable instrument for the assessment of sleep quality. It shows good linguistic interchangeability and test-retest reliability in comparison to the original English version when applied to individuals who speak the Urdu language. The PSQI-U can be a tool either for clinical management or research.

Is depression an inflammatory condition? A review of available evidence.

The current review examines the relationship between depression and the inflammatory immune response. Mood disorders are a significant cause of morbidity and the etiology of depression is still not clearly understood. Many studies have shown links between inflammatory cytokines and mood disorders, including elevated level of cytokines like tumour necrosis factor-alpha (TNF alpha), Interleukins (IL-1,IL-6) and others. Raised levels of cytokines have been shown to increase depressive behaviour in animal models, while many anti-depressants reverse this behaviour alongside reducing the Central Nervous System (CNS) inflammatory response and reduction in the amounts of inflammatory cytokines. Cytokines reduce neurogenesis, Brain Derived Neurotrophic Factor (BDNF) and neuronal plasticity in the CNS, while many anti-depressants have been shown to reverse these processes. The considerations of anti-depressants as anti-inflammatory agents, and implication of other anti-inflammatory therapeutics for the treatment of depression are pointed out.