Resilience and burnout of healthcare workers during the early COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has led to significantly more healthcare workers (HCWs) experiencing burnout than previously. This burnout is strongly associated with low resilience. Addressing organisational stresses and the introduction of resilience training will help to reduce the proportion of HCWs experiencing this phenomenon. AIMS: The aim of this study was to assess the impact of the biopsychosocial changes and challenges associated with the COVID-19 pandemic on the healthcare workforce, exploring, specifically, the impact on and relationship between HCWs' resilience and burnout. METHODS: An electronic opt-in survey was distributed to HCWs through hospital and professional association communications emails and websites, as well as social media. The survey consisted of demographic questions, the Oldenburg Burnout Inventory to assess burnout, Brief Resilience Scale to assess general resilience, and 10-item Connor-Davidson Resilience Scale to assess resilience during the pandemic. Univariate and multivariate analysis was undertaken to examine the relationship between these factors. RESULTS: A total of 1370 HCWs completed the questionnaire, with 802 (58.5%) having burnout, 348 (25.4%) having low general resilience and 390 (28.5%) having low COVID resilience. Burnout was significantly associated with being public sector workers, low general resilience and low COVID resilience. Resilience training was found to be protective for burnout. CONCLUSION: The introduction of resilience training in the workplace is a fundamental tool that will significantly benefit HCWs when working under challenging conditions.

Anogenital HPV-Related Cancers in Women: Investigating Trends and Sociodemographic Risk Factors.

The incidences of anogenital HPV-related cancers in women are on the rise; this is especially true for anal cancer. Medical societies are now beginning to recommend anal cancer screening in certain high-risk populations, including high-risk women with a history of genital dysplasia. The aim of this study is to investigate national anogenital HPV cancer trends as well as the role of demographics, deprivation, and ethnicity on anogenital cancer incidence in England, in an attempt to better understand this cohort of women which is increasingly affected by anogenital HPV-related disease. Demographic data from the Clinical Outcomes and Services Dataset (COSD) were extracted for all patients diagnosed with anal, cervical, vulval and vaginal cancer in England between 2014 and 2020. Outcomes included age, ethnicity, deprivation status and staging. An age over 55 years, non-white ethnicity and high deprivation are significant risk factors for late cancer staging, as per logistic regression. In 2019, the incidences of anal and vulval cancer in white women aged 55-74 years surpassed that of cervical cancer. More needs to be done to educate women on HPV-related disease and their lifetime risk of these conditions.

Fluid and electrolyte management: increasing the knowledge of House Officers using an interactive eLearning tool.

BACKGROUND: Interactive case-based tutorials represent a well-established method of improving House Officer learning. There has been little research on how tutorials of this kind can be improved, and whether their use changes practice. AIM: Our study aims to assess whether our eLearning tutorial on IV fluid and electrolyte prescribing improves the underlying knowledge base and confidence of participating House Officers, with regards to fluid and electrolyte balance physiology and prescribing. METHOD: An interactive eLearning module with core information on fluid and electrolyte prescribing and associated cases with questions and answers was created and distributed to participating House Officers in the 2019-2020 cohort nationwide. Participants were asked to complete pre-eLearning and post-eLearning questionnaires as well as a feedback survey to assess the efficacy of the module. RESULTS: Forty-nine House Officers completed the eLearning module and associated questionnaires. A majority of participants (69.3%) reported their previous teaching on fluid and electrolyte management as "very poor", "poor" or "mediocre". The average score for the pre-eLearning knowledge test was 75%, compared to a score of 97% for the post-eLearning knowledge test, resulting in a 22% increase in correct answers (p < 0.001). We found an increase of 53% in feeling "confident" or "very confident" in assessing and managing fluid requirements, and an increase of 57.1% in feeling "confident" or "very confident" in managing electrolyte requirements after undertaking the eLearning module. CONCLUSION: An interactive eLearning tutorial with real-world applications provides an effective, low-cost intervention that can improve confidence and skill in prescribing IV fluids.

Anal Cancer in High-Risk Women: The Lost Tribe.

In developed countries the incidence of anal squamous cell carcinoma (SCC) has been rising; especially in women over the age of 60 years who present with more advanced disease stage than men. Historically, anal SCC screening has focused on people living with Human Immunodeficiency Virus (HIV) (PLWH) who are considered to be at the highest risk of anal SCC, and its precancerous lesion, anal squamous intraepithelial lesion (SIL). Despite this, women with vulval high-grade squamous epithelial lesions (HSIL) and SCCs have been shown to be as affected by anal HSIL and SCC as some PLWH. Nevertheless, there are no guidelines for the management of anal HSIL in this patient group. The ANCHOR trial demonstrated that treating anal HSIL significantly reduces the risk of anal SCC in PLWH, there is therefore an unmet requirement to clarify whether the screening and treatment of HSIL in women with a prior genital HSIL is also beneficial. This review presents the current evidence supporting the screening, treatment, and surveillance of anal HSIL in high-risk women with a previous history of genital HSIL and/or SCC.

Axillary staging in ductal carcinoma in situ with microinvasion: A meta-analysis.

INTRODUCTION: Ductal carcinoma in situ with microinvasion (DCISM); arguably a more aggressive subtype of DCIS, currently has variable recommendations governing its staging and management in the UK. As a result, there is ongoing controversy surrounding the most appropriate management of DCISM, in particular the need of axillary staging. METHOD: A search was conducted on the databases MEDLINE and Embase using the keywords: breast, DCISM, microinvasion, "ductal carcinoma in situ with microinvasion", sentinel lymph node biopsy, SLNB, axillary staging was performed. 23 studies were selected for analysis. Primary outcome was the positivity of metastasis of lymph node; secondary outcome looked at characteristics of DCISM that may affect node positivity. RESULTS: A total of 2959 patients were included. Significant heterogeneity was observed amongst the studies with regards to metastases (I2 = 61%; P < 0.01). Lymph node macrometastases was estimated to be 2%. Significant subgroup difference was not observed between SLNB technique and lymph node macrometastases (Q = 0.74; p = 0.69). Statistical significance was observed between the focality of the DCISM and lymph node macrometastases (Q = 8.71; p = 0.033). CONCLUSION: Although histologically more advanced than DCIS, DCISM is not linked with higher rates of clinically significant metastasis to axillary lymph nodes. Survival rates are very similar to those seen in cases of DCIS. Current evidence suggests that axillary staging in cases of DCISM will not change their overall management, thus may only be an unnecessary and inconvenient additional intervention considering the majority of DCISM diagnoses are made from post-operative pathology samples. A multidisciplinary team approach evaluating pre-operative clinical and histological information to tailor the management specific to individual cases of DCISM would be a preferred approach than routine axillary staging.

Comparing and contrasting clinical consensus and guidelines for anal intraepithelial neoplasia in different geographical regions.

Anal Squamous Cell Carcinoma (ASCC) is an uncommon cancer with a recognised precursor Anal Intraepithelial Neoplasia (AIN). Although there are consistent evidence-based guidelines for the management of ASCC, historically this has not been the case for AIN and as a result there have been geographical variations in the recommendations for the treatment of AIN. More recently there have been updates in the literature to the recommendations for the management of AIN. To assess whether we are now closer to achieving an international consensus, we have completed a systematic scoping review of available guidelines for the screening, treatment and follow-up of AIN as a precursor to ASCC. MEDLINE and EMBASE were systematically searched for available clinical guidelines endorsed by a recognised clinical society that included recommendations on either the screening, treatment or follow-up of AIN. Nine clinical guidelines from three geographical areas were included. The most recent guidelines agreed that screening for AIN in high-risk patients and follow-up after treatment was necessary but there was less consensus on the modality of screening. Six Guidelines recommended the treatment of high-grade AIN and four guidelines describe a follow-up protocol of patients diagnosed with AIN. There appears to be increasing consensus on the treatment and follow-up of patients despite a poor evidence base. There is still significant discrepancy in guidance on the method to identify patients at risk of ASCC and AIN despite consensus between geographical regions on which patient subgroups are at the highest risk.

Fluid and electrolyte balance-establishing the knowledge base of Foundation Year One doctors.

BACKGROUND: Fluid and electrolyte management for hospital inpatients has been identified by multiple reports to be suboptimal, with delegation of this task to the most junior members of a medical team, Foundation Year One (FY1) doctors, also known as interns or house officers, being identified as a contributing factor. METHODS: An online survey was distributed nationally via social media to FY1 doctors between 21st August 2018 and 19th September 2018. Questions focused around cohort characteristics, team behaviours around fluid and electrolyte prescribing, as well as teaching and knowledge. RESULTS: Two hundred eighty-six doctors participated. 67.13% knew the daily water requirement of a healthy adult. 58.39 and 79.72% knew the daily requirements of potassium and sodium, respectively. 41.26 and 33.57% knew the potassium and sodium composition of Hartmann's solution (1 L), respectively, with only 31.12% of candidates knowing the correct sodium content of 1 L of normal saline 0.9%. FY1 doctors were the principle prescribers of fluid therapy (97.55%); senior house officers, registrars, and consultants were only actively involved in the process 51.75, 20.98, and 5.59% of the time, respectively. 30.77 and 23.43% of FY1s received guidelines and/or teaching on the topic within their firms or as part of their foundation teaching, respectively. At undergraduate level, 52.44% of doctors reported the teaching to be "neither poor or good," "poor," or "very poor." CONCLUSION: The principle knowledge base underlying fluid and electrolyte management is still poorly understood by FY1 doctors, with poor teaching of the subject at both undergraduate and post-graduate level potentially contributing.

Improving safety for medical students and patients during medical electives-a novel simulation-based course.

INTRODUCTION: The medical elective is a common component of undergraduate medical education in the UK and Ireland. These are often undertaken in varied hospitals and countries across the world, most of which are not related to their parent institutions, in order to explore specialties and regions of interest. However experiences are varied, with goals not always established beforehand, or indeed reached, when present. METHODS: Using a novel 20-item, self-administered questionnaire distributed via social media to 436 medical students and doctors in the UK and Republic of Ireland, we sought to delineate common elective experiences and establish what procedures and clinical scenarios medical students commonly undertake and manage during their medical electives, in order to ascertain their confidence level with each of these tasks at the time of their medical electives. We also looked to determine if there are any adverse effects or events related to these situations. Following this, we developed a simulation-based course to address knowledge and skill gaps identified in the above fields. This course was delivered to two groups of medical students from St George's University London and King's College London medical schools by the same faculty over two separate afternoons. RESULTS: We found that a significant proportion of medical students feel pressured to perform skills, which are beyond their competence level during their elective placements, putting both patient and student safety at risk. Our simulation course was successful in significantly improving key technical and non-technical skills, which would be useful for students during their medical electives.

The role of the medial and central amygdala in stress-induced suppression of pulsatile LH secretion in female rats.

Stress exerts profound inhibitory effects on reproductive function by suppressing the pulsatile release of GnRH and therefore LH. Although the mechanisms by which stressors disrupt the hypothalamic GnRH pulse generator remain to be fully elucidated, numerous studies have implicated the amygdala, especially its medial (MeA) and central nuclei (CeA), as key modulators of the neuroendocrine response to stress. In the present study, we investigated the roles of the MeA and CeA in stress-induced suppression of LH pulses. Ovariectomized rats received bilateral ibotenic acid or sham lesions targeting the MeA or CeA; blood samples (25 µl) were taken via chronically implanted cardiac catheters every 5 min for 6 h for the measurement of LH pulses. After 2 h of baseline sampling, the rats were exposed to either: restraint (1 h), insulin-induced hypoglycemia (IIH) (0.3 U/kg, iv), or lipopolysaccharide (LPS) (25 µg/kg, iv) stress. The restraint but not IIH or LPS stress-induced suppression of LH pulses was markedly attenuated by the MeA lesions. In contrast, CeA lesioning attenuated LPS, but not restraint or IIH stress-induced suppression of LH pulses. Moreover, after restraint stress, the number of Fos-positive neurons and the percentage of glutamic acid decarboxylase(67) neurons expressing Fos was significantly greater in the GnRH-rich medial preoptic area (mPOA) of rats with intact, rather than lesioned, MeA. These data indicate that the MeA and CeA play key roles in psychogenic and immunological stress-induced suppression of the GnRH pulse generator, respectively, and the MeA-mediated effect may involve γ-aminobutyric acid ergic signaling within the mPOA.