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.

New Horizons: COVID-19 and the Burden of Neuropsychiatric Illness in Pakistan.

This manuscript reviews the current state of knowledge about the burden of mental illness and assesses the impact of COVID-19 illness on mental health in Pakistan. For this we analyzed secondary data obtained from the Institute of Health Metrics and Evaluation. The Global Burden of Disease (GBD) study draws from a wide range of data sources to quantify global and regional effects of a disease. We also did a literature search on the effects of COVID-19 illness on mental health and the psychosocial effects of COVID-19 and other Corona virus related illnesses such as SARS-CoV and MERS-CoV. Data from the studies obtained was utilized to extrapolate the anticipated effects of COVID-19 illness on healthcare workers, COVID-19 patients and the general public in Pakistan. Mental illness poses a significant challenge to Pakistan's under resourced health care system. COVID-19 has the potential to strain Pakistan's healthcare system to the breaking point. So far, the general morbidity from COVID-19 illness in Pakistan has been low compared to other countries but this could change in the coming weeks and months. Hidden within this crisis are also some opportunities for both healthcare and education.

Scarlett Letter: A study based on experience of stigma by COVID-19 patients in quarantine.

BACKGROUND AND OBJECTIVES: Stigma around COVID-19 is a major barrier in global efforts to control the COVID 19 pandemic. Limited data is available regarding stigma faced by COVID-19 patients in low- and middle-income countries (LMIC). The aim of the current study was to explore the stigma experienced by hospitalized patients with COVID-19 illness in Lahore, Pakistan. METHODS: Following Institutional Review Board approval and informed consent, patients were assessed using modified HIV short form stigma scale and open-ended questions. Questions focused on experiences, feelings, and opinions as to how patients feel and how they were treated prior to and during the hospitalization. Data analysis for quantitative data was performed using SPSS-20, while qualitative responses were interpreted by content analysis method. RESULTS: One hundred and fourteen patients were interviewed (Mean age 38.8 years + 15.3) with 53.5% being males. Widespread experience of stigma was reported by patients particularly for concerns about public attitudes (7.43 + 1.43) & disclosure (6.89 + 1.45). Main themes which emerged from the qualitative responses were social stigma and rejection, humiliating behaviour of others, breach of confidentiality, loss of trust/ respect, and impact of COVID-19 diagnosis on their business. CONCLUSIONS: Existence of significant stigma among COVID-19 patients isolated in a tertiary care hospital in a LMIC highlights the need for culturally sensitive strategies to address it.

The importance of identification when measuring performance in addiction treatment.

Background: Identifying and effectively treating individuals with substance use disorders (SUDs) is an important priority for state Medicaid programs, given the enormous toll that SUDs take on individuals, their families, and their communities. In this paper, we describe how the Healthcare Effectiveness Data and Information Set (HEDIS) measure "Identification of Alcohol and Other Drug Services" can be used, along with eligible population prevalence rates, to expand states' ability to track how well their Medicaid programs identify enrollees with SUDs and link them with treatment (measured by initiation and engagement performance measures). Methods: We use the 2009 Medicaid MAX data on utilization and enrollment along with information from the National Survey of Drug Use and Health (NSDUH) to obtain state-level estimates of alcohol and drug abuse and dependence among Medicaid beneficiaries for 7 illustrative states. We calculate identification, initiation, and engagement measures using specifications from the National Committee on Quality Assurance (NCQA). Results: NSDUH data showed that the eligible population prevalence rate (the average rate of alcohol or drug abuse or dependence) among the 7 states was 10.0%, whereas the average identification rate was 2.9%. The gap between the prevalence and identification rates ranged from 5.1% to 11.0% among the 7 states. The initiation rates ranged from 36.9% to 57.1%. The states' engagement rates ranged from 11.8% to 31.1%, although rates differ by age, gender, and race/ethnicity in some states. Conclusion: Including identification along with initiation and engagement measures allows states to determine how well they are performing in a more complete spectrum from need, to recognition and documentation of enrollees with SUDs, to initiation of treatment, to continuation of early treatment.

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.

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.

Hepatic Dysfunction in Patients Receiving Intravenous Amiodarone.

OBJECTIVES: Amiodarone is a commonly used antiarrhythmic drug. Hepatotoxicity following chronic oral administration occurs in 1% to 3% of patients. Hepatotoxicity following intravenous (IV) administration is infrequent but may be associated with dramatic increases in serum transaminases. We describe the incidence of liver toxicity among patients receiving IV amiodarone during a 5-year period. METHODS: This was a single-center retrospective review of patients receiving IV amiodarone for any cause. The outcome measures were development of elevated serum transaminases and the relation of transaminitis to all-cause 30-day mortality. RESULTS: A total of 1510 patients received amiodarone intravenously between 2005 and 2011; 77 (5%) developed elevated liver enzymes. Enzyme elevation was divided into mild (100-300 IU/L), moderate (300-1000 IU/L), and severe (>1000 IU/L). The median alanine aminotransferase was 189 (37-10,006) IU/L and aspartate aminotransferase was 253 (84-12,005) IU/L. The 30-day mortality among those with transaminitis was 22%; however, no patient died of amiodarone-related liver disease. CONCLUSIONS: Amiodarone can cause severe elevation in liver enzymes. The incidence of severe transaminitis is low; deaths following IV amiodarone are rarely caused by drug-induced liver failure.

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.

Urdu translation of the Hamilton Rating Scale for Depression: Results of a validation study.

OBJECTIVE: To develop a standardized validated version of the Hamilton Rating Scale for Depression (HAM-D) in Urdu. METHODS: After translation of the HAM-D into the Urdu language following standard guidelines, the final Urdu version (HAM-D-U) was administered to 160 depressed outpatients. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation between HAM-D-U scores at baseline and after a 2-week interval was evaluated for test-retest reliability. Moreover, scores of two clinicians on HAM-D-U were compared for inter-rater reliability. For establishing concurrent validity, scores of HAM-D-U and BDI-U were compared by using Spearman correlation coefficient. The study was conducted at Mayo Hospital, Lahore, from May to December 2014. RESULTS: The Cronbach alpha for HAM-D-U was 0.71. Composite scores for HAM-D-U at baseline and after a 2-week interval were also highly correlated with each other (Spearman correlation coefficient 0.83, p-value < 0.01) indicating good test-retest reliability. Composite scores for HAM-D-U and BDI-U were positively correlated with each other (Spearman correlation coefficient 0.85, p < 0.01) indicating good concurrent validity. Scores of two clinicians for HAM-D-U were also positively correlated (Spearman correlation coefficient 0.82, p-value < 0.01) indicated good inter-rater reliability. CONCLUSION: The HAM-D-U is a valid and reliable instrument for the assessment of Depression. It shows good inter-rater and test-retest reliability. The HAM-D-U can be a tool either for clinical management or research.

Insomnia during pregnancy: Diagnosis and Rational Interventions.

UNLABELLED: Sleep disturbances are common in pregnancy. Insomnia is a frequent sleep disturbance experienced by pregnant women which can be primary or due to co-morbid conditions. The differential diagnosis of insomnia in pregnancy includes anxiety disorders, mood disorders, breathing related sleep disorders and restless legs syndrome. Early interventions to treat the sleep disturbance are recommended to avoid adverse pregnancy outcomes. Management strategies include improving sleep hygiene, behavioral therapies, and pharmacotherapy. The risks of pharmacotherapy must be weighed against their benefits due to the possible risk of teratogenicity associated with some medications. METHODS: We searched PubMed and Google Scholar employing a combination of key words: pregnancy, sleep disturbances, Obstructive Sleep Apnea, Sleep disorders and insomnia. We included original studies, review articles, meta-analysis and systematic reviews in our search prioritizing articles from the last 10-15 years. Articles older than 15 years were only included if their findings had not been superseded by more recent data. Further selection of articles was done from bibliographies and references of selected articles. CONCLUSION: Sleep disturbances in pregnancy are common and cause considerable morbidity. Management includes a combination of non-pharmacological and pharmacological treatments carefully weighing the risks and benefits of each for the expectant mother and fetus.

Towards a dynamic clamp for neurochemical modalities.

The classic dynamic clamp technique uses a real-time electrical interface between living cells and neural simulations in order to investigate hypotheses about neural function and structure. One of the acknowledged drawbacks of that technique is the limited control of the cells' chemical microenvironment. In this manuscript, we use a novel combination of nanosensor and microfluidic technology and microfluidic and neural simulations to add sensing and control of chemical concentrations to the dynamic clamp technique. Specifically, we use a microfluidic lab-on-a-chip to generate distinct chemical concentration gradients (ions or neuromodulators), to register the concentrations with embedded nanosensors and use the processed signals as an input to simulations of a neural cell. The ultimate goal of this project is to close the loop and provide sensor signals to the microfluidic lab-on-a-chip to mimic the interaction of the simulated cell with other cells in its chemical environment.

Antibiotic prophylaxis in hip surgery: A comparision of two vs. three doses of cefuroxime.

OBJECTIVE: To compare the efficacy of two-dose regime with a three-dose regime of cefuroxime in the prevention of post-operative wound infection in hip surgery patients and to determine the most effective regime of antibiotic prophylaxis for such patients. METHODS: The prospective, comparative, multi-centre cohort study was conducted from January 1998 to June 1998 at Dundee Royal Infirmary and attached district hospitals (Stirling Royal Infirmary and Falkirk Royal Infirmary). It comprised patients who had hip surgery i.e. fracture fixation, hemiarthroplasty or total hip replacement. Patients were assigned to two groups. Group A patients received cefuroxime 750mg at induction of anaesthesia and 750mg at the end of the procedure, while Group B patients received 1.5gm of cefuroxime at the induction of anaesthesia, followed by 750mg 8 and 16 hours after the operation. Patients were assessed post-operatively daily according to the ASEPSIS wound scoring system during the hospital stay. RESULTS: There were 280 patients in the study, with 140(50%) in each of the two groups. In Group A 60(43%) patients required fracture fixation, the rate of wound infection was 2(3.3%), 40(28.5%) required hemiarthroplasty and the rate of wound infection was 1(2.5%) and 40(28.5%) required total hip replacement and the rate of wound infection was zero. In Group B, the corresponding numbers were 1/60 (1.6%), 1/40 (2.5%) and zero. No evidence of minor, moderate or severe wound infection was observed in 272(97%) patients regardless of the group. The most frequent pathogens were Staphylococcus aureus in 3(1%) patients and Staphylococcus epidermidis in 2(0.7%). CONCLUSIONS: There was no significant difference in the prevalence of wound infection between the patients who had received two or three doses of cefuroxime.

Visceral abdominal obesity measured by CT scan is associated with an increased risk of Barrett's oesophagus: a case-control study.

OBJECTIVE: Abdominal obesity has been associated with increased risk of Barrett's oesophagus (BE) but the underlying mechanism is unclear. We examined the association between visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) and the risk of BE. DESIGN: A case-control study among eligible patients scheduled for elective oesophagastroduodenoscopy (EGD) and in a sample of patients eligible for screening colonoscopy recruited at the primary care clinic. All cases with definitive BE and a random sample of controls without BE were invited to undergo standardised mid-abdomen non-contrast computerised axial tomography images, which were analysed by semiautomated image segmentation software. The effect of VAT and SAT surface areas and their ratio (VAT to SAT) on BE were analysed in logistic regression models. RESULTS: A total of 173 BE cases, 343 colonoscopy controls and 172 endoscopy controls underwent study EGD and CT scan. Participants with BE were more than twice as likely to be in the highest tertile of VAT to SAT ratio (OR: 2.42 (1.51 to 3.88) and adjusted OR 1.47 (0.88 to 2.45)) than colonoscopy controls, especially for those long (≥3 cm) segment BE (3.42 (1.67 to 7.01) and adjusted OR 1.93 (0.92 to 4.09)) and for white men (adjusted OR 2.12 (1.15 to 3.90)). Adjustment for gastroesophageal reflux disease (GERD) symptoms and proton pump inhibitors (PPI) use attenuated this association, but there was a significant increase in BE risk even in the absence of GERD or PPI use. CONCLUSIONS: Large amount of visceral abdominal fat relative to subcutaneous fat is associated with a significant increase in the risk of BE. GERD may mediate some but not all of this association.

Actigraphy in post traumatic stress disorder.

UNLABELLED: Patients with posttraumatic stress disorder (PTSD) frequently complain of sleep disturbances such as insomnia and nightmares. Evaluation of sleep disturbances is often difficult due to the subjective nature of the complaints. Polysomnography (PSG) and other sleep studies are generally not indicated in the evaluation of insomnia or nightmares associated with PTSD. Actigraphy, (electronic activity monitoring) has been used in research to evaluate sleep disturbances in patients with PTSD. We reviewed the literature on the use of actigraphy in evaluation of sleep problems in patients with PTSD. METHODS: A literature search for articles on the topic was conducted on PubMed using the search algorithm (actigraphy[Title/Abstract] OR actigraphic[Title/Abstract]) AND PTSD[Title/Abstract]. Out of 11 search results, 9 studies in which application of actigraphy had relevance to the primary objective and outcome in PTSD patients with sleep problems were selected for review. We also handpicked one additional article from personal communication with our colleagues who have done some of these studies. CONCLUSION: Actigraphy has been used to evaluate circadian rhythm sleep disorders. Use of actigraphy in psychiatry clinics is uncommon. There is no data to support that there are specific actigraphic sleep related findings in PTSD patients. However, it can be a useful tool to complement the use of sleep diaries when assessing sleep and wake patterns in patients with PTSD.

Mechanical forces across compartments coordinate cell shape and fate transitions to generate tissue architecture.

Morphogenesis and cell state transitions must be coordinated in time and space to produce a functional tissue. An excellent paradigm to understand the coupling of these processes is mammalian hair follicle development, which is initiated by the formation of an epithelial invagination-termed placode-that coincides with the emergence of a designated hair follicle stem cell population. The mechanisms directing the deformation of the epithelium, cell state transitions and physical compartmentalization of the placode are unknown. Here we identify a key role for coordinated mechanical forces stemming from contractile, proliferative and proteolytic activities across the epithelial and mesenchymal compartments in generating the placode structure. A ring of fibroblast cells gradually wraps around the placode cells to generate centripetal contractile forces, which, in collaboration with polarized epithelial myosin activity, promote elongation and local tissue thickening. These mechanical stresses further enhance compartmentalization of Sox9 expression to promote stem cell positioning. Subsequently, proteolytic remodelling locally softens the basement membrane to facilitate a release of pressure on the placode, enabling localized cell divisions, tissue fluidification and epithelial invagination into the underlying mesenchyme. Together, our experiments and modelling identify dynamic cell shape transformations and tissue-scale mechanical cooperation as key factors for orchestrating organ formation.

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.

The touch of madness:manto as a psychiatric case study.

UNLABELLED: Saadat Hasan 'Manto' is widely acknowledged as one of the greatest short story writers in the world. He died at the age of forty three from complications of alcoholism. All of his life, he suffered from symptoms of anxiety and depression and his alcohol abuse was intimately linked both to his mental distress as well as his creative genius. This paper examines the life of Manto from a psychiatric perspective and the link between creativity and mental illness. We show how Manto's particular family circumstances led to the development of restlessness and later anxiety in his life; how his substance abuse, especially alcohol abuse exacerbated this mental distress and how it eventually led to his death and how all of these factors were intimately linked to his creative genius and were the source of so many of his literary masterpieces. METHODS: We reviewed seventy five short stories considered to be his best. Writings about Manto's life including his own were reviewed to construct a picture of his life as well as find clues to his mental distress and alcohol abuse. A literature search for articles related to creativity and mental illness was conducted using Google Scholar containing the search terms 'creativity and madness' and 'creativity and mental illness' in the titles of the articles. References most relevant to our case study were identified. CONCLUSION: Manto suffered from symptoms of anxiety and depression which today would meet the diagnostic criteria for Alcohol Dependence and, in later life, Alcohol-induced Psychosis. Appropriate treatment may have prolonged his life although that may have come at the expense of his creativity.

Nocturnal Awakening & Sleep Duration in Veterans with PTSD: An Actigraphic Study.

OBJECTIVE: To assess whether awakenings from sleep and sleep duration in Post Traumatic Stress Disorder (PTSD) were related to demography, posttraumatic or depressive symptoms, subjective sleep quality, and daytime sleepiness. METHODS: Sample consisted of 23 veterans with lifetime PTSD and current sleep disturbance not due to apnea or other diagnosable conditions. Data collection included demography, two weeks of actigraphy, Beck Depression Inventory, Posttraumatic Checklist, Clinical Assessment of Posttraumatic Symptoms, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. RESULTS: The study revealed that awakenings increased with younger age. Variability in awakenings also increased with younger age (p = 0.002). More awakenings were associated with shorter sleep duration. CONCLUSIONS: These paradoxical observations regarding younger age and more awakening may be related to increased sleep symptoms early in the course and then gradual waning of posttraumatic symptoms over time, since awakenings tend to increase with age in normals (rather than decrease, as we observed).

Gender Discrimination among Medical Students in Pakistan: A Cross Sectional Survey.

OBJECTIVE: To examine the prevalence and magnitude of gender discrimination experienced by undergraduate medical students, and its repercussions on their academic performance and emotional health. METHODOLOGY: A cross sectional study of 500 medical and dental students studying at a private medical college in Lahore, Pakistan. RESULTS: Majority (78%) of students reported being victims of gender discrimination. Females were the main perpetrators (70.8%).Most common forms were denied opportunities (63%), followed by neglecting students' needs (44.3%), and unethical talk (43.6%). Most common places of gender discrimination were teachers' offices (43.7%) and lecture halls (37.2%). Most of the perpetrators were clerical staff (48%) and professors (43%).Gender discrimination did not affect the academic performance of most victims (62.6%). The most common emotional responses were anger (57.6%), frustration (46.7%) and helplessness (40.3%). 52.4% of students said that gender discrimination still continues and the majority (83.3%) did not report the problem to college authorities. CONCLUSIONS: RESULTS demonstrate that gender discrimination is widely prevalent in undergraduate medical education. Females are both the main victims as well as the main perpetrators. In most cases gender discrimination does not affect academic performance but does cause emotional distress.