'Everything was just getting worse and worse': deteriorating job quality as a driver of doctor emigration from Ireland.

BACKGROUND: Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job-high pay, high job control, challenging demands, with those of a low-quality job-long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return. METHODS: Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July-August 2018. RESULTS: Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman's work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland. DISCUSSION: The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

What the public think about participation in medical research during an influenza pandemic: an international cross-sectional survey.

OBJECTIVES: The public and patients are primary contributors and beneficiaries of pandemic-relevant clinical research. However, their views on research participation during a pandemic have not been systematically studied. We aimed to understand public views regarding participation in clinical research during a hypothetical influenza pandemic. STUDY DESIGN: This is an international cross-sectional survey. METHODS: We surveyed the views of nationally representative samples of people in Belgium, Poland, Spain, Ireland, the United Kingdom, Canada, Australia and New Zealand, using a scenario-based instrument during the 2017 regional influenza season. Descriptive and regression analyses were conducted. RESULTS: Of the 6804 respondents, 5572 (81.8%) thought pandemic-relevant research was important, and 5089 (74.8%) thought 'special rules' should be applied to make this research feasible. The respondents indicated willingness to take part in lower risk (4715, 69.3%) and higher risk (3585, 52.7%) primary care and lower risk (4780, 70.3%) and higher risk (4113, 60.4%) intensive care unit (ICU) study scenarios. For primary care studies, most (3972, 58.4%) participants preferred standard enrolment procedures such as prospective written informed consent, but 2327 (34.2%) thought simplified procedures would be acceptable. For ICU studies, 2800 (41.2%) preferred deferred consent, and 2623 (38.6%) preferred prospective third-party consent. Greater knowledge about pandemics, trust in a health professional, trust in the government, therapeutic misconception and having had ICU experience as a patient or carer predicted increased willingness to participate in pandemic-relevant research. CONCLUSIONS: Our study indicates current public support for pandemic-relevant clinical research. Tailored information and initiatives to advance research literacy and maintain trust are required to support pandemic-relevant research participation and engagement.

Enabling recruitment success in bariatric surgical trials: pilot phase of the By-Band-Sleeve study.

BACKGROUND: Randomized controlled trials (RCTs) involving surgical procedures are challenging for recruitment and infrequent in the specialty of bariatrics. The pilot phase of the By-Band-Sleeve study (gastric bypass versus gastric band versus sleeve gastrectomy) provided the opportunity for an investigation of recruitment using a qualitative research integrated in trials (QuinteT) recruitment intervention (QRI). PATIENTS/METHODS: The QRI investigated recruitment in two centers in the pilot phase comparing bypass and banding, through the analysis of 12 in-depth staff interviews, 84 audio recordings of patient consultations, 19 non-participant observations of consultations and patient screening data. QRI findings were developed into a plan of action and fed back to centers to improve information provision and recruitment organization. RESULTS: Recruitment proved to be extremely difficult with only two patients recruited during the first 2 months. The pivotal issue in Center A was that an effective and established clinical service could not easily adapt to the needs of the RCT. There was little scope to present RCT details or ensure efficient eligibility assessment, and recruiters struggled to convey equipoise. Following presentation of QRI findings, recruitment in Center A increased from 9% in the first 2 months (2/22) to 40% (26/65) in the 4 months thereafter. Center B, commencing recruitment 3 months after Center A, learnt from the emerging issues in Center A and set up a special clinic for trial recruitment. The trial successfully completed pilot recruitment and progressed to the main phase across 11 centers. CONCLUSIONS: The QRI identified key issues that enabled the integration of the trial into the clinical setting. This contributed to successful recruitment in the By-Band-Sleeve trial-currently the largest in bariatric practice-and offers opportunities to optimize recruitment in other trials in bariatrics.

Clinical impact of DVH uncertainties.

Dose-volume histograms (DVH), along with dose and volume metrics, are central to radiotherapy planning. As such, errors have the potential to significantly impact the selection of appropriate treatment plans. Dose distributions that pass tests in one TPS may fail the same tests when transferred to another, even if using identical structures and dose grid information. This work shows the design and implementation of methods for assessing the accuracy of dose and volume computations performed by treatment planning systems (TPS), and other analytical tools. We demonstrate examples where differences in calculations between systems can change the assessment of a plan's clinical acceptability. Our work also provides a more detailed DVH analysis of single targets than earlier published studies. This is relevant for SRS plans and small structure dose assessments. Very small structures are a particular problem because of their coarse digital representation, and the impact of this is thoroughly examined. Reference DVH curves were derived mathematically, based on Gaussian dose distributions centered on spherical structures. The structures and dose distributions were generated synthetically, and imported into RayStation, MasterPlan, and ProKnow. Corresponding DVHs were analytically derived and taken as ground truth references, for comparison with the commercial DVH calculations. Two commonly used dose metrics PCI and MGI were used to determine the limit of calculation accuracy for small structures. In addition, to measure the DVH differences between a larger range of commercial DVH calculators, the D95 metric from a set of real clinical plans was compared across both the 3 DVH calculators under test, and across a further six TPSs from other hospitals. We show that even slight deviations between the results of DVH calculators can lead to plan check failures, and we illustrate this with the commonly used D95 planning metric. We present clinical data across eight planning systems that highlight instances where plan checks would pass in one software and fail in another due to DVH calculation differences. For the smallest volumes tested, errors of up to 20% were observed in the DVHs. RayStation was tested down to a 3 mm radius sphere (≈0.1 cc) and this showed close to 10% error, reducing to 1% for 10 mm radius (≈4.0 cc) and 0.1% for 20 mm radius (≈33 cc). In clinical plans, the variation in D95 was up to 9% for the smallest volumes, and typically around 2% in the range 0.5 cc-20 cc, and 1% in 20 cc-70 cc, falling to <0.1% for large volumes. Paddick Conformity Index (PCI) and Modified Gradient Index (MGI) are commonly used plan quality indicators for very small volumes. For volumes ≈0.1 cc we observed errors of up to 40% in PCI, and up to 75% in MGI. Our study extends the range of tested DVH calculators in published work, and shows their performance over a wider range of volume sizes. We provide quantitative evidence of the critical need to test the accuracy of DVH calculators in the TPS before clinical use. This work is particularly relevant for both stereotactic plan evaluation and for assessment of small volume doses in published dose constraint recommendations. We demonstrate that significant errors can occur in DVHs for volumes less than 1 cc, even if the volumes themselves are calculated accurately. Even for large structures, deviations between the outputs of DVH calculators can lead to indicated or reported plan check failures if they do not include appropriate tolerances. We urge caution in the use of DVH metrics for these very small volumes and recommend that appropriate DVH uncertainty tolerances are set in organ dose constraints when using them to evaluate clinical plans.

A prospective comparison of totally minimally invasive versus open Ivor Lewis esophagectomy.

The majority of esophagectomies in Western parts of the world are performed by a transthoracic approach reflecting the prevalence of adenocarcinoma of the lower esophagus or esophagogastric junction. Minimally invasive esophagectomy (MIE) has been reported in a variety of formats, but there are no series that directly compare totally minimally invasive thoracolaparoscopic 2 stage esophagectomy (MIE-2) with open Ivor Lewis (IVL). A prospective single-center cohort study of patients undergoing elective MIE-2 or IVL between January 2005 and November 2010 was performed. Short-term clinicopathologic outcomes were recorded using validated systems. One hundred and six patients (median age 66, range 36-85, 88 M : 18 F) underwent two-stage esophagectomy (53 MIE-2 and 53 IVL). Patient demographics (age, sex, body mass index, American Society of Anesthesiologists grade, tumor characteristics, neoadjuvant chemotherapy, and TNM stage) were comparable between the two groups. Outcomes for MIE-2 and IVL were comparable for anastomotic leak rates (5 [9%] vs. 2 [4%], P= 0.241), resection margin clearance (R0) (43 [81%] vs. 38 [72%], P= 0.253), median lymph node yield (19 vs. 18, P= 0.584), and median length of stay (12 [range 7-91] vs. 12 [range 7-101] days), respectively. Blood loss was significantly less for MIE-2 compared with IVL (median 300 [range 0-1250] mL vs. 400 [range 0-3000] mL, respectively, P= 0.021). MIE-2 in this series of selected patients supports its efficacy, when performed by an experienced minimally invasive surgical team. A well-designed multicenter trial addressing clinical effectiveness is now required.

Impact of integrated PET/CT in the staging of oesophageal cancer: a UK population-based cohort study.

AIM: To document the impact of integrated positron-emission tomography and computed tomography (PET/CT) on the management of a cohort of UK patients undergoing PET/CT as part of their staging investigations for potentially curable oesophageal cancer. MATERIALS AND METHODS: A multicentre, prospective study of newly diagnosed patients with oesophageal cancer undergoing PET/CT was set up across five cancer networks covering a total population of 6.6 million. Data were prospectively collected for cases diagnosed between 1 November 2006 and 31 October 2007. RESULTS: One hundred and ninety-one patients underwent PET/CT, with 31 (16%) positive for possible metastatic disease. Amongst the 31 positive examinations, 18 (9.4%) were confirmed to have metastatic disease, and 13 (6.5%) patients had no subsequent evidence of metastatic disease, although in three (1.6%) of these a second previously unsuspected pathology was diagnosed. Two patients had false-negative PET/CT and were found to have metastatic disease. The results of the PET/CT examination down-staged 10 (5%) patients thought to have coeliac/M1a node involvement on CT. Fifteen of 110 (13%) patients with stage 3 or 4 disease at CT and endoscopic ultrasound (EUS) had confirmed metastatic disease at PET/CT, compared with none of 18 with stage 2b, three of 52 (6%) with stage 2a, and none of 10 with stage 1 disease. CONCLUSION: This study confirms the role of PET/CT in a multicentre UK setting in the management of patients with potentially curable carcinoma of the oesophagus, improving the accuracy of pre-treatment staging compared with CT and EUS alone. Early tumours infrequently show evidence of metastasis on PET/CT, although further data are required to confidently determine the stage of tumours where PET/CT has no additional value.

A two-consultant approach is a safe and efficient strategy to adopt during the learning curve for laparoscopic Roux-en-Y gastric bypass: our results in the first 100 procedures.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be technically challenging. It is imperative that patient morbidity and mortality are minimized while teams are on the learning curve for this procedure. METHODS: This retrospective study evaluated the peri-operative risk of LRYGBP utilizing a two-consultant surgeon approach in a newly established bariatric service. 100 consecutive patients undergoing LRYGBP were included. Two consultants participated in each procedure. RESULTS: Median operative duration was 113 minutes (range 80-240) and fell with increasing experience [127 minutes (range 90-240) in cases 1-50 and 105 minutes (range 80-210) in cases 51-100; P=0.009]. Multivariate analysis found operation time correlated only with number of procedures performed (P<0.001). There were no conversions to laparotomy. Intra-operatively, 2 patients had hand-assisted completion of the jejuno-jejunostomy, and 2 underwent laparoscopic revision of the reconstruction. Postoperative complications were observed in 8 patients on the operative admission. Median stay was 4 days (range 3-7). 4 patients required readmission. There was no mortality. Percentage of excess BMI loss was 47%, 53% and 70% at 3, 6 and 12 months respectively. CONCLUSION: A learning curve for LRYGBP is evidenced in this series by reduction in operative time with increasing experience. Complication rates in line with large published series can be achieved by adopting a two-surgeon approach, which we propose as a safe method to adopt in the development of new bariatric services.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study.

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

The concept of splitting and its clinical relevance.

After briefly reviewing various contributions to the concept of splitting, the authors describe the clinical manifestations of this defense. These include 1) inability to experience ambivalence, 2) impaired decision making, 3) oscillation of self-esteem, 4) egosyntonic impulsivity, and 5) intensification of affects. The authors then discuss the relevance of such conceptualizations to the differential diagnosis and psychotherapy of personality disorders.

The demographic profile of borderline personality disorder.

In a survey of borderline personality disorder, 23 studies that included data on age, sex, or race of the patient samples were identified. Comparison of patients who had borderline personality disorder with control groups in these studies revealed that a significant preponderance of patients with the disorder were young, white, and female. This finding cannot be considered conclusive because data were pooled from studies with questionable sampling techniques. Yet, this demographic profile warrants confirmation because it may imply diagnostic biases or actual differences in the prevalence of borderline personality disorder among various groups.

Management of thoracic outlet syndrome.

Twelve hundred patients with thoracic outlet syndrome have been managed between 1973 and 1978. Diagnosis was based on a careful history and detailed physical examination designed to establish the presence of brachial plexus irritation. The cervical spine was evaluated and nerve conduction studies were obtained. All patients were initially treated with a comprehensive physical therapy program. One hundred thirteen patients had transaxillary first rib resections. Eighty percent of surgical patients had complete relief of symptoms and 13 percent were improved. Seven percent were unimproved and none was made worse by operation. There were no operative deaths. Complications occurred in 3 percent, and there were no recurrences requiring operation. This management plan reduced the number of patients requiring operation to 9.4 percent while maintaining satisfactory surgical results.

Site distribution of oesophagogastric cancer.

AIMS: It has been suggested that adenocarcinomas of the lower oesophagus and gastric cardia should be reclassified as oesophagogastric junction (OGJ) cancers. This study aimed to define the frequency of OGJ cancers in a geographically defined population of 4.3 million people. METHODS: All cases of oesophageal and gastric cancer occurring in 1993 were identified by the North Western Regional Cancer Registry. A total of 1192 hospital case notes were reviewed and a study group of 1067 patients was defined. Tumour involvement was documented at individual subsites in the oesophagus and stomach, allowing for tumour presence in more than one oesophageal/gastric subsite. RESULTS: There were 627 tumours in men and 440 in women. The tumour was confined to the oesophagus in 281 (26.3%) cases and to the stomach in 454 (42.6%) cases. The tumour encroached upon or crossed the OGJ in 332 (31.1%) cases. Overall, tumours involved the cardia, OGJ, or lower oesophagus in 633 (59.3%) cases; in 179 (18.5%) cases the tumour involved the lower oesophagus but not the OGJ, and in another 122 (11.4%) cases the cardia was involved but not the OGJ. CONCLUSIONS: Oesophagogastric cancers in this population predominantly involve the OGJ, lower oesophagus, and/or cardia.

The aortic homograft: evolution of indications, techniques, and results in 107 patients.

BACKGROUND: Homograft aortic valve replacement has been performed in 107 patients during the past 7 years. Two primary methods of implantation were used (intraaortic and root replacement). Results of both methods are presented. METHODS: Intraaortic implantation (subcoronary or cylinder technique) was performed in 36 patients (mean age, 54 years) for aortic stenosis or regurgitation (31 patients) and endocarditis (5 patients). Aortic root replacement was performed in 71 patients (mean age, 62 years). The majority (58 patients) had complex root pathologies such as ascending aneurysm, dissection, or prosthetic endocarditis with annular destruction. Early results were assessed with intraoperative or predischarge echocardiography; annual echocardiograms provided long-term follow-up. Left ventricular mass was calculated in patients with long-standing pathology for whom preoperative and postoperative data were available. RESULTS: Early valvular insufficiency was documented in 16 of the 36 intraaortic implants (44%); 9 of these have had progression of the insufficiency. Of the 20 patients who had trivial or no early insufficiency, significant insufficiency has developed in 7 and mild insufficiency has developed in 5. Calculation of left ventricular mass revealed a mean reduction of 11% at 1 year. There has been no mortality, endocarditis, or homograft-related reoperation in the intraaortic group with a mean follow-up of 50 months. The root replacement group had a hospital mortality of 17%. The cardiac pathology was limited to the aortic valve in 12 patients; mortality in this subset was zero. There has been no significant early or late postoperative valvular insufficiency in the 59 surviving patients. More rapid left ventricular mass reduction was seen in this group with a 26% mean reduction within 1 year. A mean follow-up of 32 months in the root replacement group has seen no homograft-related reoperations. CONCLUSIONS: Although the lack of early mortality in the intraaortic group makes this technique appealing, the high incidence of early insufficiency with the realistic expectation of progression has led to our abandonment of the intraaortic technique. Homograft aortic root replacement confers a higher mortality based on the severity of aortic pathology, but offers excellent long-term hemodynamics in any patient. We have expanded our indication for homograft root replacement to include patients with isolated valvular disease rather than reserving it for those patients with extensive root pathology.

Pyoderma gangrenosum associated with active chronic hepatitis: report of two cases.

In two patients, active chronic hepatitis was complicated by the development of pyoderma gangrenosum. The favorable response of the pyodermatous lesions to azathioprine therapy suggests that this drug may be of value in treating this disorder in patients for whom corticosteroid therapy produces no benefit or is contraindicated because of side effects. Azathioprine, too, is a potentially toxic drug and may need to be discontinued. Possible causal relationships between pyoderma gangrenosum and active chronic hepatitis are discussed.

Duodenogastric reflux of bile in health: the normal range.

Duodenogastric reflux (DGR) is suspected to be an aetiological factor in the pathogenesis of foregut disease. The 'Bilitec' bile probe allows continuous detection of bilirubin, based on spectrophotochemical properties. We aimed to describe duodenogastric bile reflux in healthy, normal volunteers in a Western European population, as a basis for the future study of DGR in disease. An international multicentre study was established. DGR was measured using 24 h ambulatory bile and pH monitoring in the proximal stomach, in 43 normal volunteers from the third to the seventh decades. Subjects adhered to a standard protocol. The total test period, supine and upright components, were analysed. The 90th percentile values for absorbance thresholds of 0.14, 0.25, 0.3, 0.4 and 0.5 were 40.5%, 20.9%, 19.6%, 11.6% and 4.6% of the total time respectively. There was a wide range of absorbance within each threshold. Supine DGR was greater than upright, and associated with an alkaline tide. The upright phase was further subdivided into upright fasting, prandial and post prandial phases, and ranges for these periods are also described. No relationship between age, weight, or body mass index and duodenogastric reflux was seen. The results of this study form a range which allows further investigation into the contribution of duodenogastric bile reflux in the pathogenesis of foregut disease.

Psychotherapeutic issues in a Veterans Administration outpatient clinic.

Psychotherapeutic issues encountered by beginning therapists in a Veterans Administration outpatient clinic are described. Emphasis is placed on the differences between the VA outpatient setting and the traditional dyadic, fee-for-service model of psychotherapy. In particular, issues of institutional transference, third-party presence, and disability compensation are discussed as possible obstacles to psychotherapy. Illustrative case vignettes are provided. The need for the beginning therapist to recognize these issues is stressed, in order to overcome potential therapeutic pessimism and improve treatment.

The South Australian Nurse Practitioner Project: a midwife's perspective on a new initiative.

Midwifery education in Australia is currently the focus of intense debate both within and outside the field of midwifery. Proposed changes arsing from these debates centre principally around the issue of midwifery as a separate profession from nursing. This paper describes a case in point as to how changes in attitude and practice are occurring. As a midwife representing the Australian College of Midwives Inc.- SA Branch (ACMI-SA) on the Advisory Committee of the South Australian Nurse Practitioner Project, I provide an insight into some of the debates around midwifery and its relationship with this project. ACMI was a member of the Ministerial Advisory Committee established following the initiative of the Executive of the Department of Human Services (DHS) (formerly the South Australian Health Commission) in forming the Nurse Practitioner Project. The Terms of Reference for this committee included the development of an operational framework for the development and implementation of the Nurse Practitioner role in South Australia. A collaborative approach was seen as essential to enable nurses to best serve their communities by functioning at an advanced level of practice. The ACMI and midwives generally fully support the Nurse Practitioner Project for nurses. By Jennifer Pauline Byrne.

Reference dosimetry on TomoTherapy: an addendum to the 1990 UK MV dosimetry code of practice.

The current UK code of practice for high-energy photon therapy dosimetry (Lillicrap et al 1990 Phys. Med. Biol. 35 1355-60) gives instructions for measuring absorbed dose to water under reference conditions for megavoltage photons. The reference conditions and the index used to specify beam quality require that a machine be able to set a 10 cm × 10 cm field at the point of measurement. TomoTherapy machines have a maximum collimator setting of 5 cm × 40 cm at a source to axis distance of 85 cm, making it impossible for users of these machines to follow the code. This addendum addresses the specification of reference irradiation geometries, the choice of ionization chambers and the determination of dosimetry corrections, the derivation of absorbed dose to water calibration factors and choice of appropriate chamber correction factors, for carrying out reference dosimetry measurements on TomoTherapy machines. The preferred secondary standard chamber remains the NE2611 chamber, which with its associated secondary standard electrometer, is calibrated at the NPL through the standard calibration service for MV photon beams produced on linear accelerators with conventional flattening filters. Procedures are given for the derivation of a beam quality index specific to the TomoTherapy beam that can be used in the determination of a calibration coefficient for the secondary standard chamber from its calibration certificate provided by the NPL. The recommended method of transfer from secondary standard to field instrument is in a static beam, at a depth of 5 cm, by sequential substitution or by simultaneous side by side irradiation in either a water phantom or a water-equivalent solid phantom. Guidance is given on the use of a field instrument in reference fields.