Arteriovenous differences in cord blood gas analysis and the prediction of adverse neonatal outcome.

INTRODUCTION: The aim of this paper was to determine whether arteriovenous differences of pH and pCO2 are useful predictors of adverse neonatal outcome in acidemic neonates. MATERIAL AND METHODS: An established database of 8759 term, singleton, non-anomalous neonates with validated cord gases and outcomes [Encephalopathy (Grade 2/3), Apgar <7 at five minutes and composite neonatal outcomes of neurological and systemic involvement] was used. Analysis was of the cohort of the 520 acidemic (arterial pH <7.10) neonates. Chi-square tests with odds ratio (OR), 95% CI were calculated for dichotomous cut-offs of differences; hierarchical logistic regression was used to examine the predictive performance over and above arterial pH. RESULTS: Arteriovenous hydrogen ion concentration ([H+ ion]) differences do not predict neonatal outcomes except low Apgar scores, and large pCO2 differences are associated with worse neonatal outcomes. Nevertheless, neonates with large arteriovenous [H+ ion] and pCO2 differences have lower arterial pH values. Hierarchical regression demonstrates that arteriovenous pCO2 differences do not add predictive value beyond arterial pH and arteriovenous [H+ ion] adds only to the prediction of low Apgar scores. CONCLUSIONS: Arteriovenous differences of [H+ ion] and pCO2 are not useful independent predictors of adverse neonatal outcomes in acidemic neonates.

Factors associated with less-than-full-time working in medical practice: results of surveys of five cohorts of UK doctors, 10 years after graduation.

BACKGROUND: The greater participation of women in medicine in recent years, and recent trends showing that doctors of both sexes work fewer hours than in the past, present challenges for medical workforce planning. In this study, we provide a detailed analysis of the characteristics of doctors who choose to work less-than-full-time (LTFT). We aimed to determine the influence of these characteristics on the probability of working LTFT. METHODS: We used data on working patterns obtained from long-term surveys of 10,866 UK-trained doctors. We analysed working patterns at 10 years post-graduation for doctors of five graduating cohorts, 1993, 1996, 1999, 2000 and 2002 (i.e. in the years 2003, 2006, 2009, 2010 and 2012, respectively). We used multivariable binary logistic regression models to examine the influence of a number of personal and professional characteristics on the likelihood of working LTFT in male and female doctors. RESULTS: Across all cohorts, 42 % of women and 7 % of men worked LTFT. For female doctors, having children significantly increased the likelihood of working LTFT, with greater effects observed for greater numbers of children and for female doctors in non-primary care specialties (non-GPs). While >40 % of female GPs with children worked LTFT, only 10 % of female surgeons with children did so. Conversely, the presence of children had no effect on male working patterns. Living with a partner increased the odds of LTFT working in women doctors, but decreased the odds of LTFT working in men (independently of children). Women without children were no more likely to work LTFT than were men (with or without children). For both women and men, the highest rates of LTFT working were observed among GPs (~10 and 6 times greater than non-GPs, respectively), and among those not in training or senior positions. CONCLUSIONS: Family circumstances (children and partner status) affect the working patterns of women and men differently, but both sexes respond similarly to the constraints of their clinical specialty and seniority. Thus, although women doctors comprise the bulk of LTFT workers, gender is just one of several determinants of doctors' working patterns, and wanting to work LTFT is evidently not solely an issue for working mothers.

The significance of base deficit in acidemic term neonates.

OBJECTIVE: Much emphasis is placed on the metabolic component of umbilical cord acidemia at birth, with an importance attached to an arterial level of <7.00 accompanied by a base deficit of 12 mmol/L. We hypothesized that in acidemic neonates, the level of arterial base deficit provides no prognostic information beyond that provided by the level of arterial pH. STUDY DESIGN: This is a cohort study using a database of deliveries from a major teaching hospital, with additional information from neonatal records. A total of 8797 term, singleton, nonanomalous neonates were identified who had paired and validated cord blood gas analysis. Of these, 520 were acidemic (pH <7.1) and 84 were severely acidemic (pH <7.0). Outcomes examined were encephalopathy grade 2/3 and/or death, Apgar <7 at 5 minutes, neonatal unit admission, and composite outcomes of neurological and systemic involvement. Hierarchical logistic regressions were done using IBM SPSS Statistics 20.0 (Armonk, NY) to assess the predictive value of arterial pH and arterial base deficit. RESULTS: For each outcome the median pH and base deficit of those neonates affected by the adverse outcome was significantly lower than for those who were unaffected. Hierarchical logistic regressions showed that pH is a significant predictor of all adverse outcomes studied (P < .001 for all outcomes). When base deficit, and then the cross-product, are added to the model, neither add predictive value. CONCLUSION: In acidemic neonates, the metabolic component does not predict those at risk of adverse outcomes once pH is taken into account. The apparently worse outcomes with greater base deficit simply reflect a greater degree of acidemia. The prognostic significance attached to the base deficit among acidemic neonates is questionable.

Foundation doctors' views on whether their medical school prepared them well for work: UK graduates of 2008 and 2009.

PURPOSE OF THE STUDY: The transition from medical student to junior doctor is a critical stage in career progression. We report junior doctors' views 1 year after graduation on whether their medical school prepared them well for clinical work. STUDY DESIGN: Questionnaire surveys of the medical graduates of 2008 and 2009, from all UK medical schools, 1 year after graduation. Responses were compared with those of UK medical graduates of 1999, 2000, 2002 and 2005. The main outcome measure was the doctors' level of agreement that medical school had prepared them well for work. RESULTS: 53% of 2008 graduates and 49% of 2009 graduates agreed that their medical school had prepared them well. The percentage who felt unprepared has fallen from 31% of the 1999-2005 graduates, combined, to 19% of the 2008 and 2009 graduates (the remainder gave neutral responses). Combining 2008 and 2009 graduates' responses, percentages who agreed that they had been well prepared ranged from 83% (95% CI 78 to 89) at the medical school with the highest level of agreement to 27% (95% CI 20 to 34) at the lowest. 25% of doctors specified that feeling unprepared had been a serious or medium-sized problem for them (only 2.7% regarded it as serious). CONCLUSIONS: Medical schools need feedback from their graduates about elements of medical school training that could improve preparedness for medical work. It also seems likely that there are some reasonably straightforward lessons that medical schools could learn from each other.

Career choices for emergency medicine: national surveys of graduates of 1993-2009 from all UK medical schools.

BACKGROUND: In the UK, recruitment of adequate numbers of doctors to emergency medicine (EM) has been problematic. With this as background, we analysed data about career choice for, and progression in, EM in a large multi-purpose study of doctors' careers. METHODS: Questionnaire surveys of medical graduates of 1993, 1996, 1999, 2000, 2002, 2005, 2008 and 2009 from all UK medical schools. RESULTS: EM was specified as a first choice of career by 4.2% of graduates in postgraduate year 1, 4.8% in year 3, and 3.8% in year 5. Graduates who chose EM were much less likely to be certain about their choice than those who chose other specialties. Of those who specified EM as their first choice of career in year 1, only 26% still had it as their first choice in year 5. Of those who gave EM as their first career choice in year 5, only 27% had given EM as their first choice in year 1. Switches to EM were made, notably, by doctors who previously favoured surgical specialties, hospital physician-led specialties and anaesthetics. CONCLUSIONS: Early career choices for EM are less predictive of career destinations than choices for other specialties, and, compared with many other specialties, doctors who pursue it may turn to it relatively late. Training policies on transferable competencies should enable clinical trainees in other related specialties to bank some of their skills if they transfer to EM, rather than necessarily having to start core training in year 1 of EM specialty training.

Career choices of the United Kingdom medical graduates of 2005, 2008 and 2009: questionnaire surveys.

OBJECTIVES: To compare specialty choices of the UK medical graduates of 2005, 2008 and 2009, one year after graduation, with those of graduates from previous years and with the distribution of senior medical practitioners working in England. METHOD: Postal questionnaire surveys. RESULTS: The proportion of graduates giving more than one specialty choice rose in the most recent cohorts. Among men, choices for surgical careers fell from 37% of 2005 graduates to 25% of 2008 and 2009 graduates. The percentages who specified anaesthetics, general practice and obstetrics and gynaecology rose. Among women, general practice and surgery were unchanged in popularity, but increasing percentages specified paediatrics, anaesthetics and obstetrics and gynaecology. Choices for psychiatry and emergency medicine showed no trend. General practice was substantially under-represented, and hospital surgical and medical specialties were over-represented, in choices when compared to the distribution of senior National Health Service doctors. CONCLUSION: More current graduates consider two or more specialties than did their predecessors, which may reflect an increase in uncertainty about obtaining a post in their favoured specialty. The specialty preferences expressed by newly qualified doctors, notably the shortfall in numbers choosing general practice, remain inconsistent with future service needs.

The association between cord pH at birth and intellectual function in childhood.

BACKGROUND: Acidemia at birth is very common but little is known about its long-term consequences. AIM: To determine if pH at birth is related to established tests of intellectual function. SUBJECTS: School children aged 6-8, for whom obstetric data were available, who had been delivered after labour at term, and had an umbilical cord arterial pH>7.00 (i.e. that was not extremely acidemic). STUDY DESIGN/OUTCOMES: Retrospective cohort study correlating birth and arterial pH data with childhood tests for non-verbal intelligence, grammar comprehension and literacy. METHODS: Relationships between pH and cognitive measures were analysed with parametric correlations. Partial correlations were used to examine these relationships, controlling for possible confounding factors. RESULTS: Arterial pH was significantly negatively correlated with literacy (p=0.001) and with non-verbal intelligence (p=0.033). CONCLUSIONS: Lower arterial pH is associated with higher scores on literacy and non-verbal intelligence tests at ages 6-8. This is unlikely to be a chance finding and is further evidence that acidemia in isolation should not be considered an adverse outcome. Further research on the relationship between labour and long-term cognitive measures is required.

Attitudes to e-learning, learning style and achievement in learning neuroanatomy by medical students.

BACKGROUND: Two main learning approaches adopted by students have been identified by research: deep (seeking for meaning motivated by interest in the subject matter) and surface (rote-learning motivated by fear of failure). There is evidence that learning approach is influenced by learning environment (e.g. Trigwell et al. 1999). Online courses pose the challenge of designing software that will encourage the more desirable approach to learning. AIMS: The aims were to evaluate how successful an online course is at encouraging deep approach to learning, which factors might influence the approach adopted towards it, and whether the approach adopted is related to academic performance. METHOD: Using 205 second-year pre-clinical medical students, we compared their approach to learning, as measured by Biggs et al. (2001) 2F-SPQ-R, for a computer-aided learning (CAL) course in Neuroanatomy with that for their studies in general. We then examined student attitudes towards the CAL course and the ratings of the course Web pages in terms of the learning approach they encourage (done by 18 independent raters). RESULTS: The students reported using significantly less deep approach to learning for the CAL course. However, their approach for the course was not related to results on a neuroanatomy assessment based on it. Enjoyment of the course, assessment of the amount of information in it as appropriate, and ease of understanding the course were all associated with a deeper approach. The only agreement between the raters of the CAL course was for some pages that included patient case studies, which were unanimously given a very high deep rating. Assessment marks for questions referring to these pages were higher than for the rest of the assessment. CONCLUSIONS: The study suggests that maximizing the use of clinical relevance should increase the interest and enjoyableness of the course and thereby aid deep learning and retention of information.

Umbilical cord arterial base deficit and arterial pH as predictors of adverse outcomes among term neonates.

OBJECTIVE: To determine the importance of arterial pH and arterial base deficit (ABD) for predicting adverse outcomes among all term neonates, regardless of acidemic status. METHODS: The present observational cohort study included consecutive term, non-anomalous singleton neonates with validated paired cord gas data at a single UK teaching hospital between June 23, 2005, and December 31, 2009. Outcomes included encephalopathy (Sarnat grade 2-3) and/or death; 5-minute Apgar score below 7; a composite neurologic adverse outcome; and systemic involvement. Comparison of areas under the curve and hierarchical logistical regressions were used to examine the importance of arterial pH and arterial base deficit (ABD) in predicting adverse outcomes. RESULTS: There were 8759 neonates included. In all, 111 (1.3%) neonates had high ABD (≥12 mmol/L). Encephalopathy and/or death was recorded in 17 (0.2%) neonates in the whole cohort and 6 (5.4%) from the high ABD group. The mean arterial pH values for these two groups were 7.23 and 7.03, respectively. Comparison of the area under the receiver operating characteristic curves showed that adding ABD to arterial pH did not improve the prediction. Further, hierarchical logistic regression analysis demonstrated that ABD was not an independent predictor of adverse outcomes when adjusted for arterial pH. CONCLUSIONS: ABD demonstrated no predictive value for adverse neonatal outcomes beyond using arterial pH alone.

Self-injurious behavior and eating disorders: the extent and nature of the association.

We have reviewed the literature on the association between self-injurious behaviors (SIB) and eating disorders from the psychological-behavioral perspective. Our aims were to investigate the extent and possible reasons for the association. A literature search was conducted using the following electronic databases (1989-2005): Medline, PsychInfo and EMBASE. References in identified articles were also screened. The reported occurrence of SIB in eating disorder patients ranged between 25.4% and 55.2%. The figures for occurrence of eating disorders in SIB patients ranged between 54% and 61%. These figures indicate that there is a strong association between these disorders. Impulsivity, obsessive-compulsive characteristics, affect dysregulation, dissociation, self-criticizing cognitive style and need for control were identified as potential factors involved in the association. Early trauma such as childhood sexual abuse and possibly certain characteristics of early family environment might contribute to the development of these factors. We present a hypothetical model which includes these factors and argue that the co-existence of eating disorders and SIB in patients results from several factors being present. SIB and eating disorder symptoms may provide a means whereby patients can deal with each factor simultaneously. The clinical implications of the findings are discussed.

Teaching neuroanatomy using computer-aided learning: What makes for successful outcomes?

Computer-aided learning (CAL) is an integral part of many medical courses. The neuroscience course at Oxford University for medical students includes CAL course of neuroanatomy. CAL is particularly suited to this since neuroanatomy requires much detailed three-dimensional visualization, which can be presented on screen. The CAL course was evaluated using the concept of approach to learning. The aims of university teaching are congruent with the deep approach-seeking meaning and relating new information to previous knowledge-rather than to the surface approach of concentrating on rote learning of detail. Seven cohorts of medical students (N = 869) filled in approach to learning scale and a questionnaire investigating their engagement with the CAL course. The students' scores on CAL-course-based neuroanatomy assessment and later university examinations were obtained. Although the students reported less use of the deep approach for the neuroanatomy CAL course than for the rest of their neuroanatomy course (mean = 24.99 vs. 31.49, P < 0.001), deep approach for CAL was positively correlated with neuroanatomy assessment performance (r = 0.12, P < 0.001). Time spent on the CAL course, enjoyment of it, the amount of CAL videos watched and quizzes completed were each significantly positively related to deep approach. The relationship between deep approach and enjoyment was particularly notable (25.5% shared variance). Reported relationships between deep approach and academic performance support the desirability of deep approach in university students. It is proposed that enjoyment of the course and the deep approach could be increased by incorporation of more clinical material which is what the students liked most. Anat Sci Educ 10: 560-569. © 2017 American Association of Anatomists.

Influence of training changes on the stability of specialty choices of UK medical graduates: surveys of the graduates of 2002 and 2008.

OBJECTIVES: To explore the impact of Modernising Medical Careers (MMC) training on the stability of medical career choices in the UK. SETTING UK PARTICIPANTS: Graduates of 2002 and 2008 from all UK medical schools, 1 and 3 years postgraduation. DESIGN: Questionnaire surveys were conducted of 2002 and 2008 graduates from all UK medical schools 1 and 3 years post graduation. MAIN OUTCOME MEASURES: Doctors gave their specialty choice(s) and rated the influence of each of 11 factors on their career choice. RESULTS: 2008 graduates were a little more likely than graduates of 2002 to retain their year 1 choice in year 3 (77.3% vs. 73.3%; p = 0.002). Among 2008 graduates, the percentage retaining their year 1 choice varied between 42% (clinical oncology) and 79% (general practice). Enthusiasm for a specialty, student experience and inclinations before medical school were associated with choice retention; consideration of domestic circumstances and hours/working conditions were associated with changes of choice. 2008 graduates were more likely than 2002s to be influenced by enthusiasm for a specialty, self-appraisal of their skills, working hours and their domestic circumstances; and less likely to be influenced by their experience of jobs, a particular teacher/department or eventual financial prospects. CONCLUSIONS: Post-MMC, graduates were less likely to change their career choice and more likely to be motivated by personal factors and self-assessment of their suitability to a particular area of work.

Career progression of men and women doctors in the UK NHS: a questionnaire study of the UK medical qualifiers of 1993 in 2010/2011.

OBJECTIVES: To report the career progression of a cohort of UK medical graduates in mid-career, comparing men and women. DESIGN: Postal and questionnaire survey conducted in 2010/2011, with comparisons with earlier surveys. SETTING: UK. PARTICIPANTS: In total, 2507 responding UK medical graduates of 1993. MAIN OUTCOME MEASURES: Doctors' career specialties, grade, work location and working pattern in 2010/2011 and equivalent data in earlier years. RESULTS: The respondents represented 72% of the contactable cohort; 90% were working in UK medicine and 7% in medicine outside the UK; 87% were in the UK NHS (87% of men and 86% of women). Of doctors in the NHS, 70.6% of men and 52.0% of women were in the hospital specialties and the great majority of the others were in general practice. Within hospital specialties, a higher percentage of men than women were in surgery, and a higher percentage of women than men were in paediatrics, obstetrics and gynaecology, clinical oncology, pathology and psychiatry. In the NHS, 63% of women and 8% of men were working less-than-full-time (in general practice, 19% of men and 83% of women; and in hospital specialties, 3% of men and 46% of women). Among doctors who had always worked full-time, 94% of men and 87% of women GPs were GP principals; in hospital practice, 96% of men and 93% of women had reached consultant level. CONCLUSIONS: The 1993 graduates show a continuing high level of commitment to the NHS. Gender differences in seniority lessened considerably when comparing doctors who had always worked full-time.

Gender, ethnicity and graduate status, and junior doctors' self-reported preparedness for clinical practice: national questionnaire surveys.

OBJECTIVES: Medical schools need to ensure that graduates feel well prepared for their first medical job. Our objective was to report on differences in junior doctors' self-reported preparedness for work according to gender, ethnicity and graduate status. DESIGN: Postal and electronic questionnaires. SETTING: UK. PARTICIPANTS: Medical graduates of 2008 and 2009, from all UK medical schools, one year after graduation. MAIN OUTCOME MEASURES: The main outcome measure was the doctors' level of agreement with the statement that 'My experience at medical school prepared me well for the jobs I have undertaken so far', to which respondents were asked to reply on a scale from 'strongly agree' to 'strongly disagree'. RESULTS: Women were slightly less likely than men to agree that they felt well prepared for work (50% of women agreed or strongly agreed vs. 54% of men), independently of medical school, ethnicity, graduate entry status and intercalated degree status, although they were no more likely than men to regard lack of preparedness as having been a problem for them. Adjusting for the other subgroup differences, non-white respondents were less likely to report feeling well prepared than white (44% vs. 54%), and were more likely to indicate that lack of preparedness was a problem (30% non-white vs. 24% white). There were also some gender and ethnic differences in preparedness for specific areas of work. CONCLUSIONS: The identified gender and ethnic differences need to be further explored to determine whether they are due to differences in self-confidence or in actual preparedness.