A national qualitative investigation of the impact of service change on doctors' training during Covid-19.

BACKGROUND: The Covid-19 crisis sparked service reconfigurations in healthcare systems worldwide. With postgraduate medical education sitting within these systems, service reconfigurations substantially impact trainees and their training environment. This study aims to provide an in-depth qualitative understanding of the impact of service reconfiguration on doctors' training during the pandemic, identifying opportunities for the future as well as factors that pose risks to education and training and how these might be mitigated. METHODS: Qualitative parallel multi-centre case studies examined three Trusts/Health Boards in two countries in the United Kingdom. Data were collected from online focus groups and interviews with trainees and supervisors using semi-structured interview guides (September to December 2020). A socio-cultural model of workplace learning, the expansive-restrictive continuum, informed data gathering, analysis of focus groups and coding. RESULTS: Sixty-six doctors participated, representing 25 specialties/subspecialties. Thirty-four participants were male, 26 were supervisors, 17 were specialty trainees and 23 were foundation doctors. Four themes described the impact of pandemic-related service reconfigurations on training: (1) Development of skills and job design, (2) Supervision and assessments, (3) Teamwork and communication, and (4) Workload and wellbeing. Service changes were found to both facilitate and hinder education and training, varying across sites, specialties, and trainees' grades. Trainees' jobs were redesigned extensively, and many trainees were redeployed to specialties requiring extra workforce during the pandemic. CONCLUSIONS: The rapid and unplanned service reconfigurations during the pandemic caused unique challenges and opportunities to doctors' training. This impaired trainees' development in their specialty of interest, but also presented new opportunities such as cross-boundary working and networking.

Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.

BACKGROUND: Effective communication within teams is crucial, especially in crisis situations. Hierarchy gradients between team members can contribute to communication failures and are influenced by many factors. The effect of gender on team performance has not been well studied. The objective of this study was to examine the effect of the physician's gender on respiratory therapists' ability to effectively challenge clearly incorrect clinical decisions during a life-threatening crisis. METHODS: Respiratory therapists were recruited to take part in a high-fidelity simulation of can't-intubate can't-oxygenate scenarios. They were randomized into two groups, either assisting a male or a female anaesthetist in managing an airway crisis during which the anaesthetist made incorrect clinical decisions. Two independent raters scored the performances using the modified Advocacy-Inquiry Score (min 1, max 6). RESULTS: Twenty-nine subjects completed the study. The median best challenge score when the staff anaesthetist was female was 4 (3-5 IQR [2-6 range]) compared with 3 (3-3[0-3]) for challenges to a male anaesthetist (P=0.017). The median of the total challenges against a female staff member 11 (7.3-14.8 [2-18]) was significantly higher compared with 4 (3.5-7 [2-11.5]) for a male staff (P=0.006). CONCLUSIONS: The study showed a significant effect of superiors' gender on a respiratory therapist's ability to challenge leadership. A female staff anaesthetist was challenged more often and with greater assertiveness and effectiveness. This has implications for an educational intervention targeting the ability to challenge a wrong decision by a supervisor and emphasizing the effect of gender on the willingness to speak up.

Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency.

A key factor that may contribute to communication failures is status asymmetry between team members. We examined the effect of a consultant anaesthetist's interpersonal behaviour on trainees' ability to effectively challenge clearly incorrect clinical decisions. Thirty-four trainees were recruited to participate in a video-recorded scenario of an airway crisis. They were randomised to a group in which a confederate consultant anaesthetist's interpersonal behaviour was scripted to recreate either a strict/exclusive or an open/inclusive communication dynamic. The scenario allowed trainees four opportunities to challenge clearly wrong decisions. Performances were scored using the modified Advocacy-Inquiry Score. The highest median (IQR [range]) score was 3.0 (2.2-4.0 [1.0-5.0]) in the exclusive communication group, and 3.5 (3.0-4.5 [2.5-6.0]) in the inclusive communication group (p = 0.06). The study did not show a significant effect of consultant behaviour on trainees' ability to challenge their superior. It did demonstrate trainees' inability to challenge their seniors effectively, resulting in critical communication gaps.

What do patients expect of psychiatric services? A systematic and critical review of empirical studies.

The article reviews literature concerning patients' expectations of psychiatric care. Early research (pre-1980) is outlined, followed by a systematic review of 21 studies fulfilling specific inclusion criteria from 1980 onwards. Overall, patients expected to improve as a result of psychiatric treatment, and had higher expectations of the helpfulness of psychological and combined treatments than other interventions. Few studies considered expectations of the process of psychiatric care or determinants of expectations. The majority of studies focused on examining the relation between expectations and outcomes. There were indications that expectations of improvement were linked to clinical outcomes, although the relationship appeared to be complex. There was also some evidence that when expectations of the process of care were incongruent with the service provided, outcomes were poorer. The findings of studies in the systematic review were generally congruent with earlier work (pre-1980), although expectations of improvement appeared to be higher in the later studies. Interventions to prepare patients for what to expect were found to have beneficial effects on attendance, satisfaction and the accuracy of expectations about the process of psychiatric care. Future research should focus on developing valid and reliable measures for use in different settings, and on determining the mechanism by which expectations may relate to outcomes, including clinical outcomes, attendance and satisfaction.

What do patients want and do we want to know? A review of patients' requests of psychiatric services.

OBJECTIVE: A systematic review was conducted of the literature concerning patients' requests of psychiatric care in order to identify the types of requests patients make, psychiatrists' perceptions of their patients' requests, and the relationship between requests and the outcome of care. METHOD: A total of 28 published original articles which fulfilled specific inclusion criteria were reviewed. RESULTS: The studies showed that there are certain core requests that patients make irrespective of the type of service attended. Patients mainly request psychological approaches, and the most common requests are for 'clarification', 'psychological expertise' and 'psychodynamic insight'. There is evidence that patients normally feel inhibited about making requests, and that psychiatrists often fail to identify what their patients want. CONCLUSION: The majority of patients attending psychiatric services have requests which they will express when encouraged to do so, but little is known about the relationship between patients' requests and the outcome of care. Recommendations are made for future research.

Human immunodeficiency virus seropositivity in critically ill neonates in the south Bronx.

Cord blood was anonymously screened to determine the prevalence of human immunodeficiency virus (HIV) seropositivity in neonates admitted to the neonatal intensive care unit (NICU) at the Bronx Lebanon Hospital Center, located in the South Bronx. We speculated that factors leading to admission to the NICU such as low birth weight, prematurity and being small for gestational age would also be associated with an increased prevalence of HIV seropositivity. During the study period the prevalence of HIV seropositivity was 11.6% in the NICU population. There was no significant difference in maternal age, gravidity, race and sex in HIV-seropositive vs. HIV-seronegative newborns. There was a significantly increased incidence of maternal drug use (P less than 0.01), babies small for gestational age (P less than 0.005) and microcephaly (P less than 0.02) in seropositive vs. seronegative NICU babies. The results of this study suggest that the NICU population may comprise a significant number of infants of HIV-infected mothers.

Relationship of pulse oximetry to arterial oxygen tension in infants.

Pulse oximetry is a useful technique for noninvasive oxygen monitoring in sick infants. We simultaneously measured oxygen saturation by pulse oximetry and on arterial blood samples by co-oximetry as well as PaO2 and the relative content of fetal (F) and adult hemoglobin in order to evaluate the reliability of pulse oximetry. Comparisons were made in triplicate in ten infants with acute cardiorespiratory disease less than 7 days of age and in 11 infants with chronic lung disease greater than 28 days of age. Oxygen saturation pulse oximetry and arterial saturation were well correlated over a wide range of saturation values. In infants with chronic lung disease, PO2 derived from pulse oximetry was within 10 torr of measured PaO2 in 73% of comparisons. In contrast, calculated PaO2 was within 10 torr of measured PaO2 in only 50% of comparisons in patients with acute disorders. The chronic infants all had less than 10% hemoglobin F, but in the acute infants, hemoglobin F ranged from 26% to 83%. Nonetheless, correction of oxygen dissociation curves for type of hemoglobin in these acute infants failed to improve the correlation between calculated and measured PaO2. We conclude that pulse oximetry saturations and their derived PaO2 values correlated well with measured arterial saturation and PaO2 obtained from arterial blood samples in neonates with chronic lung disease and prolonged oxygen dependence. In infants with acute cardiorespiratory problems, pulse oximetry unreliably reflects PaO2, but may be useful in detecting clinical deterioration.

Adrenergic stimulation of the rat mesenteric vascular bed: a combined micro- and macrocirculatory study.

The sympathetic nervous system is one of the primary factors controlling vascular resistance. Vascular smooth muscle contraction by sympathetic stimulation is mediated primarily by alpha-adrenoceptors. In this study, we investigated the effects of different forms of adrenergic stimulation on simultaneously measured macro- and microcirculatory dynamics in the rat mesenteric vascular bed. Macrocirculatory effects were measured by means of registration of changes in mean arterial pressure (MAP) and blood flow feeding this tissue via a miniaturized Doppler flow probe around the superior mesenteric artery. Microvascular changes were measured at the level of A2 arterioles by means of intravital microscopic registration of arteriolar diameters and red blood cell velocity (RBC vel). Topical or intra-arterial application of noradrenaline caused a dose-dependent decrease in arteriolar diameter and RBC vel at doses that did not cause significant systemic effects. On the other hand, during intravenous application of noradrenaline or other vasopressor substances an increase in MAP and decrease in organ (Doppler) blood flow was not parallelled by a decrease in arteriolar diameter or RBC vel. In contrast, RBC vel increased in a dose-related manner, whereas arteriolar diameter only secondarily decreased to a small degree. Similar results were obtained when the sympathetic nervous system was activated by means of electrical stimulation of the posterior hypothalamus. These data indicate that adrenergic stimulation can elicit different vascular responses. The ultimate microvascular effect depends upon the way of stimulation or route of drug administration.

Transient changes in expiratory time during hypercapnia in premature infants.

The transient ventilatory responses to hypercapnia were studied in nine healthy preterm infants. We administered 4% CO2 in air for at least 7 min during quiet sleep and measured frequency (f), inspiratory time (TI), expiratory time (TE), tidal volume (VT), and minute ventilation (VI). Frequency increased over the first 2 min of CO2 inhalation (P less than 0.05) and then decreased to control values (P less than 0.05). This response was secondary to changes in TE, which decreased over the first 2 min (P less than 0.05) and then returned to control values, whereas TI did not change. The late increase in TE was associated with an increased percent of breaths exhibiting retardation of expiratory flow (braking) (P less than 0.05). These breaths had longer TE than the breaths without braking (P less than 0.05). Exponential curves made to fit the increases in VI and VT revealed that only 67% of the infants reached 90% of steady state for both VI and VT over the 7-min study period. The time to 90% of steady state was always shorter for VI than VT (P less than 0.05) due to the transient changes in f. The results indicate that the transient changes of f in response to hypercapnia are secondary to changes in TE, which appear unique to human infants. We speculate that the expiratory braking that develops during the course of CO2 inhalation increases lung volume, resulting in prolongation of TE via mechanoreceptor-mediated reflexes.

Left ventricular hypertrophy in left bundle branch block.

The detection of left ventricular hypertrophy (LVH) in the presence of left bundle branch block (LBBB) remains a difficult clinical problem. Its prevalence and significance have not previously been studied in a group of living patients. M-mode echocardiography was utilized to determine the prevalence of anatomic LVH in 28 patients with LBBB. Various ECG and chest x-ray criteria as predictors of LVH were assessed. Anatomic LVH was present in 89% by echocardiography. A left atrial abnormality on ECG and a cardio-thoracic ratio greater than .50 were the best predictors of LVH. Hypertension and/or ischemic heart disease was present in 78.5% of the patients while only one patient was free of any evidence of cardiovascular disease.

Mitral valve prolapse. Cross sectional and provocative M-mode echocardiography.

False-negative supine M-mode echocardiograms occur in some patients with proved mitral valve prolapse. To investigate further, we performed M-mode echocardiography (MME) during standing and after the inhalation of amyl nitrite in 17 patients (group 1) selected for auscultatory evidence of mitral valve prolapse (MVP) but negative supine MME. To validate the standing MME technique, eight patients with classic auscultatory MVP with positive supine MME for MVP (group 2) and 15 control subjects (group 3) were studied. Supine cross-sectional echocardiography (CSE) was compared to MME in all three groups. Standing MME elicited echocardiographic evidence of MVP in 14/17 (82 percent) of group 1--auscultatory evidence of MVP but negative supine MME; CSE demonstrated MVP in 8/13 (62 per cent) of the same patients. There was no clear advantage of the CSE long axis view over the CSE apical four chamber view in the diagnosis of MVP in these selected subjects; however, the two views were complementary. Amyl nitrite was ineffective in eliciting echocardiographic evidence of MVP.

Pericardial disease in familial Mediterranean fever: an echocardiographic study.

We studied 30 randomly selected patients with familial Mediterranean fever (FMF) by M mode echocardiography to determine the frequency of pericardial involvement. There was no evidence of congestive heart failure, uremia, or any other illness known to be associated with pericardial disease in the study population. Eight of the 30 patients (27 percent) had echocardiographic evidence of pericardial disease. Two had pericardial effusions, two had pericardial thickening, and four either or both. Patients with pericardial involvement had a mean duration of FMF of 28.9 +/- 12.2 (SD) years vs 18.5 +/- 10.6 (SD) years for those without pericardial disease (P less than .02). We concluded that pericardial involvement is common in FMF and that its occurrence as detected by echocardiography increases with duration of illness.

Nuclear-substituted styryl ketone analogs: effects on neoplasms, microorganisms, and mitochondrial respiration of tumorous and normal cells.

Analogs of some antineoplastic and cytotoxic Mannich bases derived from conjugated styryl ketones were prepared and evaluated for activity in the P-388 lymphocytic leukemia screen. Most of the new compounds had lower antineoplastic and murine toxicity than the parent compounds. Antimicrobial evaluation of some oximes and alcohols related to the Mannich bases revealed activity against certain Gram-positive bacteria and fungi. Primary pharmacological evaluation showed that some compounds containing a dimethylaminomethyl group displayed analgesic and antihistaminic properties. Five of the Mannich bases were evaluated as respiratory inhibitors in mitochondria derived from hepatic tumors, liver tissue from tumor-bearing animals, and normal rat liver. No statistical difference between the sensitivity of the three tissues to the compounds was obtained.

Synthesis of oximes, aziridines, and allyl alcohols derived from substituted 1-phenyl-1-nonen-3-ones as potential cytotoxic and antitumor agents.

A number of nuclear-substituted 1-phenyl-1-nonen-3-one oximes were synthesized. Reduction of several of these compounds with lithium aluminum hydride yielded the corresponding 1-phenyl-2,3-epiminononanes, shown by 100-MHz NMR spectroscopy to be the cis-geometrical isomers. When several ring-substituted 4-dimethylaminomethyl-1-phenyl-1-nonen-3-ones were treated with hydroxylamine hydrochloride under forcing conditions, the product isolated was the corresponding oxime. Reaction under mild conditions led only to the isolation of the Michael addition product of the oxime in low yield. Reduction of some nuclear-substituted 4-dimethylaminomethyl-1-phenyl-1-nonen-3-ones with sodium borohydride led to the formation of the corresponding allyl alcohols, and the products were shown by 1H- and 13C-NMR spectroscopy to be the threo-isomers or, alternatively, a mixture of erythro- and threo-isomers. Reaction of phosphoric acid with one of the substituted allyl alcohols led to a diolefin, shown by NMR spectroscopy to be a mixture of (E, E)- and (E, Z)-isomers in a ratio of 65:35.

Effect of antineoplastic and cytotoxic Mannich Bases derived from conjugated styryl ketones on mitochondrial respiration in rat liver cells.

Five cytotoxic Mannich bases (5-dimethylamino-1-substituted phenyl-1-penten-3-ones), three having antineoplastic activity, were evaluated for respiratory-inhibiting properties in rat liver mitochondria in the presence of four substrates: succinate, glutamate, 3-hydroxybutyrate, and palmitylcarnitine. Four compounds (Ib--Ie) showed significant inhibiting properties which, on occasion, were reversed partially by coenzyme Q10. Evaluation of the spectra of the mitochondrial cytochromes indicated that Ib--Ie blocked the electron transport chain prior to the sequence of cytochromes. Since inhibition occurred when different substrates were used, a common site of action for Ib--Ie is likely; competition of Ib--Ie with coenzyme Q10 probably occurs. Compounds Ia--Ie inhibited RNA polymerase from Swiss mouse kidney cells but were virtually bereft of activity versus RNA polymerase from L-1210 leukemia cells. Polarography of the Mannich bases and the related styryl ketones showed that antineoplastic activity was associated with higher half-wave potentials.

Synthesis of diastereoisomeric 4-dimethylamino-3-phenyl-2-butanols and related esters for antimicrobial evaluation.

4-Dimethylamino-3-phenyl-2-butanone was reduced to the corresponding diastereoisomeric alcohols, which were separated by fractional crystallization of the corresponding hydrochloride salts. The configuration of the diastereoisomeric alcohols was determined by PMR spectroscopy. The assignments were confirmed by a consideration of the mass spectral data obtained for the two alcohols. Acylation of the alcohols gave the corresponding esters. Antimicrobial evaluation of the compounds prepared showed that 4-dimethylamino-3-phenyl-2-butanone had a promising level of antifungal activity while the other derivatives showed either a low level of potency or were inactive.

Comparison of antimicrobial activity of nuclear-substituted aromatic esters of 5-dimethylamino-1-phenyl-3-pentanol and 3-dimethylamino-1-phenyl-1-propanol with related cyclic analogs.

A series of six aromatic esters of both 5-dimethyl-amino-1-phenyl-3-pentanol and 3-dimethylamino-1-(2-phenylcyclohexyl)-1-propanol was prepared. Antimicrobial evaluation showed that the cyclic analogs had approximately twice the activity of the open chain series; in particular, the o-chlorophenyl ester showed pronounced activity against three pathogenic fungi at approximately 10 ppm. Aromatic esters of 3-dimethylamino-1-phenyl-1-propanol were prepared and demonstrated lower activity than two esters of 2-dimethylamino-1-phenylcyclohexanol. The screening results showed that the best activity was found when a dimethylene chain was present between the phenyl ring and the carbon atom bearing the acyloxy function and that the cyclic derivatives were more active than their more flexible counterparts.