Resident burnout: evaluating the role of the learning environment.

BACKGROUND: Although burnout is viewed as a syndrome rooted in the working environment and organizational culture, the role of the learning environment in the development of resident burnout remains unclear. We aimed to evaluate the association between burnout and the learning environment in a cohort of Belgian residents. METHODS: We conducted a cross-sectional online survey among residents in a large university hospital in Belgium. We used the Dutch version of the Maslach Burnout Inventory (UBOS-C) to assess burnout and the Dutch Residency Educational Climate Test (D-RECT) to assess the learning environment. RESULTS: A total of 236 residents (29 specialties) completed the survey (response rate 34.6%), of which 98 (41.5%) met standard criteria for burnout. After multivariate regression analysis adjusting for hours worked per week, quality of life and satisfaction with work-life balance, we found an inverse association between D-RECT scores and the risk of burnout (adjusted odds ratio; 0.47 for each point increase in D-RECT score; 95% CI, 0.23 - 0.95; p = 0.01). CONCLUSIONS: Resident burnout is highly prevalent in our cohort of Belgian residents. Our results suggest that the learning environment plays an important role in reducing the risk of burnout among residents.

ABO incompatibility and glucose-6-phosphate dehydrogenase deficiency presenting as Hydrops Foetalis.

ABO incompatibility and glucose-6-phosphate dehydrogenase deficiency G6PD are common haematological problems affecting the newborn. The resulting haemolytic disease of foetus and newborn (HDFN) caused by either of these pathologies generally follows a benign course. It is typically characterized by mild jaundice without significant anaemia. ABO incompatibility alone as a cause of foetal hydrops is extremely rare. We report a case of a newborn baby girl with an anti-B isoimmunisation and G6PD deficiency manifesting with hydrops foetalis, anaemia and hyperbilirubinaemia, born to a mother with blood group O.

Optimization of making barrel-fermented dry muscatel wines.

The optimization of making barrel-fermented muscatel wines requires determining what type of must clarification is most suitable for the quality of the wine, as well as what type of barrel will yield the most acceptable wines. This is achieved by adding pectolytic enzymes to clarify part of the muscatel must statically; the rest is clarified by vacuum filtration. The musts obtained are fermented in French and American oak barrels and, once fermentation has ceased, they are kept with their lees for 2 months, with periodic stirring. Eleven conventional parameters and 31 volatile compounds were quantified, and a sensory analysis of the wines was produced, which led us to conclude that static clarification with pectolytic enzymes from the muscatel musts produces the best-structured wines and the larger content of higher alcohols, esters, and terpenic compounds. The wines fermented in American oak barrels received the highest overall marks, which may be due to the greater aromatic complexity given off by the compounds in the wood.

Anticonvulsant activities of ethanolic extract and aqueous fraction isolated from Delphinium denudatum.

Dried roots of Delphinium denudatum Wall. are a popular folk remedy for the treatment of epilepsy in the traditional Unani system of medicine in the sub-continent. We carried out anticonvulsant screening of the ethanolic extract (EE) and aqueous fraction (AF) of this plant utilising the maximal electroshock (MEST) and subcutaneous pentylenetetrazole (scPTZ), bicuculline (scBIC), picrotoxin (scPTX) and strychnine (scSTN) tests for anticonvulsant activity. EE had weak dose-dependent anticonvulsant effects on seizures induced by PTZ and BIC. AF exhibited dose-dependent activity against hind limb tonic extension phase (HLTE) of MEST and comparatively stronger anticonvulsant activity against seizures induced by PTZ and BIC. The results suggest the presence of potent anticonvulsant compounds in AF of D. denudatum and deserve further investigation for isolation of active compounds and elucidation of the mechanism of anticonvulsant action.

Anticonvulsant activities of the FS-1 subfraction isolated from roots of Delphinium denudatum.

Delphinium denudatum Wall. (Ranunculaceae) is a medicinal herb used for the treatment of epilepsy in the subcontinent. The present study reports the anticonvulsant activities in the maximal electroshock test (MEST) and subcutaneous pentylenetetrazole (PTZ), bicuculline (BIC), picrotoxin (PIC)-induced seizures of the FS-1 subfraction (FS-1) that was obtained by purification of an aqueous fraction isolated from the roots of D. denudatum. In CF 1 mice, FS-1 (600 mg/kg i.p.) exhibited very potent anticonvulsant activity that was comparable to the effects of the well-known antiepileptic drug phenytoin (20 mg/kg) in MEST and protected 100% animals from hind limb tonic extension phase of this model. FS-1 also suppressed PTZ-induced threshold seizure and the loss of the righting reflex with tonic fore and hind limb extension by 100%, similar to the antiepileptic drug valproic acid (350 mg/kg). BIC-induced seizures were suppressed in 80% of the animals. FS-1 exhibited weak anticonvulsant effect on PIC-induced seizures, however, it significantly reduced mortality and delayed the onset of seizures. FS-1 had no effect on strychnine (STN)-induced extensor seizures. The results demonstrate the broad and potent anticonvulsant activity of the compounds in FS-1 of D. denudatum.

Characterization and fat migration of palm kernel stearin as affected by addition of desiccated coconut used as base filling centre in dark chocolate.

The characterization and fat migration of palm kernel stearin (PKS) and desiccated coconut, used as base filling centre in dark chocolate were studied. C36 and C38 triglycerides of PKS decreased by 11% and 9.6% respectively, whereas C32 and C34 increased by 97% and 48% respectively. The change in the triglycerides composition of PKS shift the melting point of PKS from 33.2 to 31.4 degrees C. Solid fat content (SFC) of PK reduced by 40% at 30 degrees C. The rate of fat migration was very slow at 18 degrees C storage compared to 30 degrees C. The rate of change of C36 in the chocolate layer was 0.1% week-1 and 1.2% week-1 at 18 and 30 degrees C respectively. Chocolate stored at 18 degrees C showed post hardening during storage period and withstood bloom during the storage period, whereas that stored at 30 degrees C became soft and bloomed faster after 3 weeks of storage.

Use of palm mid-fraction in dark chocolate as base filling centre at different storage temperatures.

Dark chocolates filled with palm mid-fraction (PMF) were stored at different temperatures to evaluate the physical and chemical changes. Storage at low temperature (18 degrees C) reduces the PMF migration to negligible extent. Higher storage temperatures (30 and 35 degrees C) increased the PMF migration from the filling centre into the chocolate coating. As a consequence of fat migration, fatty acid composition, triglyceride composition, hardness, solid fat content, melting point and polymorphic structure changed, leading to bloom formation, which started by fat migration and was influenced by recrystallization tendency within the chocolate coating.

Bio-active cardenolides from the leaves of Nerium oleander.

A bioactivity directed isolation of the methanolic extract of the fresh, uncrushed leaves of Nerium oleander showing a central nervous system (CNS) depressant effect in mice has been undertaken. As a result, four CNS depressant cardenolides including a new cardenolide, neridiginoside and three known constituents, nerizoside, neritaloside and odoroside-H, have been isolated which exhibited CNS depressant activity in mice at a dose of 25 mg/kg. The structure of neridiginoside was elucidated as 3 beta-O-(D-diginosyl)-5 beta, 14 beta-dihydroxy-card-20(22)-enolide, using spectroscopic methods including one-dimensional and two-dimensional NMR (COSY-45, NOESY, J-resolved, HMQC and HMBC). The known compounds have been indentified through spectral studies and comparison of data with those reported in the literature.

Maternal vitamin-D deficiency in Pakistan.

OBJECTIVE OF THE STUDY: This study was performed to assess the vitamin D status of healthy Pakistani nursing mothers and their breastfed infants. METHODS: Seventy-one nursing mothers and their breastfed infants belonging to upper and lower socio-economic class were examined 6 weeks to 11 months after delivery. Serum 25-hydroxy vitamin D [25(OH)D], serum calcium, phosphorus and alkaline phosphatase were measured. RESULTS: The mean serum 25(OH)D in mothers was 36.7+/-32.4 nmol/L and 41.25+/-35.4 nmol/ L in infants. Thirty-four (48%) mothers and 37 (52%) infants had levels less than 25 nmol/ L. Significantly higher levels were found in uneducated mothers (p=0.01), mothers of lower socio-economic class (p<0.001) and in those living in mud houses (p<0.001). A significant correlation was found between serum 25(OH)D levels of infants under three months of age and their mothers (p<0.01). CONCLUSIONS: High prevalence of vitamin D deficiency was found in nursing mothers and their infants predominantly in the upper socioeconomic class.

Vitamin D status of breastfed Pakistani infants.

This study was conducted to evaluate the vitamin D status of healthy breastfed Pakistani infants and their nursing mothers. Sixty-two breastfed healthy infants and their nursing mothers belonging to the upper and lower socioeconomic classes were examined. Serum 25-hydroxy vitamin D [25(OH)D], serum calcium, phosphorus and alkaline phosphatase were measured. The mean serum 25(OH)D in infants was 34.59 +/- 26.56 nmol/l. Fifty-five percent of infants and 45% of mothers had very low serum 25(OH)D levels (<25 nmol/l). Significantly higher levels were found in infants of lower socioeconomic class (p < 0.001) and in those living in mud houses (p = 0.002) and infants >6 months (p < 0.001). A high prevalence of vitamin D deficiency was found in breastfed infants and nursing mothers, predominantly among those belonging to the upper socioeconomic class. Infants of the lower socioeconomic class had comparatively higher serum 25(OH)D levels, but even these levels were below the normal range for infants (90 +/- 27.5 nmol/l).

Cardenolides from the methanolic extract of Nerium oleander leaves possessing central nervous system depressant activity in mice.

Two new cardenolides, 3 beta-O-(D-2-O-methyldigitalosyl)-14 beta-hydroxy-5 beta-carda-16,20(22)-dienolide (1) and 3 beta-hydroxy-8,14-epoxy-5 beta-carda-16,20(22)-dienolide (2), and two known cardenolides, 3 beta-O-(D-digitalosyl)-14 beta-hydroxy-16 beta-acetoxy-5 beta-card-20(22)-enolide (3) and 3 beta-O-(D-digitalosyl)-14 beta-hydroxy-5 beta-card-20(22)-enolide (4), have been isolated from the leaves of Nerium oleander following a bioactivity-directed isolation of the MeOH extract, which showed central nervous system (CNS) depressant activity in mice at a dosage of 50 mg/kg i.p. Their structures were established on the basis of chemical and spectral data. Compounds 1, 3, and 4 were found to exhibit sedation in mice at a dosage of 25 mg/kg, although 2 had no effect on the CNS of mice at a dosage of up to 50 mg/kg.

Studies on the constituents of the leaves of Nerium oleander on behavior pattern in mice.

Fresh, undried and uncrushed leaves of Nerium oleander were subjected to methanol extraction and bioassay directed fractionation. This led to the isolation of two purified fractions namely, B-1 and B-3. Fractions B-1 and B-3 were studied with respect to their actions on the central nervous system and behavior pattern in mice. Both fractions were found to produce reduction in locomotor activity, rota rod performance and potentiation of hexobarbital sleeping time. These fractions also showed analgesic activity. When tested against picrotoxin induced convulsions fraction B-1 showed 40% protection, while fraction B-3 exhibited 60% protection against bicuculline induced convulsions. These findings suggest that both fractions possess a CNS depressant action.

Possible presence of calcium channel blocker(s) in Rubia cordifolia: an indigenous medicinal plant.

Crude extract of Rubia cordifolia (RC) was tested in isolated tissue preparations for its possible calcium channel antagonistic activity. RC suppressed the spontaneous contractions of guinea-pig atria, rabbit jejunum and rat uterus in a concentration dependent manner (0.1-3 mg/ml). In rabbit aorta, it inhibited norepinephrine (10 microM) and KCl (80 mM) induced contractions. Replacement of physiological salt solution with calcium free solution abolished the spontaneous movements of rabbit jejunum. However, addition of calcium (25 micrograms/ml) in the tissue bath restored the spontaneous movements. When the tissues were pretreated with plant extract (1 mg/ml) or verapamil (0.5 microgram/ml), addition of calcium failed to restore spontaneous contractions. These results indicate that the plant extract exhibits spasmolytic activity similar to that of verapamil suggestive of presence of calcium channel blocker like constituent(s) in this plant.

Evidence for involvement of amino acid neurotransmitters in anesthesia and naloxone induced reversal of respiratory paralysis.

General anesthetics render a person unconscious and may produce respiratory paralysis at therapeutic doses. No pharmacological agent is available to restore respiration and the mechanism/s of anesthesia or apnea is not clearly understood. In this report, we present evidence to show that naloxone reversed respiratory failure induced by thiopental, ketamine, halothane but not that induced by phenobarbital. Furthermore, 25 mg/kg, i.v. thiopental, 140 mg/kg, i.v. ketamine, and 3% halothane produced anesthesia without significantly altering respiratory rate, increased GABA and decreased glutamate (except ketamine and phenobarbital) levels in rat brain stem and cortex, but not in caudate and cerebellum. Aspartate, glycine and alanine levels were not affected in four brain regions studied. Pretreatment with TSC for 30 minutes did not change GABA or glutamate contents, but abolished the anesthetic as well as the respiratory depressant actions of the anesthetics. Increasing the doses of anesthetics produced respiratory failure with further rise in GABA and fall in glutamate in brain stem and cortex. Naloxone reversed respiratory paralysis and restored GABA close to control values in rat brain stem and cortex with no changes in caudate or cerebellum. Data presented here suggest that GABA may be necessary to produce loss of consciousness and naloxone reverses anesthetic induced respiratory failure.

Vitamin A status of children in the urban slums of Karachi, Pakistan, assessed by clinical, dietary, and biochemical methods.

We assessed the vitamin A status of 532 children with an age range of 6-60 months who were living in slum areas of Karachi, Pakistan, using three methodologies: clinical eye examination, dietary vitamin A intake, and serum retinol level. No definite clinical signs of xerophthalmia were observed in any of these children. The mean +/- SD vitamin A intake estimated from a food frequency questionnaire for the group with inadequate (low and deficient) serum retinol levels (< 20 micrograms/dl) was 362 +/- 332 retinol equivalents (RE) compared with 431 +/- 332) RE in the group with adequate serum levels (P < 0.005). Deficient serum retinol levels (< 10 micrograms/dl) were present in 12 children (2%); two of these had a healed corneal scar. Low serum retinol levels (10-19 micrograms/dl) were present in 46%, while 51% children had adequate levels (> or = 20 micrograms/dl). The mean +/- SD serum retinol level for the inadequate (< 20 micrograms/dl) and adequate groups were 15.3 +/- 2.8 and 26.6 +/- 6.7 micrograms/dl, respectively. These results suggest that a significant number of children in these communities have low vitamin A levels and thus may constitute an at risk group. These results also suggest that the dietary intake method may be a simple and inexpensive screening tool for assessment of vitamin A status in communities.

Chloramphenicol clearance in typhoid fever: implications for therapy.

We prospectively studied the pharmacokinetics of intravenous Chloramphenicol succinate (CS) in children (age 6 months-14 years) with culture proven typhoid fever (n = 30) and non typhoidal illnesses (n = 10). CS was administered in three different dosage regimens (50, 75 and 100 mg/kg/d-q 6 hourly). Liver function tests were monitored. Plasma trough and peak chloramphenicol concentrations were measured by HPLC analysis after 42 hrs. The 50 mg/kg/day dosage schedule was terminated midway through the study, as blood levels were consistently low and two patients with typhoid relapsed, children with typhoid had significantly lower clearance of CS in comparison with those with non-typhoidal illness (0.29 +/- 0.1 versus 0.5 +/- 0.37 1/kg/hr, P 0.05). There was no significant difference between mean peak and trough concentrations of chloramphenicol on 100 mg/kg/day and 75 mg/kg/day in children with typhoid. However, two children on 100 mg/kg/day dosage developed trough concentrations greater than 20 mcg/ml. No correlation was found between CS clearance and serum bilirubin, SGPT (alanine transaminase) and alkaline phosphatase. Our data show altered clearance of CS in children with typhoid and suggests that 75 mg/kg/day may be a safer dose in children with hepatic dysfunction in typhoid.

Chloramphenicol therapy of typhoid fever.

In a prospective study we compared two different dosage regimens of IV chloramphenicol succinate (100 mg/kg/day and 75 mg/kg/day) in children with culture proven typhoid. Trough and peak blood samples, obtained at 48 hrs, were analysed for free chloramphenicol by high pressure liquid chromatography (HPLC). Although the mean trough (8.8 +/- 7.7 versus 5.4 +/- 2.6 mcg/ml) and peak (19.9 +/- 12.2 versus 15.4 +/- 6.1 mcg/ml) chloramphenicol concentrations were comparable in both groups, a significantly wider range was found in the group receiving 100 mg/kg/day. Potentially toxic levels (greater than 30 mcg/ml) developed in two patients with liver dysfunction. Chloramphenicol in a dosage of 75 mg/kg/day is adequate and safe for the treatment of paediatric typhoid.