Identifying and exploring factors influencing career choice, recruitment and retention of anaesthesia trainees in the UK.

BACKGROUND: Many acute hospital specialties are experiencing low recruitment and high attrition of trainees. Understanding what is important to current trainees is critical in terms of identifying and addressing factors which adversely affect recruitment and retention. OBJECTIVES: To identify and explore factors involved in anaesthetic trainees' career decision making. METHODS: This was a mixed methods study using a questionnaire survey (assessing how influential 18 different factors were when choosing anaesthetics, using a five-point Likert scale), supplemented by semi-structured interviews, carried out in August-December 2014, in Scotland, UK. RESULTS: 42/68 (62%) completed responses were received, representing over half of all core (58%) and Acute Care Common Stem (65%) trainees across Scotland. Overall, questionnaire data indicated that the following were most important in career decision making: perceived job satisfaction among those already in the specialty, structured training, the nature of the work (practical, varied, immediate outcomes). Thirteen interviews were carried out. These highlighted that prior positive exposure and experience with anaesthetists encouraged trainees into the specialty. Enthusiastic, supportive colleagues and structured training (including clear milestones, regular teaching and feedback) were considered to enhance the quality of training. Sustainable working conditions, flexibility within programme and out-of-programme opportunities were valued. Respondents reported concerns about the impact of increasing service delivery demands on training quality. CONCLUSIONS: Many of the elements important to today's anaesthetics trainees are related to positive learning and working environments. This fits with research findings from other professional groups. These findings can inform the development of programmes which cultivate trainee commitment to, and enthusiasm for, anaesthetics.

Attracting healthcare professionals to remote and rural medicine: learning from doctors in training in the north of Scotland.

BACKGROUND: Research exploring the experiences of trainee doctors in remote and rural locations is scarce. Our aim was to gain an understanding of the experiences and perceptions of Foundation Programme (FP) doctors training in placements in remote and rural areas of the north of Scotland. METHODS: FP doctors training in remote and rural areas in Scotland took part in a qualitative study (focus groups and individual interviews) exploring their training experiences and career plans. To make sense of a potential multitude of factors, we selected social cognitive careers theory (SCCT) to underpin data collection and analysis. RESULTS: A total of 20 trainees participated. Using data-driven analysis, three themes relevant to the SCCT emerged. These are the educational experience (e.g., opportunities to develop skills, greater responsibility), geographical isolation factors (e.g., the impact of staff shortages, poor accommodation, travel) and personal factors (e.g., social isolation, attitudes towards the experience). CONCLUSION: Many factors impact on trainees' experience of learning and living in remote and rural medicine (R&R) environments. These experiences can be very positive for some individuals but factors external to the educational environment influence the perception of the overall experience. SCCT helps clarify the interaction between individual and contextual factors in career decision making.

A mixed-methods study identifying and exploring medical students' views of the UKCAT.

BACKGROUND: The United Kingdom Clinical Aptitude Test (UKCAT) is used by 23 UK medical schools. Research to date has focused on validity and utility but it is also critical to examine selection processes from the applicant's perspective. METHODS: This was a mixed-methods study using a paper-based survey and focus groups with first year medical students in Scotland in 2009-2010. Questionnaire data were analysed using SPSS, focus group data using framework analysis. RESULTS: The survey return rate was 88% (883/1005). More than 99% of respondents had sat the UKCAT. Only 20% of respondents agreed the UKCAT was useful in the selection procedure. Nineteen students then took part in three focus groups held in three medical schools. These identified four themes related to views of the UKCAT: lack of face validity, concerns about fairness and cost, and the use of data by medical schools and influence of preparation. CONCLUSION: The UKCAT was viewed unfavourably by first year medical students completing it pre-admission. These negative views seem due to concern as to the use of UKCAT data, and the fairness of the test. More evidence as to validity and fairness of the UKCAT and how it is used in practice is required.

A case of hepatosplenic gamma-delta T-cell lymphoma with a transient response to fludarabine and alemtuzumab.

Hepatosplenic gamma-delta T-cell lymphoma is a rare, usually fatal lymphoma and available literature on management is sparse. Allografting is probably the only curative option. We describe a further case with a dramatic, though transient response to Fludarabine and Alemtuzumab combination, following a failure of conventional chemotherapy. Given the dreadful prognosis with conventional chemotherapy, it is a regimen worth pursuing as a disease reduction strategy prior to allograft where appropriate.

Polymorphisms in the interleukin-10 and interferon gamma genes in Hodgkin lymphoma.

Genetic factors are known to be important in the development of Hodgkin lymphoma (HL). Interleukin-10 (IL-10) secretion by both malignant and reactive cells is thought to be important in the pathogenesis of HL especially Epstein-Barr virus (EBV) positive cases. Polymorphisms of the IL-10 gene have been reported to be associated with susceptibility to EBV infection. The cytotoxic response to EBV is determined by a Th1 biased immune response which is characterised by interferon gamma (IFNgamma) secretion. We therefore investigated polymorphisms in the IL-10 (-1082 G/A and -592 C/A) and IFNgamma (intron 1 CA repeat) genes as predisposing factors in the development 147 cases of HL. A difference of borderline statistical significance was demonstrated for the IFNgamma gene polymorphism but significance was lost when analysis was restricted to the common genotypes. No significant differences in the distributions of genotypes were found for the IL-10 gene polymorphisms. IL-10 and IFNgamma levels were also measured on 26 patients with HL. No statistically significant differences were detected when the results were analysed by genotype. We found little evidence IL-10 and IFNgamma genotypes predispose to the development of HL or influence the inflammatory host response.

Transfusion-associated graft-versus-host disease in a patient with Waldenstrom's macroglobulinaemia.

BACKGROUND AND OBJECTIVES: Routine irradiation of cellular blood products is not presently recommended for patients with non-Hodgkin's lymphoma (NHL). MATERIALS AND METHODS: We report the case of a 72-year-old-man with Waldenstrom's macroglobulinaemia who developed transfusion-associated graft-versus-host disease (TA-GvHD) 13 days following a non-irradiated red cell transfusion. RESULTS: The patient had not previously received purine analogues and none of the donors was homozygous for a human leucocyte antigen (HLA) haplotype that was shared by the recipient. Therefore, his only apparent risk factor was lymphoplasmacytoid NHL. CONCLUSIONS: This case further strengthens the argument that NHL per se is a risk factor for TA-GvHD and supports the proposal that the guidelines for prophylactic irradiation of cellular blood products be extended to include all cases of NHL.

Y stenting of a bifurcation stenosis using a new radiopaque stent.

A case of Y stenting using radiopaque stents for a bifurcation stenosis is described. Angiography and intravascular ultrasound demonstrate that in spite of optimal stent placement there is an area of the lesion that is not fully covered by the stents. This may predispose to subacute thrombosis and restenosis. This case illustrates a potential deficiency of this type of bifurcation stenting.

Carcinoid constrictive pericarditis.

A 78 year old man presented with diarrhoea, anorexia, and progressive lower limb oedema. He was in atrial fibrillation and had a right pleural effusion and ascites. Ultrasound of the abdomen and 24 hour urinary hydroxyindoleacetic acid output indicated metastatic carcinoid syndrome. Cardiac catheterisation revealed pericardial constriction, and pericardial exploration showed a greatly thickened pericardium with no evidence of tumour invasion. The patient died within 24 hours of surgery. Necropsy findings were consistent with a diagnosis of constrictive pericarditis secondary to metastatic carcinoid syndrome.

Noncritical disease of the left main coronary artery: limitations of angiography and the role of intravascular ultrasound.

OBJECTIVE: To review the diagnosis and management of noncritical left main stem disease. DATA SOURCES: MEDLINE was searched using the key phrases 'intravascular ultrasound' and 'left main coronary artery'. DATA EXTRACTION: Articles addressing the angiographic or ultrasound assessment of left main stem disease were systematically reviewed. Reference is also made to articles dealing with outcomes for patients with left main stem disease. DATA SYNTHESIS: The assessment of left main stem disease by coronary angiography is often suboptimal. Intravascular ultrasound has demonstrated significant left main stem disease in angiographically normal arteries. It has also demonstrated that mild to moderate left main stem disease frequently accompanies disease in the other coronary arteries. The natural history of mild to moderate left main stem disease has not been well characterized; thus, the optimum management of this condition is not known. CONCLUSIONS: To establish the natural history of noncritical left main stem stenosis, it is proposed that centres performing frequent intravascular ultrasound examinations systematically and quantitatively interrogate the left main stem during all left coronary examinations. Angiographic and ultrasonic measures of left main stem disease can then be correlated with clinical outcome during long term follow-up. This will clearly require the collaboration of several centres to generate a sufficiently large database to address these clinical questions.

Long-term survival of a patient with left ventricular free wall rupture without surgical repair.

This report describes the case of a patient who developed postinfarction left ventricular free wall rupture and cardiac tamponade. He was managed conservatively, made a successful recovery, and is alive and asymptomatic 10 months after the index episode. Only 17 cases in which the patients survived subacute rupture of the ventricular free wall over the long term without surgical repair have been reported in the literature.

A survey of factors affecting the recruitment and retention of Medical Laboratory Scientific Officers in Pathology.

OBJECTIVE: To survey the perceptions and attitudes of Medical Laboratory Scientific Officer (MLSO) staff in Pathology to explain difficulties in recruitment and retention and inform attempts to solve the difficulties. DESIGN: Questionnaire to a defined group of MLSOs. SETTING: The Laboratory Medicine Directorate, Aberdeen Royal Infirmary. SUBJECTS: MLSO1 and MLSO2 staff currently or recently working in Pathology (histopathology) in Aberdeen. RESULTS: The survey return rate was 100%. Opportunities for career development in Pathology are poor, this being the worst feature of working in Pathology. Remuneration is poor and is a disincentive to remaining in the speciality. MLSOs feel undervalued in relation to other health care workers. Many have concerns about laboratory organisation, but find a sociable and supportive environment that provides job satisfaction. Staff seek work in other laboratories because of opportunities for promotion, learning new skills and increased pay, although pay in specialities other that Pathology is greater only because of shift working in these disciplines. There is a need to increase public awareness of MLSOs' central role in providing and maintaining excellence in Pathology services. CONCLUSION: MLSO staff have concerns about their career structure and salary scales. The responsibility of MSLOs in Pathology for quality assurance and managing MLAs is not recognised. These factors form a disincentive to working in Pathology laboratories and threaten our ability to staff the service and to maintain the turnover and quality of Pathology services. These issues require to be addressed nationally and rapidly to prevent the continuing decline in MLSO numbers. Matters of local organisation might be addressed by trusts and departments, but recognition of the need to resource changes would require reflection in budgets.

The transthoracic impedance cardiogram is a potential haemodynamic sensor for an automated external defibrillator.

AIMS: The American Heart Association has endorsed the concept of Public Access Defibrillation. However, there have been reports of inappropriate direct current shocks from automatic external defibrillators. The specificity of automatic external defibrillators for shockable rhythms may be improved by the incorporation of a haemodynamic sensor. METHODS AND RESULTS: This study examined the use of four parameters extracted from the impedance cardiogram i.e. Peak dz/dt (the peak of the impedance cardiogram measured from the line dz/dt=0 ohms(-1)), Peak-trough (the peak-to-trough measurement of the impedance cardiogram ohms(-1)), Area 1 (the area under the C wave of the impedance cardiogram above the line dz/dt=0 mohm) and Area 2 (the area under the impedance cardiogram 50 ms on either side of the Peak and above the line dz/dt=0 mohm) as predictors of cardiac output. At 116 cardiac arrest calls the ECG and impedance cardiogram were recorded through two ECG/defibrillator pads placed in an antero-apical position. Nine recordings were rejected for artefact. The rhythm recorded in the remaining 107 calls was asystole (19), ventricular fibrillation (14), agonal rhythm (20), electromechanical dissociation (22), ventricular tachycardia (27) and sinus rhythm (5). These rhythms were divided into those associated with haemodynamic collapse i.e. no pulse -- asystole, ventricular fibrillation, agonal rhythm, electromechanical dissociation and shockable ventricular tachycardia (associated with loss of consciousness, pulselessness or a systolic blood pressure of <80 mmHg) (Group 1) and those associated with a satisfactory cardiac output i.e. non-shockable ventricular tachycardia (conscious with a pulse) and sinus rhythm (Group 2). On univariate analysis each of the four impedance cardiogram parameters were significantly greater in Group 2 than Group 1 (P<0.001). On multivariate analysis the parameters which best differentiated the two groups were Area 1 and Peak-trough. CONCLUSION: Thus the impedance cardiogram is a potential haemodynamic sensor for an automatic external defibrillator.