The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life balance and the role of social support.

BACKGROUND: The organisation of junior doctors' work hours has been radically altered following the partial implementation of the European Working Time Directive. Poorly designed shift schedules cause excessive disruption to shift workers' circadian rhythms. METHOD: Interviews and focus groups were used to explore perceptions among junior doctors and hospital managers regarding the impact of the European Working Time Directive on patient care and doctors' well-being. RESULTS: Four main themes were identified. Under "Doctors shift rotas", doctors deliberated the merits and demerits of working seven nights in row. They also discussed the impact on fatigue of long sequences of day shifts. "Education and training" focused on concerns about reduced on-the-job learning opportunities under the new working time arrangements and also about the difficulties of finding time and energy to study. "Work/life balance" reflected the conflict between the positive aspects of working on-call or at night and the impact on life outside work. "Social support structures" focused on the role of morale and team spirit. Good support structures in the work place counteracted and compensated for the effects of negative role stressors, and arduous and unsocial work schedules. CONCLUSIONS: The impact of junior doctors' work schedules is influenced by the nature of specific shift sequences, educational considerations, issues of work/life balance and by social support systems. Poorly designed shift rotas can have negative impacts on junior doctors' professional performance and educational training, with implications for clinical practice, patient care and the welfare of junior doctors.

Snore site discrimination using statistical moments of free field snoring sounds recorded during sleep nasendoscopy.

The non-invasive measurement of free field snoring sounds to estimate the site of snoring is an important development in the diagnosis, treatment and management of sleep-related breathing disorders. We investigated characteristics of the probability density function by testing the sensitivity of the statistical moments to amplitude patterns in the snoring acoustic signal. Snoring sounds from 15 patients were recorded whilst performing sleep (under anaesthetic) nasendoscopy evaluation. We demonstrated, using a fuzzy 2-means clustering method, that a combination of the statistical dimensionless moment coefficients of skewness and kurtosis could discriminate between pure palatal and non-palatal snoring subject groups.

Comparison of an oxygen concentrator and wall oxygen in the assessment of patients undergoing long term oxygen therapy assessment.

Long term oxygen therapy (LTOT) is a recognised management option for hypoxaemic patients with chronic respiratory disease. Formal assessment is required which is usually conducted in the hospital and performed on piped oxygen to ensure correction of the hypoxaemia. However, an oxygen concentrator is the standard oxygen source for the patient at home who requires LTOT. The oxygen concentration delivered is lower from a concentrator than piped oxygen. Here, we present a study of ten hypoxaemic patients using both delivery sources in a cross-over design. The partial pressure of oxygen was lower in patients when receiving oxygen from a concentrator, p < 0.05. This encourages the Clinician to consider formal assessments on an oxygen concentrator in order to ensure that the hypoxaemia will be corrected when they are prescribed a concentrator for home use.

Multi-system Infection with Nocardia farcinica-therapy with linezolid and minocycline.

We describe a case of disseminated infection with a multiple-resistant strain of Nocardia farcinica, probably resulting from direct inoculation during a road traffic accident. Initial presentation was with pulmonary symptoms, with subsequent development of cutaneous, renal, soft tissue and cerebral involvement. Precise microbiological diagnosis was delayed. Once sensitivity test results were available, the patient was stabilised on linezolid and minocycline. Premature withdrawal of therapy at one month resulted in recrudescence of infection, requiring re-institution of treatment. Linezolid was discontinued after a total of 4 months, because of evidence of myelosuppression and visual impairment, which subsequently improved. Monotherapy with minocycline was continued for a total of 12 months. The patient now remains well.

Asbestos-related disease.

Until the 1980s, asbestos was widely used throughout the UK. The incidence of asbestos-related disease is still climbing because of the long delay in developing the disease from the initial exposure. The spectrum of diseases encompasses malignant mesothelioma, asbestosis, asbestos-related lung carcinoma and benign pleural disease, including pleural plaques.

Sleep deprivation and junior doctors' performance and confidence.

PURPOSE OF STUDY: To determine whether sleep deprivation affects not only junior doctors' performance in answering medical questions but whether their ability to judge their own performance is also affected by lack of sleep. METHODS: A questionnaire based follow up study in two district general hospitals of the Carmarthenshire NHS Trust. Eleven house officers and 15 senior house officers (SHOs) within the medical directorate participating in the on-call rota were recruited between July 1999 and May 2000. RESULTS: SHOs answered significantly more questions correctly (p=0.04) and were more confident than house officers when they were either correct or incorrect (p<0.001). Length of unbroken or continuous sleep is associated with more correct answers (p=0.03) and higher energy (p=0.09) and confidence (p=0.07) scores self rated by the profile of mood states. Length of continuous sleep was not related to the appropriateness of confidence, as measured by the "within-subject confidence-accuracy correlation" (p=0.919). CONCLUSIONS: SHOs performed better than house officers even allowing for sleep loss. Sleep deprivation had adverse effects on mood and performance but junior doctors can still monitor their performance and retain insight into their own ability when sleep deprived.

Recent advances in the sleep apnoea/hypopnoea syndrome.

This review highlights some of the advances in sleep apnoea/hypopnoea syndrome made over the last few years, particularly in diagnosis and treatment. Recent evidence of the controversial associations of sleep apnoea/hypopnoea syndrome with increased morbidity and mortality, particularly from cardiovascular disease, is presented.

Changes in oxygen saturation and transcutaneous carbon dioxide and oxygen levels in patients undergoing fibreoptic bronchoscopy.

Patients undergoing bronchoscopy are usually monitored with pulse oximetry to measure arterial oxygen saturation, but this can fail to detect hypoventilation, particularly if added inspired oxygen is used. Transcutaneous oxygen and carbon dioxide tensions can be measured; the later reflecting respiratory drive. We compared transcutaneous PO2 and PCO2 values with oxygen saturation in patients undergoing day-case bronchoscopy, to see if this information would further improve the safety of the bronchoscopic procedure. Twenty-two consecutive patients undergoing routine fibreoptic bronchoscopy (15 male, mean age 62.3 years; range 45-82 years), were studied using pulse oximetry (OXImeter, Radiometer) and transcutaneous PCO2/PO2 monitoring (TCM3, TINA, Radiometer). We documented a statistically significant increase in transcutaneous PCO2 from mean (SD) stable baseline levels of 5.8 (0.3) kPa (range 4.2-7.9 kPa) to mean peak levels during bronchoscopy of 7.0 (1.0) kPa (range 5.0-8.7 kPa). The time to first adverse change in transcutaneous PCO2 (P = 0.046) and PO2 (P = 0.035) occurred more rapidly than reduction in oxygen saturation in 19 of the 22 cases; median times for change in PCO2 of 67 s (range 10-1800 s), PO2 of 120 s (range 26-559 s) and oxygen saturation of 174 s (range 43-1332 s), timed from administration of i.v. sedation prior to each bronchoscopy. Transcutaneous PCO2/PO2 monitoring during fibreoptic bronchoscopy provided evidence of hypoventilation with significantly elevated levels of transcutaneous PCO2. This method of monitoring provides an earlier indication of respiratory depression during fibreoptic bronchoscopy compared with pulse oximetry.

Randomised placebo-controlled crossover trial on effect of inactivated influenza vaccine on pulmonary function in asthma.

BACKGROUND: Despite current recommendations, many people with asthma do not receive annual vaccination against influenza, partly because of concern that vaccine may trigger exacerbations. Colds can trigger exacerbations, which may be mistaken for vaccine-related adverse events. We undertook a double-blind placebo-controlled multicentre crossover study to assess the safety of influenza vaccine in patients with asthma, with allowance for the occurrence of colds. METHODS: We studied 262 patients, aged 18-75 years, who recorded daily peak expiratory flow (PEF), respiratory symptoms, medication, medical consultations, and hospital admissions for 2 weeks before the first injection and until 2 weeks after the second injection. Order of injection (vaccine and placebo) was assigned randomly. There was an interval of 2 weeks between injections. The main outcome measure was an exacerbation of asthma within 72 h of injection (defined as a fall in PEF of >20%). FINDINGS: Among 255 participants with paired data, 11 recorded a fall in PEF of more than 20% after vaccine compared with three after placebo (McNemar's test p=0.06); a fall of more than 30% was recorded by eight after vaccine compared with none after placebo (binomial test p=0.008). However, when participants with colds were excluded, there was no significant difference in the numbers with falls of more than 20% between vaccine and placebo (six vs three; binomial test p=0.51), although the difference for PEF decreases of more than 30% approached significance (five vs none; binomial test, p=0.06). This association was confined to first-time vaccinees. INTERPRETATION: Our findings indicate that pulmonary-function abnormalities may occur as a complication of influenza vaccination. However, the risk of pulmonary complications is very small and outweighed by the benefits of vaccination.

A comparison of inhaled beclomethasone dipropionate and nedocromil sodium as additional therapy in asthma.

We have compared the effects of inhaled beclomethasone dipropionate (BDP) 400 micrograms day-1 with inhaled nedocromil sodium (NDS) 16 mg day-1 as additional therapy in adults with asthma not fully controlled by regular beta-2-agonist inhalers with, or without, oral theophyllines. Seventeen subjects were entered into a 2-week baseline phase, and subsequently in a double-blind crossover fashion into two 8-week phases of daily BDP or NDS. Subjects recorded daily peak expiratory flow rates, morning and evening (PEF am and pm), symptom scores and beta-2-agonist inhaler use. Thirteen subjects completed the study and the last 2 weeks of each phase were analysed. Compared to baseline, both BDP and NDS caused a significant improvement in PEF am (P less than 0.05), PEF pm (P less than 0.05) and the 'amplitude % mean' (P less than 0.001). Both drugs gave a highly significant improvement in all symptom scores. There was no significant difference between BDP and NDS for PEF am, PEF pm, amplitude % mean, cough and daytime asthma score. However, beta-2-agonist inhaler use and scores for nocturnal asthma and morning tightness were all significantly better in the BDP phase, and may have contributed to its better overall subjective performance. Thus, both NDS and BDP resulted in a significant improvement in asthma control in the subjects studied, and both drugs caused a similar improvement in PEF.

The effects of high dose inhaled beclomethasone dipropionate on glucose and lipid profiles in normal and diet controlled diabetic subjects.

We determined the effect of high doses of inhaled beclomethasone dipropionate (2000 micrograms day-1 for two weeks) on the glucose tolerance test, insulin levels, fasting cholesterol and triglyceride concentrations in fourteen normal and ten elderly diet controlled diabetic patients, in a single blind, placebo controlled trial. No significant disturbance of glucose or lipid metabolism was found in either group. This study suggests that at this high dose, BDP does not exhibit significant disturbance of glucose and lipid metabolism after two weeks use.

Sputum levels of fluconazole in humans.

We measured fluconazole levels in sputum samples obtained from 11 bronchiectatic volunteers at 4 and 24 h after a single oral dose of 150 mg of fluconazole. Levels in sputum were similar to levels in plasma at both times.

A study of evening primrose seed oil in atopic asthma.

It has shown recently that Evening Primrose Oil (Efamol) produces a significant clinical improvement in atopic eczema. Efamol contains gamma-linolenic acid which is a precursor to PGE1 a more consistent bronchodilator than PGE2. We have conducted a double blind placebo controlled study in atopic asthmatics given Efamol for an eight week period looking at the control of asthma, including histamine challenge tests. We have found no effect on the asthma or challenge tests although Efamol produced an alteration in fatty acid profile. The patients showed an abnormal fatty acid profile. We speculate that such fatty acid abnormalities could be important in the aetiology of asthma.

High-dose inhaled albuterol in severe chronic airflow limitation.

Higher doses of inhaled albuterol have been shown to cause slightly more bronchodilatation than standard doses from a metered-dose inhaler in patients with severe chronic airflow limitation. Higher doses, however, carry an increased risk of side effects, and the optimum dose balancing benefit and adverse effects have yet to be established. We have therefore looked at objective and subjective evidence of beneficial and adverse effects after 4 doses of albuterol in 30 patients with chronic bronchitis, severe airflow limitation, and less than 200 ml increase in FEV1 after 200 micrograms inhaled albuterol. Subjects were given placebo, 400 micrograms, 1 mg, 2 mg, and 4 mg albuterol by dry powder inhaler in random order on separate days in a double-blind study, and FEV1, relaxed VC, PEFR, 12-min walk distance, finger tremor, oxygen saturation, heart rate, and arrhythmias were measured at intervals over 6 h. With increasing doses of albuterol, there was a significant dose-related increase in FEV1, VC, and PEFR, the maximal mean changes being 196 ml, 480 ml, and 50 L/min, respectively. The duration of effect was longer with the higher doses. There was a dose-related increase in heart rate, tremor amplitude, and supraventricular ectopic beats and a dose-related fall in oxygen saturation. There was no drug-related effect on the frequency of ventricular ectopic beats either at rest or during the walk tests. The largest increases in walk distance occurred after the 1 and 2 mg doses and the least after the 4 mg dose.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of acute asthma in the accident and emergency department.

We have conducted a survey of all the asthmatic patients seen at the Leicester Royal Infirmary Accident and Emergency Department during a 1-year period. A significantly greater number of patients were seen in the 8-hour period 1600-2359 hours and a greater number of patients were seen on Sundays and bank holidays. Wheeze was recorded in only 43% of the patients and there was no record of any nocturnal asthmatic symptoms. Peak expiratory flow rate was only recorded in 26% of patients before treatment with nebulized salbutamol (the commonest treatment). Pulse rate, respiratory rate, time of day or month did not determine whether or not a patient was admitted. We conclude that the education of junior doctors in the management of asthma is still deficient.