Burnout assessment in house officers: evaluation of an intervention to reduce stress.

BACKGROUND: Medical house officers are at increased risk for stress related symptoms leading to professional burnout. AIMS: Measure burnout in house officers and establish whether utilization of a psychotherapeutic tool individually by physicians reduces symptoms characteristic of burnout. METHOD: Two groups of pediatric house officers at the University of California Davis Health System completed a Maslach Burnout Survey (MBS) at the beginning and end of a three-month period in 2003. An Intervention group (7 of 15 enrolled) was trained in the use of a self-administered psychotherapeutic tool. Outcome Measures were MBS scores and a qualitative interview of intervention group members. RESULTS: There were no significant differences between the two groups, prior to the study or over time. Qualitative interviews revealed that subjects experience stressors in relation to their professional activities, but already utilize some elements of the tool and were too busy to implement the entire tool systematically. CONCLUSIONS: Pediatric trainees did not seem to manifest burnout symptoms based upon the MBS; interviews suggested that some do experience significant stress, although manifestations and responses were varied, some may be at risk. Methods identifying individuals at risk for burnout, and interventions to cope with stress may be valuable to their training.

Choreographing the end of life in a neonate.

As caregivers, we often have the privilege of accompanying patients and their families at the end of life. When the patients are newborn infants, the parents are totally unprepared cognitively, emotionally, and spiritually. Their experience represents uncharted territory. The concept of uncharted territory probably applies to everyone facing the death of a loved one for the first time for both the patients and their families. Providing some guidance to patient/family dyads, while simultaneously respecting their autonomy, may be helpful to facilitate healing and meaning construction during the process of bereavement. In applying an integrative universal paradigm of care when curative measures elude us, healing measures become of paramount importance. An exemplar involving a neonate is presented in this commentary; however, healing measures are relevant to patients of all ages as well as to their loved ones.

Near-infrared spectroscopy as a screening tool for patent ductus arteriosus in extremely low birth weight infants.

BACKGROUND: Patent ductus arteriosus (PDA) is frequent and potentially pathologic in preterm infants. A simple bedside tool to screen for ductal patency would assist in the care of extremely low birth weight (ELBW) infants. OBJECTIVE: To investigate the utility of near-infrared spectroscopy (NIRS) in identifying ELBW infants who would benefit from early echocardiography. METHODS: Tissue oxygen saturation (S(t)O(2)) was measured by NIRS in the lungs, brain, skeletal muscle and kidney of 20 ELBW infants. Comparisons were made between the S(t)O(2) in these organs and the need for intervention for a PDA. All studies were performed within the first 4 days of life. Similar measurements were performed following treatment with indomethacin in nine of the patients. RESULTS: The S(t)O(2) of skeletal muscle (left deltoid) and kidney differed between the infants who were treated for PDA and those who were not (p = 0.01 for both). As a screen for a PDA requiring intervention, deltoid S(t)O(2) had sensitivity 77% and specificity 83%, and kidney S(t)O(2) had sensitivity 85% and specificity 83%. Following treatment with indomethacin, the low S(t)O(2) in the deltoid and kidney increased toward the range seen in patients who did not require treatment of a PDA. Inter- and intra-observer variability ranged from minimal to high. CONCLUSION: This pilot study of a portable NIRS device shows encouraging efficacy in identifying ELBW infants who were likely to benefit from early echocardiography and subsequent intervention to close a PDA. Further study is warranted.

Shear stress paradigm for perinatal fractal arterial network remodeling in lambs with pulmonary hypertension and increased pulmonary blood flow.

Congenital heart disease with increased blood flow commonly leads to the development of increased pulmonary vascular reactivity and pulmonary arterial hypertension by mechanisms that remain unclear. We hypothesized a shear stress paradigm of hemodynamic reactivity and network remodeling via the persistence and/or exacerbation of a fetal diameter bifurcation phenotype [parent diameter d(0) and daughters d(1) >or= d(2) with alpha < 2 in (d(1)/d(0))(alpha) + (d(2)/d(0))(alpha) and area ratio beta < 1 in beta = (d(1)(2)+ d(2)(2))/ d(0)(2)] that mechanically acts as a high resistance magnifier/shear stress amplifier to blood flow. Evidence of a hemodynamic influence on network remodeling was assessed with a lamb model of high-flow-induced secondary pulmonary hypertension in which an aortopulmonary graft was surgically placed in one twin in utero (Shunt twin) but not in the other (Control twin). Eight weeks after birth arterial casts were made of the left pulmonary arterial circulation. Bifurcation diameter measurements down to 0.010 mm in the Shunt and Control twins were then compared with those of an unoperated fetal cast. Network organization, cumulative resistance, and pressure/shear stress distributions were evaluated via a fractal model whose dimension D(0) approximately alpha delineates hemodynamic reactivity. Fetus and Control twin D(0) differed: fetus D(0)=1.72, a high-resistance/shear stress amplifying condition; control twin D(0) = 2.02, an area-preserving transport configuration. The Shunt twin (D(0)=1.72) maintained a fetal design but paradoxically remodeled diameter geometry to decrease cumulative resistance relative to the Control twin. Our results indicate that fetal/neonatal pulmonary hemodynamic reactivity remodels in response to shear stress, but the response to elevated blood flow and pulmonary hypertension involves the persistence and exacerbation of a fetal diameter bifurcation phenotype that facilitates endothelial dysfunction/injury.

Evaluation of stroke volume via arterial pulse pressure waveforms in neonatal lambs.

Arterial pulse waveforms contain information about stroke volume (SV) as an integral of pulsatile flow. SV estimation is accurate in adults with proper pulse pressure measurement technique. It is unclear whether the same methods are suitable in critically ill infants in the neonatal clinical setting where the fidelity of pulse pressure measurements are uncertain. We compared three pulse waveform SV methods with three systolic area SV methods in neonatal lambs in order to identify the most accurate and precise approach. Six newborn lambs were studied. Each lamb had a ligated ductus arteriosus and was instrumented to record high-fidelity pulsatile waveforms of arterial blood pressure using a transducer-tipped catheter and pulsatile flow via calibrated ultrasonic flow probe, respectively. Three steady-state hemodynamic conditions were induced experimentally: control, hypertension via infusion of angiotensin II, and hypotension by phlebotomy. Recordings of a range of SVs were made during a steady state that was interrupted by a transient period of decreasing SV, induced by momentarily increasing preload by pulmonary artery occlusion. Modification of pulse wave pressure measurement conditions, simulating an overdamped fluid-filled catheter system, were achieved by low-pass digital filtering of the original high-fidelity waveforms (high) to an 8-Hz cut-off (medium) and to a 2-Hz cut-off (low). The six SV estimates were then calibrated against flowmeter-derived SV and their accuracy and precision evaluated. Based on 6,479 waveforms, a systolic area method with pulse contour integration was the most accurate and precise. We conclude that neonatal pulse arterial waveforms embed SV information under a wide variety of hemodynamic and pressure waveform measurement conditions, and thus may be of potential clinical value in the assessment of newborn cardiovascular status.

Detoxifying death in the neonate: in search of meaningfulness at the end of life.

At the end of life, when curative measures have failed to conquer the terminal nature of a disease, it is imperative to introduce healing measures that deal with the human suffering associated with illness. When dealing with critically ill neonates with lethal conditions, it may be necessary to institute healing measures at the beginning of life. In such cases, healing measures must incorporate customary palliative measures but should not be limited to them. The purpose of this paper is to describe two families' approaches to palliation at the end of life in their newborn infants with Trisomy 18, a genetic abnormality usually associated with a markedly decreased life expectancy. We shall consider the concepts of interference versus intervention as we examine subtle medical differences between the two cases. We will address medical, legal, and ethical issues in each case, but special attention will be given to the provision of compassionate care. People face physical, mental, emotional, and spiritual challenges as they go through life. The families' approaches with their infants at the end of their lives may support the premise that the latter two challenges, emotional and spiritual, confront us the most at the end. Encouraging families to engage with their dying infants helps detoxify the experience and make it more meaningful.

Duplication of the cervical esophagus: a case report and review of the literature.

This report describes a newborn with a cervical esophageal duplication cyst, a rare developmental anomaly of the neck. Only a few cases of this cystic entity have been described in the literature to date. This case is unique in that the patient had an air-fluid level within the lesion as a result of communication of the duplication cyst with the native esophagus.

A case of segmental paternal isodisomy of chromosome 14.

Uniparental disomy of chromosome 14 (UPD 14) results in one of two distinct abnormal phenotypes, depending upon the parent of origin. This discordance may result from the reciprocal over-expression and/or under-expression of one or more imprinted genes. We report a case of segmental paternal isodisomy for chromosome 14 with features similar to those reported in other paternal disomy 14 cases. Microsatellite marker analysis revealed an apparent somatic recombination event in 14q12 leading to proximal biparental inheritance, but segmental paternal uniparental isodisomy distal to this site. Analysis of monochromosomal somatic cell hybrids containing either the paternally inherited or the maternally inherited chromosome 14 revealed no deletion of the maternally inherited chromosome 14 and demonstrated the presence of paternal sequences from D14S121 to the telomere on both chromosomes 14. Thus, the patient has paternal isodisomy for 14q12-14qter. Because the patient shows most of the features associated with paternal disomy 14, this supports the presence of the imprinted domain(s) distal to 14q12 and suggests that the proximal region of chromosome 14 does not contain imprinted genes that contribute significantly to the paternal UPD 14 phenotype.

Healing the caregiver.

When treating seriously ill patients, those working in the healing professions may be particularly vulnerable to their own stress symptoms. Left unattended, these professionals may go down the dark road leading to burnout, with impaired effectiveness as caregivers, diseases rooted in stress, as well as increased suicides, drug and alcohol addiction, and exacerbation of personality disorders. Early intervention may help reduce the associated problems. In this paper, we present an elementary debriefing system, a psychotherapeutic approach, to be used by the affected individual. While this methodology may be far more simplistic than those utilized in different schools of healing or caregiving, its appeal is its simplicity and practicality. We are proposing that the individual caregiver systematically consider the following: the Background of the situation; how it Affects thinking and feeling; the Troublesome element(s); how one is Handling element(s); and an Empathetic/empowering conclusion (BATHE). Ideally, these considerations may help alleviate caregivers' anguish in troublesome situations and may complement their awareness of their patients' suffering as well.