Why do physicians go to work when they are sick? Presenteeism at different career stages.

INTRODUCTION AND OBJECTIVE: Physicians find it difficult to take on the role of the patient and they show unusual behaviors when ill. One of these behaviors is presenteeism, which is working while sick. The objective of this research is to analyze the factors that contribute to the phenomenon of presenteeism in Spanish physicians. MATERIAL AND METHODS: Mixed methodology study: one national survey through the General Council of Medical Associations website (quantitative part), 22 semistructured interviews with sick residents and practicing physicians, and three focus groups involving professionals from the occupational health services (qualitative). A bivariate analysis using parametric and non-parametric tests. The significance level was p<0.05 (95% confidence interval). Qualitative analysis using the comparative-constant method until saturation of information. RESULTS: Presenteeism is reported by 89.4% of doctors who responded to the survey, and it is more common among women. Contributing factors include fear of overburdening colleagues (the main reason and more common among women 58.14% vs 48.35%), self-perception of doing one's duty (the second reason and more common among men, 44.63% vs 33.14%) and economic impact and difficulty in accepting the role of a sick person. This behavior has an impact on patient safety, and is part of the hidden curriculum that also affects the training of medical professionals. CONCLUSIONS: Presenteeism is a widespread and accepted practice among medical professionals. Although normalized, and even appreciated as a way to avoid overburdening colleagues, presenteeism has important implications for clinical ethics and patient safety.

Gender analysis of Spanish National Questionnaire on behaviours and attitudes of doctors towards their own illness (CAMAPE).

INTRODUCTION AND OBJECTIVES: Physicians' health is a key element for quality healthcare. Medical professionals have difficulty accepting their role as patients and it might be different among sexes. The aim was to describe behaviours and attitudes of doctors towards their own illness. MATERIALS AND METHODS: An online survey was launched through the General Council of Medical Associations webpage for all Spanish registered doctors. A bivariate analysis by sex was performed for all the questionnaire variables using parametric and non-parametric tests. The significance level was p<0.05 (95% confidence interval). RESULTS: A total of 4,308 registered doctors (1,858 men and 2,450 women) answered. Women were younger, single, and worked mainly in non-surgical specialities in the public sector. Men were older, married, and worked more frequently in public-private practice. Women had less chronic conditions, except for anxiety disorders (11.52% vs 15.18%). Both sexes, especially women, primarily self-treated (94.29% vs 95.02%), went to work while ill (88.16% vs 90.29%), visited their GP (56% vs 70%), and half of them underwent annual occupational health checks (40% vs 48%). Women self-prescribed more analgesics (93.43% vs 95.63%), more presenteeism (88% vs 90%) and felt more insecure when treating sick fellows (9.96% vs 20.12%) and requested training for it. More women agreed to make deontological recommendations about doctors' health (91.55% vs 96.16%) and considered revalidation may contribute to improve doctors' health (65.29% vs 66.16%). CONCLUSIONS: Male and female doctors show illness-health behaviours and attitudes at work to improve. There are differences among male and female doctors. Regarding, medical feminization, ethical recommendations may be of benefit regarding doctors' health-illness issues and considering gender perspective.

Behaviour and attitudes of Spanish physicians towards their own process of falling ill: Study protocol and validation of CAMAPE questionnaire.

Physicians have not learned their role as patients. Health programmes for doctors are focused on mental health. Nevertheless, anomalous behaviours of ill doctors exist independently of health problems. We present a study to describe behaviour and attitudes of doctors towards their own illness (CAMAPE) including the analysis of questionnaire validation. MATERIAL AND METHODS: A mix methodology study based on semi-structured interviews to ill physicians and focus groups with members of medical colleges, occupational medicine services and doctors of ill doctors was performed. A survey was designed. Survey validation process included content and face validity, construct validity through exploratory and confirmatory factor analysis and reliability by Cronbach's Alpha Index. RESULTS: A total of 27 interviews to ill doctors and 4 focus group were performed. Content and feasibility assessment was made by experts. Psychometric validation was performed with a sample of 4308 answers (2450 women, 56.87%). A 5-factor (F) model explained 78.08% variance. First factor (F1) "The work might worsen health". Second (F2) "Mental issues, toxic habits and the impact of a bad health on work performance"; Third (F3) presenteeism and sick leaves; Fourth (F4) the handling of an ill colleague and the role of medical colleges. Fifth (F5) the healthcare pathway and potential value of revalidation in medical profession. CONCLUSIONS: A comprehensive mixed study on the process of physicians becoming ill has been launched with a reliable questionnaire in a large sample of registered doctors. The analysis will help to formulate gender-sensitive policy and ethical recommendations in relation to sick doctors given the progressive feminisation of the medical profession.

"Levántate y anda", un caso de trastorno conversivo grave en la infancia / "Get up and walk", a case of severe conversion disorder in childhood

Presentamos el caso de una niña de 11 años que ingresa en Pediatría y posteriormente en Psiquiatría Infanto-Juvenil, con sospecha de un cuadro conversivo grave consistente en inmovilidad para la deambulación y negativa activa a la ingesta de sólidos y líquidos. Explicamos el abordaje multidisciplinar del caso, tanto a nivel hospitalario como ambulatorio. La recuperación completa se ha alcanzado un año después del inicio de los síntomas. Además, realizamos una breve revisión y repaso de las características de los trastornos conversivos en niños y adolescentes, poniendo especial atención al pronóstico

We report the case of a 11-year-old girl that was admitted in Paediatrics Unit and later in Childhood and Youth Psychiatry Unit, with a suspected severe conversion disorder which included immobility and refusal to eat and drink. We explain the multidisciplinary approach to the case, both hospital and ambulatory levels. Complete recovery took about a year after the onset of symptoms. Furthermore, we make a brief review about the characteristics of conversion disorders in children and adolescents, with a special focus on the prognosis

Consentimiento informado: algo más que una firma / Informed consent: more than just a signature

El consentimiento informado (CI) es la explicación que el médico o profesional sanitario da al paciente de la naturaleza de su enfermedad y del balance entre los efectos y los riesgos de las intervenciones diagnósticas y terapéuticas. Esta información debe estar adaptada al nivel de comprensión y a las características individuales del paciente. En el caso de los menores de edad, su opinión debe tenerse en cuenta y su madurez debe ser valorada por el médico. El CI debe considerarse un proceso de asistencia en la toma de decisiones y no la mera firma de un formulario. Se presenta el caso de una niña de 12 años con escoliosis idiopática en la que se indica una intervención quirúrgica que fue inicialmente rechazada tanto por la madre como por la niña. La intervención del equipo del centro de salud fue decisiva en este caso para una correcta toma de decisiones por parte de la familia (AU)

The informed consent (IC) is the explanation that the doctor or health professional gives to the patient on the nature of his disease and on the balance between the benefits and risks of the diagnostic and therapeutic interventions. This information must be adapted to the level of understanding and to the patient’s individual characteristics. In the case of the minors, his opinion must be taken into account and his maturity valued by the doctor. The IC must be considered as a process of assistance in the making of decisions and not as the mere signature of a form. The case report of a 12-year-old girl with severe idiopathic scoliosis is presented. The orthopedic team indicated a surgical intervention that was initially rejected both by the mother and the girl. The intervention of the Primary care staff was decisive in this case for a correct decisions making by the family (AU)

[Hearing loss in adolescents due to leisure noise. The OHRKAN study]. / Hörst du noch oder pfeift es schon? Hörschäden durch Freizeitlärm bei Jugendlichen und die Studie OHRKAN.

Alarming reports have been published about hearing loss in adolescents, and increasing leisure time noise exposure has been blamed. If the exposure limits from the Noise at Work Regulations are applied, discotheque music as well as music from portable music players are associated with the risk of hearing loss. The empirical evidence for this association, however, is not sufficient. Not even an increase in the prevalence of noise-induced hearing loss among adolescents can be documented. OHRKAN is a prospective cohort study aimed to produce information on the prevalence of hearing loss as well as its risk factors in adolescents. Currently, a total of 2,240 pupils in grade 9 at schools in the city of Regensburg, Germany, have been recruited. Data on noise exposure were collected using standardized questionnaires. In addition, hearing status was assessed by medical examination including tympanometry, audiometry, and distortion-product otoacoustic emissions. Developments in noise exposure as well as hearing status will be assessed in follow-up data collections. Independent of this empirical assessment preventive measures are already needed now to reduce the risk of hearing loss in adolescents and young adults.

[Multiple symmetrical lipomatosis: report of two different clinical types and review of the literature]. / Lipomatosis simétrica múltiple: presentación de dos formas clínicas diferentes y revisión de la literatura.

Multiple symmetrical lipomatosis or Lauwnois-Bensaude disease is a rare entity characterized by the development of subcutaneous fat masses around the neck shoulders and upper extremities. Peripheral neuropathy is a common finding as well as the association with alcholism, hepatopathy and glucose intolerance. Pathogenesis is unknown. We describe three cases with two different clinical types and review the data reported in medical literature.

Lipomatosis simétrica múltiple: presentación de dos formas clínicas diferentes y revisión de la literatura / Multiple symmetrical lipomatosis: report of two different clinical types and review of the literature

La lipomatosis simétrica múltiple o enfermedad de Launois-Bensaude es una entidad infrecuente caracterizada por el desarrollo de depósitos grasos subcutáneos en el cuello, hombros y porción superior de extremidades. La polineuropatía periférica es un hallazgo frecuente así como su asociación a alcoholismo, hepatopatía e intolerancia a la glucosa. La patogénesis es desconocida. Describimos tres casos con dos formas clínicas distintas de presentación y revisamos la literatura médica. (AU)

[Endoscopic multi-color deglutition study]. / Endoskopische Mehrfarben-Schluckuntersuchung.

BACKGROUND: The complexity of the diagnostic/therapeutic problem in ENT-specific as well as in neurogenic dysphagia requires that test foods be offered in a variety of consistencies (viscosities), at different temperatures, and with various tastes. The swallowing assessment is undertaken with different head and trunk postures, using different swallowing techniques. METHODS: A series of test foods of varied viscosities is prepared with different food colorings. It is given to the patient according to an individually-tailored viscosity plan, but usually in the same (repeatable) color sequence of blue-yellow or blue-yellow-black, an order which offers optimal color contrasts. RESULTS, CONCLUSIONS: During repeated swallowing assessments, the "multicolor technique" is more useful for endoscopic observation of the pharyngolaryngeal route of the food bolus than the "methylene blue swallow". Food coloring is cheap and it changes neither the taste nor the pH of the food.

Proliferation of non-Hodgkin-lymphoma lymphocytes in vitro is dependent upon follicular dendritic cell interactions.

Follicular dendritic cells (FDC) are located within the B-cell follicles of non-malignant lymphatic tissues and within non-Hodgkin-lymphomas (NHL) derived from the germinal centre or the mantlezone. The interactions between FDC and non-neoplastic B-cells have been extensively investigated but so far no data on functional studies with FDC isolated from lymphoma tissue are available. Using an enzyme cocktail to digest lymph nodes from patients with NHL followed by density centrifugation, single cell suspensions enriched in FDC and B-lymphocytes were obtained. In these preparations FDC formed small cellular clusters with an average of five neoplastic lymphocytes for every FDC. Immunocytochemistry with Ki67 revealed that after 24 h of culture 23.7% of the cells within the clusters were in late G1 to M phase. In contrast, only 10.2% of the lymphoma cells scattered outside the clusters were in these activated stages. As visualized by autoradiography, after 72 h of incubation the rate of proliferation was 16.8 times higher for the lymphoma cells involved in cluster formation as compared to those lymphocytes not associated with FDC. The data indicate that in vitro FDC from NHL lymph nodes form a microenvironment favourable for the activation and proliferation of lymphoma cells. The search for cytokines secreted by FDC in lymphoma tissue is under way.

Proliferation of germinal center B lymphocytes in vitro by direct membrane contact with follicular dendritic cells.

In secondary lymphoid organs, follicular dendritic cells (FDC) are located within B cell follicles and germinal centers. Through their cytoplasmic extensions they come into contact with a large number of neighboring lymphocytes. Using an enzyme cocktail to digest human tonsils followed by ultracentrifugation on bovine serum albumin gradients, single cell suspensions were obtained. Immunocytochemistry revealed that 7% of the cells were FDC, 5% T cells, and 5% macrophages. The remaining population were B cells with greater than 95% being of the germinal center phenotype (i.e. CD19-positive, CD39/sIgD negative). After 24 h of culture up to 44% of the lymphocytes were found in clusters centered around FDC. At the start of the culture as well as 24 and 72 h later, between 31 and 55% of the B cells within FDC associated clusters were in late G1 to M phase of the cell cycle. In contrast, less than 10% of the B cells not in contact with FDC (i.e. outside the clusters) were in an activated state. Autoradiography revealed that after three days of incubation the rate of proliferation was 26.2 times higher for the lymphocytes involved in cluster formation as compared to those cells not associated with FDC. Furthermore, the number of viable B cells after a 72 h mitogen-free culture period was determined. By adding FDC to these preparations, 31.9% of the lymphocytes were rescued from dying. These data show that FDC provide a microenvironment which can maintain the viability, activation and proliferation of germinal center B cells in vitro.

Antigenic phenotyping of human follicular dendritic cells isolated from nonmalignant and malignant lymphatic tissue.

Follicular dendritic cells (FDC) are located within follicles of secondary lymphoid tissue and in lymph nodes of patients with germinal center cell-derived non-Hodgkin lymphomas. Reliable antigenic phenotyping of FDC within tissue sections has been difficult due to simultaneous labeling of the surrounding germinal center cells. Using an enzyme cocktail to digest human tonsils and cervical lymph nodes with subsequent fractionation by albumin gradient centrifugation, cell isolates containing up to 20% FDC were obtained. This preparation allowed the determination of antigenic phenotype on individual FDC. Molecules expressed by FDC were detected by an isotype-specific immunocytochemical double-labeling procedure, i.e. a monoclonal antibody (mAb) specific for FDC (KiM4 or DRC1) in conjunction with a mAb reactive against an additional antigenic determinant. Nonspecific binding of mAb to immunoglobulin Fc receptors located on FDC membranes was avoided by incubation of cells with human IgG aggregates prior to immunostaining. The results revealed that isolated FDC from these lymphoid tissues express transferrin receptors, the intercellular adhesion molecule 1, class II antigens, the B cell antigens CD20 and CD21, and the myelomonocytic properties CD11b and CD14. Immunoglobulin mu or gamma heavy chains and the B cell antigens CD23 and CD24 are detected on 50% of an isolated FDC population. These FDC are negative for the T helper cell antigen CD4, the B cell cell antigens CD19 and CD22, the immunolobulin alpha and delta chains and the S-100 protein. FDC isolated from lymph nodes of patients with low-grade malignant non-Hodgkin lymphoma, identified by DRC1 or KiM4 mAb, presented the same antigenic profile as seen on FDC from nonmalignant tissue. This suggests that FDC from lymphoma tissue isolated in this manner have the same properties as those found in normal tissue.