Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages.

BACKGROUND: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Safety and outcome of patients with an acute ST-elevation myocardial infarction transferred for primary coronary intervention: the Neuchâtel experience.

BACKGROUND: Transferring patients with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) from a community hospital to a PCI centre has been evaluated in randomised trials and shown to be safe and effective. A prolonged transfer time may restrict the benefit of this strategy. AIM: We sought to assess 1) safety of transfer from Neuchâtel to Berne, 2) time intervals of patients transferred either directly from on-site or after evaluation in the local emergency room, and 3) clinical long-term outcome. METHODS AND RESULTS: 42 patients with STEMI eligible for reperfusion therapy were prospectively included between January 2003 and June 2004. Twenty patients (48%, group 1) were directly transferred to the PCI centre from on-site. Twenty-two were transferred after initial treatment in the local emergency room: 11 patients (26%, group 2) presented spontaneously at the hospital and 11 patients (26%, group 3) were admitted by the rescue team. No major complication occurred during transport. Median transport time was 33 minutes. Median time from first healthcare contact to balloon consisted of 131 minutes in group 1, 158 minutes in group 2 and 174 minutes in group 3. The overall rate of Major Adverse Cardiac Events (MACE) at 6 months amounted to 9.5%. CONCLUSIONS: Transfer for primary PCI of our patients with acute STEMI was safe. Direct transfer from on-site to the PCI centre reduced the time of ischaemia. The overall MACE rate was low.

[Rational utilization of antibiotics in critically ill children]. / Rationaler Einsatz von Antibiotika beim kritisch kranken Kind.

BACKGROUND: The high risks associated with untreated infection in critically ill newborns or children lower the threshold for prescription of antibiotic treatment. Inappropriate use of antibiotic therapy promotes the emergence of resistant strains. This study had three aims: to identify sources of inappropriate antibiotic utilisation, to develop revised guidelines and to implement changes. METHODS: An observational study was performed in a tertiary, multidisciplinary, neonatal and paediatric intensive care unit (PICU) of a university teaching hospital during a 7-month period (456 admissions). Guidelines addressing one of the identified sources of inappropriate utilisation (prophylaxis following surgery) were developed according to published evidence and implemented, and the effect on prescription patterns was assessed during a second observation period. RESULTS: Patients received systemic antibiotics during 54.6% of all hospitalisation days. Antibiotics prescribed for suspected or proven infection were often continued 1-2 days beyond the intended duration. Prophylaxis accounted for 28% of all systemic antibiotics given, and postsurgical prophylaxis accounted for 14.6% of all exposure days. The literature search revealed little evidence to support this practice. After new guidelines were introduced with the aim of restricting surgical prophylaxis to a single dose prior to surgery, the rate of postsurgical prophylaxis dropped from 14.6 to 11.2% of all exposure days, accompanied by a significant decline in the overall exposure rate from 54.6 to 50.2% of all hospitalisation days. CONCLUSION: Several sources of inappropriate antibiotic utilisation were identified. These include failure to discontinue treatment and prolonged prophylaxis after surgery. Implementation of new guidelines reduced antibiotic utilisation.

Use of antibiotics in pediatric intensive care and potential savings.

OBJECTIVE: Minimizing unwarranted prescription of antibiotics remains an important objective. Because of the heterogeneity between units regarding patient mix and other characteristics, site-specific targets for reduction must be identified. Here we present a model to address the issue by means of an observational cohort study. SETTING: A tertiary, multidisciplinary, neonatal, and pediatric intensive care unit of a university teaching hospital. PATIENTS: All newborns and children present in the unit (n = 456) between September 1998 and March 1999. Reasons for admission included postoperative care after cardiac surgery, major neonatal or pediatric surgery, severe trauma, and medical conditions requiring critical care. METHODS: Daily recording of antibiotics given and of indications for initiation. After discontinuation, each treatment episode was assessed as to the presence or absence of infection. RESULTS: Of the 456 patients 258 (56.6%) received systemic antibiotics, amounting to 1815 exposure days (54.6%) during 3322 hospitalization days. Of these, 512 (28%) were prescribed as prophylaxis and 1303 for suspected infection. Treatment for suspected ventilator-associated pneumonia accounted for 616 (47%) of 1303 treatment days and suspected sepsis for 255 days (20%). Patients were classified as having no infection or viral infection during 552 (40%) treatment days. The average weekly exposure rate in the unit varied considerably during the 29-week study period (range: 40-77/100 hospitalization days). Patient characteristics did not explain this variation. CONCLUSION: In this unit the largest reduction in antibiotic treatment would result from measures assisting suspected ventilator-associated pneumonia to be ruled out and from curtailing extended prophylaxis.

Inhibitors of sterol synthesis. Chemical synthesis and properties of 3 beta-hydroxy-25,26,26,26,27,27,27-heptafluoro-5 alpha-cholest-8(14)-en-15-one and 25,26,26,26,27,27,27-heptafluorocholesterol and their effects on 3-hydroxy-3-methylglutaryl coenzyme A reductase activity in cultured mammalian cells.

A side-chain fluorinated delta 8(14)-15-ketosterol has been synthesized from 3 beta-acetoxy-24-hydroxy-5 alpha-chol-8(14)-en-15-one (VII) as part of a program to prepare new analogs of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15-one (I), a potent regulator of cholesterol metabolism. 3 beta-Hydroxy-25,26,26,26,27,27,27-heptafluoro-5 alpha-cholest-8(14)-en-15-one (VIII) was prepared in five steps from VII in 38% overall yield. Dehydration of VII via the ortho-nitrophenylselenide to the 23-ene, followed by addition of (CF3)2CFI gave 3 beta-acetoxy-23R-iodo-25,26,26,26,27,27,27-heptafluoro-5 alpha-cholest-8(14)-en-15-one. Reductive deiodination with tributyltin hydride, followed by hydrolysis of the acetate gave VIII. 25,26,26,26,27,27,27-Heptafluorocholest-5-en-3 beta-ol (XXI) was prepared in eight steps in 31% overall yield from 3 alpha,6 alpha-diacetoxy-5 beta-cholanic acid (XIII). Compound XIII was reduced with borane-methyl sulfide to the corresponding 24-hydroxysteroid, which was converted to 3 alpha,6 alpha-diacetoxy-25,26,26,26,27,27,27-heptafluoro-5 beta-cholestane (XVIII) by reactions analogous to those developed for the preparation of VIII from VII. Conversion of XVIII via the 3 alpha,6 alpha-diol to the 3 alpha,6 alpha-ditosylate, followed by heating with potassium acetate in dimethylformamide and subsequent hydrolysis gave XXI. Full 1H and 13C NMR assignments are presented for VIII, XXI, and intermediates involved in their synthesis. 13C NMR assignments for 3 alpha,6 alpha-dihydroxy-5 beta-steroids have been corrected, and stereochemical assignments were established for the side-chain methylene protons of VIII, XXI, and most synthetic intermediates. Compound VIII lowered the levels of HMG-CoA reductase activity in CHO-K1 cells and in HepG2 cells with a potency comparable to that of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15-one (I). In contrast, 25,26,26,26,27,27,27-heptafluorocholest-5-en-3 beta-ol had little or no effect on reductase activity in CHO-K1 cells. These combined results indicate that metabolism of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15-one (I) to 26- and 25-oxygenated species is not required for the suppressive action of I on the levels of HMG-CoA reductase activity in CHO-K1 cells and HepG2 cells.

Induction of VCAM-1 and ICAM-1 on human neural cells and mechanisms of mononuclear leukocyte adherence.

We propose that leukocyte-derived cytokines induce the expression of adhesion molecules on the surface of neural cells that facilitates the subsequent attachment of leukocytes. Leukocyte adherence may contribute to some of the neural cell injury seen with various inflammatory diseases of the nervous system. With an in vitro model system, we have shown that mononuclear leukocytes bind to human neuroblastoma and cortical neuron cells only after the neural cells are stimulated with TNF-alpha. TNF-alpha stimulates expression of vascular cell adhesion molecule-1 (VCAM-1) in both of these neural cell lines. VCAM-1 mRNA is increased and VCAM-1 protein can be identified on the neural cell membranes with a new VCAM-1-specific mAb, CL40/2 F8. TNF-alpha also induces ICAM-1 in both of these neural cell lines. Leukocyte beta 1 (CD29) and beta 2 (CD18) integrins and their respective ligands, ICAM-1 and VCAM-1, on neural cells appear to be the dominant ligands mediating MNL:neural cell adhesive interactions. mAb to CD18 block 32 to 57% of the MNL binding to neural cells; similar inhibition is seen with mAb to ICAM-1. mAb to CD29 block 16 to 17% of the MNL binding to the neural cells suggesting that leukocyte beta 1 integrins and neural VCAM-1 may be a second route for MNL:neural cell interactions. Addition of both anti-CD18 and anti-CD29 mAb have an additive blocking effect; both ligand pairs may participate in MNL adhesion to neural cells, reminiscent of the multiplicity of ligands used by MNL when binding to endothelium.