Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study.

INTRODUCTION: France is facing a shortage of available physicians due to a greying population and the lack of a proportional increase in the formation of doctors. Emergency physicians are the medical system's first line of defence. METHODS: The authors prepared a comprehensive questionnaire using established scales measuring various aspects of working conditions, satisfaction and health of salaried physicians and pharmacists. It was made available online, and the two major associations of emergency physicians promoted its use. 3196 physicians filled out the questionnaire. Among them were 538 emergency physicians. To avoid bias, 1924 physicians were randomly selected from the total database to match the demographic characteristics of France's physician population: 42.5% women, 57.5% men, 8.2% < 35 years old, 33.8% 35-44 years old, 34.5% 45-54 years old and 23.6% ≥ 55 years old. The distribution of physicians in the 23 administrative regions and by speciality was also precisely taken into account. This representative sample was used to compare subgroups of physicians by speciality. RESULTS: The outcomes indicate that the intent to leave the profession (ITL) was quite prevalent across French physicians and even more so among emergency physicians (17.4% and 21.4% respectively), and burnout was highly prevalent (42.4% and 51.5%, respectively). Among the representative sample and among emergency physicians, work-family conflict (OR=4.47 and OR=6.14, respectively) and quality of teamwork (OR=2.21 and OR=5.44, respectively) were associated with burnout in a multivariate analysis, and these risk factors were more prevalent among emergency physicians than other types. A serious lack of quality of teamwork appears to be associated with a higher risk of ITL (OR=3.92 among the physicians in the representative sample and OR=4.35 among emergency physicians), and burnout doubled the risk of ITL in multivariate analysis. CONCLUSIONS: In order to prevent the premature departure of French doctors, it is important to improve work-family balance, working processes through collaboration, multidisciplinary teamwork and to develop team training approaches and ward design to facilitate teamwork.

Systems biology analysis of G protein and MAP kinase signaling in yeast.

Approximately a third of all drugs act by binding directly to cell surface receptors coupled to G proteins. Other drugs act indirectly on these same pathways, for example, by inhibiting neurotransmitter reuptake or by blocking the inactivation of intracellular second messengers. These drugs have revolutionized the treatment of human disease. However, the complexity of G protein signaling mechanisms has significantly hampered our ability to identify additional new drug targets. Moreover, today's molecular pharmacologists are accustomed to working on narrowly focused problems centered on a single protein or enzymatic process. Here we describe emerging efforts in yeast aimed at identifying proteins and processes that modulate the function of receptors, G proteins and MAP kinase effectors. The scope of these efforts is far more systematic, comprehensive and quantitative than anything attempted previously, and includes integrated approaches in genetics, proteomics and computational biology.

[Factors linked to premature leaving of the nursing profession. Confirmation of the impact one year later. Longitudinal analyses of nurses. PRESST/NEXT study]. / Les facteurs liés à l'abandon prématuré de la profession soignante. Confirmation de leur impact à un an d'intervalle. Analyse longitudinale des soignants de l'enquête. PRESST/NEXT

BACKGROUND: The organization of French medical institutions is changing, and the nursing personnel can encounter difficulties of adaption to these changes. The results of 2 questionnaires of the PRESST/NEXT study relative to working conditions (respectively, the questionnaires "Q0" and "Q12"), sent in a year interval to a sample of nurses were compared. METHODS: Three samples were made up: a sample of 5376 nurses having answered the initial questionnaire (Q0); a sample of 2627 nurses having answered the questionnaire sent one year after (Q12), and working in the same establishment; a group of 208 nurses having answered the questionnaire "Qex", specific to nurses who left their establishment. RESULTS: Among nurses who answered the "Qex", approximately 1/5 of nurses chose to leave the profession definitively or temporarily before the retirement age; of these, almost 13% began a new work not in the healthcare sector. Seven factors are significantly related to the intention of leaving the profession: Dissatisfaction regarding professional prospects (Q0: OR = 3.1 and Q12: OR = 2.82); Difficulties assuming the family responsabilities (Q0: OR = 1.36 and Q12: OR = 2.10); Mental health disorders for nurses not followed medically (Q0: OR = 1.76 and Q12: OR = 1.47), and for nurses receiving care for this (Q0 : OR = 1.90 and Q12: OR = 1.77); Dissatisfaction concerning the psychological support available at work (Q0: OR = 1.57 and Q12: OR = 1.87); Tiredness (Q0 : OR = 1.40 and Q12: OR = 1.6); Musculo-skeletal disorders diagnosed by doctor (Q0: OR = 1.32 and Q12: OR = 1.61); Dissatisfaction concerning the use of competences (Q0: OR = 1.27 and Q12: OR = 1.97). CONCLUSION: These results raise questions as to the benefits of new management which promotes flexibility in work and schedules, and which reduces the possibilities of support within the nursing teams. This type of management implies uncertainty for nurses as far as the technical aspects of their work are concerned, and a lack of time for the education and follow-up of patients.

Protein-calorie deficits in developing countries.

Twenty years ago, we were invited to present a paper on severe protein-malnutrition in children in a meeting organized by this same Academy. In reviewing that paper for this presentation, it was very frustrating to find that the basic principles we stated there in regard to the nature of the probelm and its epidemiology are as valid today as they were 20 years ago. As most other workers in the field, we were then particularly concerned with the severe forms of protein-calorie malnutrition (PCM): kwashiorkor and marasmus. These individual cases occupied a large proportion of pediatric beds in hospitals of most developing countries, and we were interested in finding better ways to treat them. But also we were studying these cases as a basis for understanding the responsible factors better and for designing possible preventive measures. The interrelations of kwashiorkor and marasmus were recognized then, as well the fact that both protein and calories should be considered together in the epidemiology of the problem. We were also beginning to understand that the severe clinical cases that we were seeing in the hospitals were only the visible part of a much greater problem affecting the communities from which these children came. With the knowledge then available on the epidemiology of PCM, we were also starting to explore some specific measures for its prevention. I would like now to review what progress we have made, if any, in the understanding of the nature and magnitude of the problem, its epidemiology, and in designing preventive measures.

Acetic acid visualization of the cervix to detect cervical dysplasia.

OBJECTIVE: To determine whether acetic acid visualization of the cervix can identify cervical dysplasia and improve detection of lesions missed by Papanicolaou test screening. METHODS: During a 2-year period, patients attending family planning clinics for regular gynecologic examinations had acetic acid applied to the cervix, followed by gross visualization without magnification. Patients with suspicious acetowhite lesions and normal Papanicolaou tests were referred for colposcopic evaluation. Findings from these examinations and corresponding biopsy results were analyzed retrospectively. RESULTS: Eighty-five women were referred for colposcopy because of abnormal acetowhite areas on the cervix. Thirteen patients (15%) had cervical intraepithelial neoplasia (CIN) (nine CIN I, four CIN II), 22 (26%) had koilocytosis, and 16 (19%) had benign histologic findings. In total, 51 patients had suspicious lesions at colposcopy for which biopsies were performed, and 34 (40%) had normal colposcopic examinations. CONCLUSIONS: Acetic acid visualization of the cervix can detect dysplasia otherwise missed by Papanicolaou test screening. However, further refinements in technique are required to decrease false-positive findings and unnecessary referrals for colposcopy.

Bradykinin, plasma protein fraction, and hypotension.

A directive from the Food and Drug Administration indicates that the use of plasma protein fraction (PPF) is contraindicated during cardiopulmonary bypass because of possible hypotension. Bradykinin has been implicated as the cause of this hypotension. Bradykinin levels were measured by radioimmunoassay in PPF and in 5% albumin and were found to be consistently elevated in the former and occasionally in the latter. The addition of PPF to pump primes resulted in significantly elevated levels of bradykinin, which rapidly cleared, indicating that extrapulmonary sites of bradykinin inactivation were efficient. The potential hypotensive effect of PPF was observed by determining the change in mean perfusion pressure in two groups of patients: one group with a 3,000 ml crystalloid prime and the other with a prime of 2,000 ml of crystalloid and 1,000 ml of PPF. There was no significant difference in the perfusion pressure between the two groups at any point, and the hypotensive effects seen in both groups were readily treated, suggesting that the directive against the use of PPF during cardiopulmonary bypass may be unnecessarily restrictive.

Pregnancy and its outcome among hospital personnel according to occupation and working conditions.

Relationships between occupation, working conditions, and the development and outcome of pregnancy were analysed on a sample of women employed in hospital during their pregnancy. Ancillary staff members experienced more uterine contractions during pregnancy, more preterm deliveries, and more low birthweight infants than those performing other duties; this remained true after adjusting for social characteristics. The rate of preterm delivery was significantly higher in the presence of at least two of the following arduous working conditions: stand-up work, carrying heavy loads (exclusive of patients), and heavy cleaning tasks; this was so, whatever the occupation.

Biopsy proven evolution of post streptococcal glomerulonephritis to rapidly progressive glomerulonephritis of a post infectious type.

A 15 year old boy with chronic impetigo was admitted with severe acute oliguric renal failure requiring temporary dialytic treatment. Renal biopsy revealed typical diffuse and proliferative glomerulonephritis of the poststreptococcal type. Subsequently high temperature developed with flank pains at the biopsy site, concomitantly with deterioration of renal function. On exploration, a sterile perirenal hematoma was found and a wedge renal biopsy revealed crescentic rapidly progressive glomerulonephritis of the post infectious type. Deterioration to end stage renal failure occurred within a few months. Although universally accepted, biopsy proven evolution from diffuse proliferative and exudative glomerulonephritis to crescentic form of post streptococcal glomerulonephritis has been rarely reported.

High blood pressure during pregnancy and working conditions among hospital personnel.

The relationship between working conditions and high blood pressure during pregnancy was analysed in a sample of 621 women hospital employees in the Paris region over the period 1979-1981. Data were collected by interviews during the routine medical visit at the end of postnatal leave. Women who had to work standing up for extended periods of time, who had to carry heavy loads or who had to perform heavy cleaning tasks had high blood pressure during their pregnancy more often than women not exposed to these working conditions. The accumulation of two out of the three or these three working conditions by the same woman was strongly related to high blood pressure. This relation remained significant when other risk factors of hypertension, such as age, parity, corpulence and tobacco use, were taken into account in a multiple logistic regression.

Airway obstruction in neonates and children: surgical treatment.

OBJECTIVE: This review of 54 infants and children with airway obstruction who were treated surgically emphasizes the importance of the surgical indications with respect to various anomalies causing airway obstruction and the surgical approach to their management. PATIENTS: There were 4 etiologic groups of airway obstruction. Group A comprised 12 infants with subglottic stenosis; Group B--20 infants with tracheomalacia; 21 patients (Group C) with anatomic narrowing of the trachea; and 1 infant (Group D) with laceration of a main bronchus. METHODS: The surgical procedures performed included anterior laryngotracheal decompression in 12 infants, aortopexy in 19; 1 pulmonary arteriopexy; tracheal stenting with an autologous rib graft in 3 and with Marlex mesh in 1. Tracheal widening, using a free tibia autologous graft, was performed in 3 patients; transbronchoscopic excision in 12; anterior tracheal wedge resection in 4, and segmental tracheal resection and anastomosis in 1 patient. The lacerated bronchus was repaired with fine Dexon sutures. RESULTS: There were no operative deaths. With respect to the original indications for surgery, there were 3 failures--2 in Group A and 1 in Group C. Two patients died from causes unrelated to the procedures--one 10 days postoperatively, and the other 3 months after surgery. CONCLUSIONS: The surgical approach to tracheal obstruction in infants and children offers effective treatment, with no operative mortality, a low complication rate, and good long term survival.

Nutrition and the future of mankind.

Malnutrition is primarily due to poverty, a manifestation of social injustice with inadequate distribution of resources and services within and between countries. By limiting the capability of poor people to improve their economical and social status, malnutrition helps to perpetuate this situation. A change in developmental policies taking more into account the improvement of living conditions of the poor is needed to correct this social problem.

[Epidemiology of cardiovascular risk factors in 1505 females working in hospitals]. / Epidémiologie des facteurs de risque cardiovasculaire chez 1505 femmes travaillant en milieu hospitalier.

One thousand and five women working in 26 wards of Paris hospitals were included in the study during their mandatory annual examination. The prevalence of arterial hypertension, calculated on this casual measurement (two readings) was 15.1 per cent; 6 per cent of the women were under medication for high blood pressure. In one fifth of the treated hypertensive women the blood pressure levels were not controlled by treatment. Two-thirds of the hypertensive women were untreated. Concerning the working conditions, psychic stress was associated with high blood pressure in women aged 30 to 39. The percentage of smokers was high (45 per cent below 30 years of age, 27 per cent between 30 and 40). The weight of 15 per cent of the women was at least 20 per cent over the "ideal" weight. The prevalence of cardiovascular risk factors is high among these female hospital workers. Prevention therefore must be developed in order to improve their health and to give the patients an opportunity to benefit from advice in this field during their stay in hospital.

Pre-employment screening among health care workers--ethical issues.

Occupational health practitioners deal with the questions of confidentiality, relation between the right to work and the right to health, between individual freedom and the risks other can run. An audit of pre-employment health assessment of health care workers, in the United Kingdom and in France, discussed the efficiency of pre-employment screening. Screening tests and medical examinations should not be used as a pretext to avoid implementing effective preventive measures. The pre-employment examination has mostly to be used for education of the future employees and for collection of baseline data. Appropriate procedures such as developing preventive policies, health promotion, and control of hazards in the work environment are efficient for the promotion of equal employment rights for women, older workers, or people with disabilities.

[Occupational health and ergonomics. IV. Case of hospital professionals]. / Ergonomia y salud en el trabajo (y IV). El caso de las profesionales hospitalarias.

The last of a series presented by Dr. Estryn Behar which analyzes the influences architecture and working conditions may have on the health and quality of life of health care professionals. Concepts such as ergonomics, flexibility, architectural participation, etc., are shown to be essential to achieve a better environment for these workers.

[Working conditions of operating room personnel. Different symptoms observed and pregnancy outcome]. / Conditions de travail des personnels des blocs opératoires. Symptômes divers observés et issue des grossesses.

Neuropsychological symptoms and tiredness were reported more frequently by workers in less often scavenged theatres than by controls. The rate of spontaneous abortions was higher among pregnancies for which women were working in operating theatres.

[Burnout in French doctors: a comparative study among anaesthesiologists and other specialists in French hospitals (SESMAT study)]. / Enquête comparative sur le syndrome d'épuisement professionnel chez les anesthésistes réanimateurs et les autres praticiens des hôpitaux publics en France (enquête SESMAT).

OBJECTIVE: Burnout is one of the main chronic health problems with negative consequences on health care givers but also on quality of care. The main goal of Physician Health Survey was to study the frequency of burnout among salaried physicians and pharmacists and to compare anesthesiologists and intensivists (AI) with other practitioners (OP). The secondary end points were to analyze risk factors of burnout in each group. MATERIAL AND METHODS: An anonymous, self-administered questionnaire was diffused via a specific website. Burnout was measured using the Copenhagen Burnout Inventory (CBI). Several different factors were examined: work/family conflict, salary satisfaction, quality of teamwork, interpersonal relationships, workplace influence, workload and perceived health. The role of each factor was calculated by multivariate logistic regression and comparisons were made between AI and OP. RESULTS: Among the 3196 responses, CBI revealed an elevated score of burnout in 38.4% in AI and in 42.4% in OP. In each group, a great gap was displayed between the CBI results and the self-assessment of burnout (15%). Among AI, risk factors of burnout were high quantitative demand (ORadj=3.40; CI(95) 1,34-8,63), Work/family conflict (ORadj=; 3.12 CI(95) 1.60-6.08), low quality of teamwork (ORadj=1.99; CI(95)1.14-3.47) and tense Relation within team (ORadj=1.92; CI(95) 1.25-2.95). All these factors are observed also among OP. Female gender, young age and dissatisfaction with pay have significant influence but different in the two groups. Claims of recurrent harassment by superiors is a risk factor for burnout only for the AP (adj.OR=1.83; CI(95) 1.04-3.22). DISCUSSION: Burnout affected near one about two salaried physicians and pharmacists in France. AI were not more concerned by burnout than OP but all of whom have difficulty identifying their own levels of psychological stress and burnout. Decreasing the level of different risk factors i.e. by improving the quality of teamwork should lead to reduce burnout frequency.

Work week duration, work-family balance and difficulties encountered by female and male physicians: results from the French SESMAT study.

OBJECTIVE: France encounters difficulties attracting physicians to work in hospitals. Organisation at work and at home may be at the heart of the problem for female as well as for male physicians. PARTICIPANTS: A comprehensive questionnaire was filled out online by a representative sample of 1924 French hospital physicians. METHODS: We conducted gender bivariate and multivariate analysis of the risk factors for burnout and intent to leave the profession(ITL). RESULTS: ITL was declared by 17.4% of physicians. According to 41.3% of female physicians (FP), their profession was an obstacle to having children (versus 19.3% for male physicians (MP)). Major factors linked with burnout were Effort/Reward imbalance (FP adjOR = 5.09, MP adjOR = 5.93), Work-family conflicts (FP adjOR = 2.97, MP adjOR = 3.04), and Low quality of teamwork (FP adjOR = 1.82, MP adjOR = 2.68). Major factors linked with ITL were Low quality of teamwork (FP adjOR = 4.49, MP adjOR = 3.03), Patient-related burnout (FP adjOR = 2.10, MP adjOR = 2.35) and General burnout (FP adjOR = 1.85, MP adjOR = 1.45). CONCLUSIONS: Excessive job demands are linked with burnout and with work-family conflicts, conducting to difficulties in organising one's life in order to have and raise children. Potential solutions include facilitating teamwork in order to reduce departure, which increase workload on those who stay increasing their work family conflict.

The impact of social support upon intention to leave among female nurses in Europe: secondary analysis of data from the NEXT survey.

OBJECTIVES: This study examined the importance of one's social work environment in the light of prevention of premature leave from the nursing profession. A research model with social support (from direct supervisor and close colleagues) as predictor and intention to leave as the dependent variable has been tested, while controlling for job satisfaction and age. Moreover, we have studied the impact of nurses' age upon the prevalence of social support from both parties. PARTICIPANTS: Data were obtained from 17,524 registered female nurses working in hospitals throughout Europe (Belgium, Germany, Finland, France, Italy, The Netherlands, Poland, and Slovakia). RESULTS: Our findings indicated that a lack of job satisfaction is an important risk factor in the light of nurses' turnover as for most countries the intention to leave cannot be buffered by social support from one's close colleagues. However, in general, social support from one's direct superior appeared to contribute negatively to the intention to leave the profession, over and above job satisfaction and age. As regards age effects, in line with our expectation, we have found a significant negative relationship between age and social support from close colleagues, while the hypothesis regarding the relationship between age and supervisory support could not be confirmed. CONCLUSIONS: Given its importance in the light of preventing premature leave, we advocate not to neglect the possible positive effects of social support from important key figures like nurses' direct supervisor and close colleagues. It is necessary for health care institutions to carefully pay attention to finding opportunities to obtain more social support for all staff members. In Section 5, limitations and practical implications of this study are dealt with.