A Burnout Reduction and Wellness Strategy: Personal Financial Health for the Medical Trainee and Early Career Radiation Oncologist

PurposePhysician burnout is reported in more than one out of every 2 practicing clinicians and is just as prevalent in training physicians. Burnout severity is also associated with increasing levels of financial debt. Medical professionals are notable for their high and increasing levels of debt; despite this, financial literacy is poor among physicians, and financial education is largely absent from medical education. Radiation oncologists (ROs) are no different in this regard, with 33% of residents reporting high levels of burnout symptoms, 33% carrying >$200,000 of educational debt, and 75% reporting being unprepared to handle future financial decisions. To fill this gap, we reviewed the basic tenets of personal financial health for the early career RO.Methods and materialsThe core concept of financial independence (FI) is introduced, and we review 4 basic tenets of personal financial health for the young medical professional: debt, behavior, investment, and asset protection strategies.ResultsFI is achieved by saving until the desired quality of life can be maintained, independent of employment income. Debt strategy involves minimizing debt accrual, understanding student loans, and having a debt management plan. Behavioral strategy involves setting financial goals, calculating worth and a savings rate, budgeting, and frugal living. The basics of investing include asset allocation, diversification, rebalancing, and minimizing expenses. Finally, asset protection includes insuring against catastrophic events with disability, life, health, liability, and property insurance.ConclusionsHealthy financial practices can lead to FI and may facilitate professional and personal freedoms with the goal of mitigating burnout-associated stressors. The tenets of strong financial health for ROs in the early stages of their career include sound debt, behavioral, investment, and asset protection strategies. Furthermore, initial and continuing financial education is an overlooked but important curriculum component. ROs with their financial houses in order can devote more resources to learning and practicing good medicine while living healthy, rewarding lives.     

恢复体验类型在调节紧张相关健康状况的作用分析

目的评价不同恢复体验类型(RE)的护士群体职业紧张、身心健康、职业生命质量的差异,分析评价恢复体验类型在调节紧张相关健康状况的作用。方法对某市7家三甲医院298名在岗护士,以单纯随机抽样的方法抽取研究样本,采用工作内容问卷(JCQ)测量职业紧张、中文版恢复体验问卷(REQ-C)测量恢复体验水平、聚类分析方法区分恢复体验类型、职业生命质量问卷(QWL7-32)测量紧张相关健康状态。结果聚类分析将298名护士分为充分型、中间型和缺乏型三种RE类型;三种类型的护士心理健康和职业生命质量得分存在差异(P0.01)。不同RE类型的对象,其心理健康与职业生命质量水平随紧张水平变化的趋势不同;因变量为心理健康得分的多元线性回归分析中,结果显示相对于缺乏型来说,充分型的β值为-2.48(P0.05),RE类型为心理健康的独立影响因素。结论不同恢复体验类型对心理健康、职业生命质量的调节作用存在差异。     

Functional interaction–based nonlinear models with application to multiplatform genomics data

Functional regression allows for a scalar response to be dependent on a functional predictor; however, not much work has been done when a scalar exposure that interacts with the functional covariate is introduced. In this paper, we present 2 functional regression models that account for this interaction and propose 2 novel estimation procedures for the parameters in these models. These estimation methods allow for a noisy and/or sparsely observed functional covariate and are easily extended to generalized exponential family responses. We compute standard errors of our estimators, which allows for further statistical inference and hypothesis testing. We compare the performance of the proposed estimators to each other and to one found in the literature via simulation and demonstrate our methods using a real data example.     

Oral fungal and bacterial infections in HIV-infected individuals: an overview in Africa

Oral opportunistic infections developing secondary to human immunodeficiency virus (HIV) infection have been reported from the early days of the epidemic and have been classified by both the EC-Clearinghouse and the World Health Organisation (WHO). Among the fungal infections, oral candidiasis, presenting in African HIV-infected patients has been sporadically documented. We review the literature with respect to candidal carriage, oral candidiasis prevalence and the predictive value of oral candidiasis for a diagnosis of underlying HIV disease in African HIV-infected patients. The use of oral candidiasis as a marker of disease progression, the species of yeasts isolated from the oral cavity in Africa and the resistance of the yeasts to antifungal agents and treatment regimens are discussed. Orofacial lesions as manifestations of the systemic mycoses are rarely seen in isolation and few cases are reported in the literature from Africa. In spite of the high incidence of noma, tuberculosis, chronic osteomyelitis and syphilis in Africa, surprisingly there have been very few reported cases of the oral manifestations of these diseases in HIV-positive individuals. Orofacial disease in HIV-infected patients is associated with marked morbidity, which is compounded by malnutrition. The authors indicate specific research areas, initially directed at the most effective management strategies, which would complete data in this important area.     

Public clonotype usage identifies protective Gag-specific CD8+ T cell responses in SIV infection

Despite the pressing need for an AIDS vaccine, the determinants of protective immunity to HIV remain concealed within the complexity of adaptive immune responses. We dissected immunodominant virus-specific CD8⁺ T cell populations in Mamu-A*01⁺ rhesus macaques with primary SIV infection to elucidate the hallmarks of effective immunity at the level of individual constituent clonotypes, which were identified according to the expression of distinct T cell receptors (TCRs). The number of public clonotypes, defined as those that expressed identical TCR β-chain amino acid sequences and recurred in multiple individuals, contained within the acute phase CD8⁺ T cell population specific for the biologically constrained Gag CM9 (CTPYDINQM; residues 181–189) epitope correlated negatively with the virus load set point. This independent molecular signature of protection was confirmed in a prospective vaccine trial, in which clonotype engagement was governed by the nature of the antigen rather than the context of exposure and public clonotype usage was associated with enhanced recognition of epitope variants. Thus, the pattern of antigen-specific clonotype recruitment within a protective CD8⁺ T cell population is a prognostic indicator of vaccine efficacy and biological outcome in an AIDS virus infection.The global HIV pandemic demands an effective vaccine. However, while immunogenic vectors enter advanced clinical trials, the parameters on which to base measurements of efficacious immunity in a prospective manner remain unclear. Indeed, the recent Merck STEP trial failure has exposed our rudimentary understanding of protective determinants within the adaptive T cell response to HIV (1–3). It is established that specific CD8⁺ T cell immunity suppresses HIV replication in vivo and that certain patterns with respect to antigen targeting and MHC class I restriction are consistently associated with low levels of virus load (4–6). However, simple quantitative correlates, at least in peripheral blood, have proved elusive (7, 8). This paradox is exemplified by the SIV model, in which CD8⁺ T cell responses to the structurally constrained Gag CM9 epitope restricted by Mamu-A*01 are protective yet insufficient in terms of magnitude alone to define outcome (9, 10).In the absence of consistent numerical correlates of immune control, recent observational studies have focused on functional profiling in attempts to identify the properties that demarcate effective HIV-specific CD8⁺ T cell responses (11–15). Indeed, a broad consensus indicates that polyfunctionality within pathogen-specific T cell populations, which is related to the sensitivity of antigen recognition among other parameters, correlates with improved outcome measures (3, 16). However, the qualitative properties of CD8⁺ T cell populations are clearly affected by viral replication, and the extent to which such functional associates reflect deterministic attributes remains uncertain. Similarly, phenotypic analyses of HIV-specific CD8⁺ T cell populations have yet to provide definitive indicators of immune control (3). At a more fundamental level, a given cognate T cell response is defined by the nature of its constituent clonotypes, which are defined on the basis of their expressed TCRs and can be considered the elemental units of any antigen-specific T cell population. Thus, the primary interface between the virus and adaptive T cell immunity occurs at the level of TCR-mediated recognition of peptide-MHC antigen; these signal transduction events, in turn, dictate the ontogeny and biological characteristics of individual cognate T cells in vivo. Given the seminal importance of clonotype-dependent TCR-mediated recognition events, it is not unreasonable to propose that the potential efficacy of a composite virus-specific CD8⁺ T cell population might depend on the idiosyncrasies with which individual cognate TCRs engage the targeted viral antigen.In a previous study, we examined the clonotypic composition of immunodominant CD8⁺ T cell populations in acute SIV infection to illuminate the role of TCR usage in the process of mutational immune escape (17). In the present study, we conducted a detailed prospective study of vaccine-induced SIV-specific CD8⁺ T cell responses to the same immunodominant epitopes to establish whether the mobilized antigen-specific TCR repertoire can influence virologic outcome.     

术前血糖水平对糖尿病患者行输尿管软镜碎石术后发生感染相关并发症的影响

观察2型糖尿病（T2DM）患者行输尿管软镜碎石术（FURL）后出现感染相关并发症的影响因素,探讨T2DM患者术前血糖水平与发生术后感染相关并发症的关系,为T2DM患者在接受FULR术后发生感染相关并发症的早期预防及治疗提供参考。     

Tadalafil therapy and severe chronic foot wound resolution

We report an unanticipated medication effect resulting in near‐complete wound healing in a patient after beginning tadalafil therapy of 20 mg thrice daily. This patient was treated for 50 years with state‐of‐the art acute and then chronic wound interventions after a traumatic farm machinery accident which resulted in a devascularised foot wound. This infection was both life‐ and limb‐threatening. The patient had undergone multiple vascular and plastic surgeries and antimicrobial therapies in addition to hospitalisations for sepsis. Limb amputation was being considered, when his urologist placed him on daily phosphodiesterase‐5 inhibitor therapy, prior to unrelated urologic surgery. Remarkably, his foot wound underwent near‐complete resolution and has been stable for 2 years.     

The locomotor system of the ocean sunfish Mola mola (L.): role of gelatinous exoskeleton,horizontal septum,muscles and tendons

Adult ocean sunfish are the heaviest living teleosts. They have no axial musculature or caudal fin. Propulsion is by unpaired dorsal and anal fins; a pseudocaudal fin (‘clavus’) acts as a rudder. Despite common perception, young sunfish are active predators that swim quickly, beating their vertical fins in unison to generate lift‐based propulsion and attain cruising speeds similar to salmon and marlin. Here we show that the thick subcutaneous layer (or ‘capsule’), already known to provide positive buoyancy, is also crucial to locomotion. It provides two compartments, one for dorsal fin musculature and one for anal fin muscles, separated by a thick, fibrous, elastic horizontal septum that is bound to the capsule itself, the roof of the skull and the dorsal surface of the short vertebral column. The compartments are braced sagittally by bony haemal and neural spines. Both fins are powered by white muscles distributed laterally and red muscles located medially. The anal fin muscles are mostly aligned dorso‐ventrally and have origins on the septum and haemal spines. Dorsal fin muscles vary in orientation; many have origins on the capsule above the skull and run near‐horizontally and some bipennate muscles have origins on both capsule and septum. Such bipennate muscle arrangements have not been described previously in fishes. Fin muscles have hinged tendons that pass through capsular channels and radial cartilages to insertions on fin rays. The capsule is gelatinous (89.8% water) with a collagen and elastin meshwork. Greasy in texture, calculations indicate capsular buoyancy is partly provided by lipid. Capsule, septum and tendons provide elastic structures likely to enhance muscle action and support fast cruising.