Resident work hours and working environment in otolaryngology. Analysis of daily activity and resident perception

OBJECTIVE.--To analyze the working environment and work hours of a cohort of otolaryngology--head and neck surgery residents. DESIGN.--Environmental analysis questionnaire and a log of daily activities. SETTING.--Residents were on a clinical rotation system. PARTICIPANTS.--Fifty-nine residents from six programs, including three public and three private institutions, from geographically diverse regions of the country were involved in the study. Residents were equally distributed from their second year through their fifth year of postgraduate work. All eligible residents participated in and completed the study. INTERVENTION.--The environmental analysis survey was designed to elicit resident perception of different aspects of their working environment. The daily activity log required the resident to report on activities for each half-hour period for 7 consecutive days. RESULTS.--Residents were on call an average of 52.8 hours (2.2 days) and worked 79.4 hours per week. Seventy-five percent believed that the level of faculty supervision and the degree of resident responsibility was about right. Two major inefficiencies were the time involved in completion of paperwork and the lack of nonmedical support services. Thirty-one percent of the residents responded that fatigue resulted in substandard patient care 10% of the time. Forty-seven percent responded that their educational experience was substandard 25% of the time secondary to fatigue. Two thirds responded that the demands of residency training had a negative impact on their family and personal life. CONCLUSIONS.--Seventy percent of the otolaryngology--head and neck surgery residents surveyed at six institutions believe that an 80-hour workweek, including being on call every third night with no more than 24 hours of continuous work without sleep, approximates a reasonable, maximum work schedule. Residents working the longest hours expressed concern about rendering substandard care and developing negative attitudes toward patients. Noneducational inefficiencies were identified and solutions were proposed. Demands of residency training, even within guidelines established as reasonable, can have detrimental effects on residents' educational activities and personal life.     

Effects of changing work patterns on general surgical training over the last decade

BACKGROUND There is concern across all medical specialties that shift patterns and reduced working hours are detrimental to training, and that craft specialties have been most affected. This study aimed to examine the effects of these changes to training on the quantity of operating performed by surgical trainees in a UK teaching hospital. METHODS This retrospective study of prospectively collected computerised theatre data examined elective and emergency general surgical operations performed over four time periods: 1996 (Calman), 2001 (New Deal), 2004 and 2009 (European Working Time Directive). Procedures were analysed according to grade of surgeon and time of day. RESULTS In 1996, most appendicectomies (72.2%) were performed by senior house officers (SHOs), compared with 3.8% in 2009. By 2009, SHOs did not perform any emergency procedures other than abscess drainage and appendicectomy. The proportion of emergency operating performed by specialist registrar (SpRs) has remained constant, but elective operating has reduced from 34.6% (1996) to 15.7% (2009). Supervision of both SHOs and SpRs has increased between 1996 and 2009 in both elective and emergency work. CONCLUSIONS The proportion of operating performed by SpRs and SHOs has fallen over the last decade, coinciding with implementation of structural changes to training, the advent of minimally invasive techniques, and the drive for a consultant led health service. Trainees may therefore require increased supervision as well as protected theatre sessions to balance operative training with ward based duties. Education must be integrated into working practice in order for trainees to achieve expected competencies and ultimately produce adequately experienced consultants.     

脑微透析探针导管埋置手术对大鼠海马葡萄糖、乳酸含量的影响

目的:明确脑微透析的探针导管埋置手术对大鼠海马葡萄糖、乳酸含量的影响,探讨合适的术后恢复期。方法:使用微透析系统分别于探针导管埋置手术后1~7 d进行连续5 h的微透析取样,分析检测大鼠海马葡萄糖、乳酸含量。结果:术后大鼠海马葡萄糖、乳酸含量显著升高,1~7 d呈线性下降趋势,术后第4 d出现统计学差异(P0.05)。结论:脑微透析探针导管埋置手术对大鼠海马葡萄糖、乳酸含量具有影响,术后至少选择3 d进行恢复。     

European Working Time Directive and the use of simulators and models in Irish orthopaedics

Objective

To report on the perceptions of a group of orthopaedic trainees and trainers on perceived effects of the proposed introduction of European Working Time Directive (EWTD) restrictions into Ireland and on the use of simulators in training orthopaedic skills.

Methods

A structured questionnaire was developed to evaluate the opinions of a group of orthopaedic surgeons and trainees at the annual national orthopaedic conference.

Results

There were 44 participants [12 consultants, 32 trainees (15 specialist registrars, 8 registrars, 9 senior house officers)]. Seventy-five percent of participants felt that both the quality of patient care and training would be negatively affected. A higher proportion of consultants than trainees felt that quality of life would be affected. A high proportion of participants (81.8%) had used a simulator or model to learn a surgical skill and 100% would consider using them again.

Conclusions

While we wait for the full introduction of the EWTD hours the perception is that both quality of patient care and training will be affected. Models and simulators are well perceived as a method of training.     

A five-year review of publication productivity among Irish orthopaedic units

Background

The academic productivity of trainees, consultants and institutions is frequently judged by the quantity of articles published in peer-reviewed medical journals.

Aim

To assess the publication history of Irish orthopaedic units over a 5-year period, and to identify patterns of publication.

Methods

A PubMed search was performed of each consultant affiliated with each orthopaedic unit in the country for between 2004 and 2008. Publications were classified by individual, institution, publication type and impact factor.

Results

Over the 5 years of the study, 239 papers were published from 19 orthopaedic units, in 69 different journals. Fifty-six consultants had at least one senior author publication, with seven consultants having more than ten. Impact factors of the journals targeted varied considerably and reveals an interesting duality among authors when opting for profile or prestige.

Conclusion

We feel this study represents a comprehensive and novel review of the state of publishing in a surgical specialty.     

Evaluation of the efficacy and acceptability to patients of a physiotherapist working in a health centre

The records of the first 805 patients who had been referred by general practitioners at this health centre to the attached physiotherapist were examined in November 1985, three years after the physiotherapy department was opened. Seventy per cent (549) of the patients had been treated within one week, treatment having started on the same day for 8.5% (67) of the patients. This compares with a mean of six weeks for direct access to a district general hospital that is eight miles away and between six and 13 months for the three nearest orthopaedic consultants who are 13 miles away. The most common conditions treated were knee injuries (16.5%), followed by cervical (15.5%) and shoulder (13.8%) injuries. Surprisingly, only 9% were back injuries. The non-attendance rate was 2.2% and only 7% of patients failed to complete treatment. Nearly all the patients were able to attend the clinic, only 4% requiring home treatment. By March 1986, 90 treatments a week were being carried out at a cost of 6.11 pounds per patient. Compared with official hospital figures, this represents a savings of 21,500 pounds a year for a practice of 12,000 patients.     

外伤后肾梗塞皮质缘征的CT表现

目的 评价外伤后肾侧支循环代偿肾皮质缘征的CT表现、发生时间及短期的变化，探索CT检查明确诊断的最佳时间。方法 回顾性研究20例经增强CT扫描确诊的外伤后局灶性或全肾梗塞病例，评价梗塞的大小及肾皮质缘征出现的时间与行CT检查的时问的关系。结果 表现肾皮质缘征14例，其中8例多次行CT检查，最早出现时间是外伤后8h，平均出现时间7d；未表现肾皮质缘征的6例，CT检查均在外伤后10h内进行，平均时间4h。结论 肾脏外伤后侧支循环至少需要8h才能开放，并在CT扫描中显示出来，外伤后1W行CT检查肾皮质缘征显示的阳性率高。     

An observational study of emergency department intern activities

OBJECTIVES: To describe how intern time is spent, and the frequency of activities performed by interns during emergency department (ED) rotations. DESIGN AND SETTING: Prospective observational study of 42 ED interns from three Melbourne city teaching hospitals during 5 months in 2006. Direct observations were made by a single researcher for 390.8 hours, sampling all days of the week and all hours of the day. MAIN OUTCOME MEASURES: Proportion of time spent on tasks and number of procedures performed or observed by interns. RESULTS: Direct patient-related tasks accounted for 86.6% of total intern time, including 43.9% spent on liaising and documentation, 17.5% obtaining patient histories, 9.3% on physical examinations, 5.6% on procedures, 4.8% ordering or interpreting investigations, 3.0% on handover and 4.9% on other clinical activities. Intern time spent on non-clinical activities included 4.2% on breaks, 3.7% on downtime, 1.7% on education, and 1.3% on teaching others. Adjusted for an 8-week term, the ED intern would take 253 patient histories, consult more senior ED staff on 683 occasions, perform 237 intravenous cannulations/phlebotomies, 39 arterial punctures, 12 wound repairs and apply 16 plasters. They would perform chest compressions under supervision on seven occasions, observe defibrillation twice and intubation once, but may not see a thoracostomy. CONCLUSIONS: The ED exposes interns to a broad range of activities. With the anticipated increase in intern numbers, dilution of the emergency medicine experience may occur, and requirements for supervision may increase. Substitution of ED rotations may deprive interns of a valuable learning experience.     

AQ和CK评价静脉溶栓再灌注对急性心肌梗死患者左室早期重塑的影响

目的 :采用声学定量 ( acoustic quantification,AQ)和彩色室壁运动 ( color kinesis,CK)技术评价静脉溶栓再灌注对急性心肌梗死 ( AMI)患者左室早期重塑的影响。方法 :选择首次发病的Q波 AMI患者 ,将溶栓再通 1 3例作为研究组 ( 组 ) ,未溶栓治疗 1 5例作为对照组 ( 组 )。应用AQ和 CK技术分别在入院后 2 4 h内、1周和 4周时 ,对两组患者 AMI后左室容积和心功能的变化进行观察及对比研究。结果 :1不同时期溶栓再通组的 EDV、ESV明显小于未溶栓组 ;2入院后2 4 h内 ,两组患者的左室射血分数 ( EF)、峰值充盈率 ( PFR)及峰值排空率 ( PER)差异无显著性 ,而在 1周及 4周时溶栓再通组 EF、PFR和 EPR则明显高于入院后 2 4 h和对照组 ;3在入院后 2 4 h内 ,两组室壁运动指标比较差异无显著性 ,在第 1周和 4周时溶栓再通组室壁运动减弱和运动消失节段明显少于对照组。结论 :应用 AQ和 CK评价 AMI后左室功能和室壁运动的变化以及观察心肌缺血 -再灌注结果客观、准确 ,简便、省时、无创 ,患者易于接受。     

医院手术室利用效率的统计分析初探

目的：探讨手术科室和手术室的利用规律,为医院合理利用手术室资源提供依据。方法：从医院信息系统（HIS）中提取部分手术科室及部分手术室的相关信息,通过分类统计,分别得到反映手术科室工作量及手术室利用效率的统计指标。结果：外科楼手术间正常工作时段日均工作7．16小时,工作日超时工作时段日均工作0．65小时,节假日日均工作0．82小时。结论：外科楼手术间正常工作时段已经处于满负荷状态,尽管从改进麻醉和手术配合管理方面还可提高利用率,但很有限;节假日和工作日超时时间段内尚可利用,但涉及到手术医师、麻醉医师、手术室护士等资源的加强,同时需要有超额劳务补贴发放等方面的制度和政策保证。     

The Effect of the COVID-19 Pandemic on the Workload of an Adult Major Trauma Centre in Northern Ireland

Introduction:Based in Belfast, the Royal Victoria Hospital is the only Major Trauma Centre in Northern Ireland. Due to the COVID-19 pandemic, on 23rd March 2020, Northern Ireland was placed into ‘lockdown'' with the majority of the population advised to “stay at home”. The objective of this paper is to identify what effect the lockdown restrictions had on the workload of the Major Trauma Service at the Royal Victoria Hospital.Method:Patients were identified at the orthopaedic trauma meetings and from direct referral to the Major Trauma Service (MTS). Patients admitted and seen by the MTS from 23/03/20, the day lockdown was announced, to 29/05/20, when restrictions were partially lifted, were included in the analysis. Admissions data from this time period was then compared to admissions data from the same period in 2019 (23/03/19 - 29/05/19).Results:When comparing pre-lockdown and lockdown groups there was an overall decrease of 26% in admissions to the MTS (n=57 vs n=42). Road Traffic Accidents were reduced by 53% (n=31 vs n=15) and falls from >2m were reduced by 29% (n=21 vs n=15).Conclusion:Overall the number of admissions to the major trauma service was reduced during the lockdown period. A significant proportion of the reduction may be a result of social restrictions that reduced volume of traffic on Northern Irelands roads. Further study of future lockdowns and including admissions data of other MTCs in the UK would allow us to draw more robust conclusions.     

Out-of-hours work in cardiothoracic surgery: implications of the New Deal and Calman for training

With the introduction of the New Deal and the Calman Report, the duration of higher specialist training will be halved. We have examined the effect of reduced on-call rotas on exposure to relatively uncommon out-of-hours emergencies in cardiothoracic surgery. Operations for post-infarction ventricular septal defect, aortic dissection or transection, oesophageal perforation and pulmonary embolus performed out-of-hours between 1990 and 1995 were identified from hospital records. Over 6 years, the period of higher specialist training in cardiothoracic surgery, a trainee would see seven aortic emergencies on a 1:2 rota, four on a 1:4 rota and two on a 1:6 rota. These figures provide a powerful argument in support of the English Clause which allows trainees to be available for 83 hours a week, equivalent to a 1:4 rota, rather than 56 hours a week, equivalent to a 1:6 rota under the New Deal. This may need supplementation by a mechanism whereby trainees are `on call for training''.


     

陕西省关中地区公共场所从业人员健康行为影响因素分析

目的 分析陕西省关中地区不同公共场所内从业人员个人健康行为影响因素,为加强公共场所卫生监督管理工作以及公共场所从业人员聘用提供依据。方法 调查2020年陕西省关中地区公共场所从业人员1 479人次,采用二分类非条件Logistic回归模型分析影响因素,卡方检验分析率之间是否存在差异。结果 除工作时主动佩戴防护手套合格率较低（81.95%）外,其余健康行为合格率均在90%以上;经Logistic回归分析得出性别、文化程度和工作时长三项指标对从业人员个人健康行为有影响（P<0.05）,女性的个人健康行为合格情况高于男性（OR=1.881）,低文化程度的从业人员个人健康行为合格情况高于高文化程度（OR=0.816）,工作时长≤8 h的从业人员个人健康行为合格情况高于工作时长>8 h的（OR=0.733）;三种影响因素中性别对于个人健康行为的影响面最广。结论 提示公共场所从业人员招聘中除岗位对体力有比较高的要求外,可以优先选择录用女性;高文化程度可能并不能作为公共场所从业人员选拔的标准,且在进行卫生知识培训的同时一定要加强监督管理;管理者用人制度要合理,每天工作时长最好不要超过8 h。     

职业人群工作时间、心理健康状况与失眠的关系

 目的  探究上海市职业人群工作时间、心理健康状况与失眠的关系。方法  采用方便抽样的方法,在上海市抽取24家用人单位,再从用人单位中抽取2 000名职工进行自编问卷调查。采用WHO-5身心健康指标检测心理健康状况、Nakata失眠状况问卷检测失眠状况。同时调查人口学特征、每周平均工作时间、职业紧张情况、行为危险因素及慢性病患病情况等。结果  将心理健康状况与工作时间的交互作用纳入分析模型发现,当心理健康状况较差,合并平均每周工作>40 h患有失眠的危险性最大,相对心理状况较好并且每周工作≤40 h 的OR为2.80 (95%CI:1.98~3.97),而当心理健康状况较好,平均每周工作时间>40 h表现为与失眠无统计学意义,相对心理健康状况较好并且每周工作≤40 h的OR值为0.77 (95%CI:0.56~1.08)。结论  工作时间与睡眠的关系可能受心理健康状况的影响,在心理健康状况不良的情况下,超时工作成为失眠的危险因素,在心理健康状况良好的情况下,超时工作与失眠无统计学关系。     

虎力散胶囊应用于骨关节术后的临床疗效研究

目的 探讨虎力散胶囊(Huli San Capsules)对骨关节术后创伤俢复及并发症预防的疗效及临床意义.方法 将120例骨关节手术方式相同的患者,随机分为治疗组(60例)和对照组(60例),在同等住院条件下治疗2周,治疗组采用口服虎力散胶囊(云南云河药业有限公司,0.3 g/粒),1粒/次,2次/d,2周为1个疗程.对照组采用口服双氯芬酸钠肠溶片(Diclofenace Acetate Tablets,50 mg/粒),1粒/次,2次/d,2周为1个疗程.疗效评价标准参照改良利斯霍姆评分标准,功能评定应用视觉模拟(VAS)评分法及关节库亚拉(Kujala)评分标准.结果 治疗后患者均得到随访,平均随访16.5个月(12～19个月).两组患者治疗后疗效比较,差异有统计学意义(P＜0.01);治疗后关节VAS评分、Kujala评分比较,差异均有统计学意义(P＜0.01);两组不良反应发生率比较,差异有统计学意义(P＜0.01).结论 虎力散胶囊可以有效促进骨科无菌术后软组织康复,减少关节瘢痕粘连等功能障碍,而且不良反应发生率较低.     

CHANGES OF INTERLEUKIN-6 AND RELATED FACTORS AS WELL AS GASTRIC INTRAMUCOSAL Ph DURING COLORECTAL AND ORTHOPAEDIC SURGICAL PROCEDURES

SURGICALproceduremightcauseinterferencetothebodyhomeostasis,likeinfectionortrauma,despiteitstherapeuticvalue.Changesofimmuno endocrinalsystemhappenalongwiththesurgicalinsult,whileinterleukin6(IL6)hasbeenconsideredasthemost sensitiveaswellasvitalindicatora…     

重型颅脑外伤后胃粘膜内pH值的变化及其与应激性溃疡出血的关系

目的 :研究重型颅脑外伤患者胃粘膜内 pH值 (pHi)的变化及其与应激性溃疡出血的关系。　 方法 :1 9例重型颅脑外伤患者 ,利用胃肠张力管检测不同时间 pHi,同时测定不同时段胃液 pH值、血浆胃泌素浓度 ,比较发生与未发生应激性溃疡出血患者的差异。　结果 :1 9例患者中 5例发生了应激性溃疡出血 ,其入院时的pHi均值与未发生溃疡出血者无显著差异 ;入院后第 1 2、2 4h、第 3、5、7天两组间均有显著差异。出血组与未出血组的胃液 pH值、胃泌素水平在不同治疗阶段均无显著差异。　结论 :监测 pHi对于重型颅脑外伤后应激性溃疡出血的发生具有预警作用     

骨科围手术期C反应蛋白动态监测的临床意义

目的：探讨骨科围手术期动态监测C反应蛋白（CRP）浓度变化的临床意义。方法：选取我院收治的骨科手术患者60例,根据有无使用内固定材料分为A、B两组,各30例,A组使用内固定材料,B组未使用内固定材料,于术前、术后第l、3天,采患者晨起空腹血,采用免疫散射比浊法测定CRP浓度,A组于术前、术后1、3、5、7、10、14d检测CRP,对比两组不同时间点CRP浓度变化,观察其变化趋势。结果：两组术后第一天CRP较治疗前升高,第3天升高更为明显,A组CRP升高幅度较B组更为明显,组间比较差异有统计学意义（P〈0．05）;A组术后第3天CRP达峰值,术后第5天明显回落,术后第14天降至术前水平。结论：骨科围手术期CRP表达呈一定规律性,即手术创伤越大,CRP浓度升高越明显,cRP动态监测有助骨科继发感染或并发症的发现及干预。     

Changes in T-lymphocyte subsets in patients with orthopedic trauma and effects of yipanzhu decoction on the impaired immune function

The effects of yipanzhu decoction (YD) on immune function in 40 patients [2 groups, YD and normal saline (NS) group] with orthopedic trauma by taking T lymphocyte subsets as indexes were observed. The peripheral venous blood samples randomly taken from 30 healthy subjects served as control. The blood were collected within 24 hours after trauma. Then the YD and NS were respectively given to the patients in the 2 groups for 3 days, and the blood were taken 4th, 7th, 14th day after trauma for the observation of T subsets. The results revealed that before administration of YD the percentage of pan-T cells was reduced with an increased percentage of Ts cells and a decreased ratio between Th and Ts cells; 3 days after giving the drugs in YD group the percentage of pan-T cells was slightly increased, and the changed percentage of Ts cells and the ratio of Th/Ts cells mentioned above was recovered to normal, while in NS group all these indexes remained at abnormal range during the period we observed. The results suggested that YD could promote the recovery of abnormal T lymphocyte subsets in traumatized patients, and it possessed to some extent the function of immune regulation that was helpful to reduce the ratio of infection after trauma.     

中药加味玉屏风散外用对乳头皲裂预防效果的研究

目的 探讨加味玉屏风散(主要由黄芪、白术、防风、桑白皮和甘草组成)煎汤乳头涂抹对乳头皲裂/疼痛的预防效果。 方法 本实验采用随机对照设计,选取2014年12月-2015年6月的初产妇,简单随机化分组分为全程干预组(95例)、产后干预组(94例)、对照组(90例)。全程干预组于孕37周始开始使用加味玉屏风散煎汤涂抹乳头、乳晕,每日早晚各一次,于每次哺乳后继续使用延续至产后7 d;产后干预组于分娩后2 h回病房时给予加味玉屏风散煎汤涂抹,并于每次哺乳后使用至产后7 d,涂抹方法同全程干预组;对照组仅用清水清洁乳头,时间每天一次,如有初乳分泌,则挤出初乳涂抹于乳头表面。各组均给予正确母乳喂养姿势及相关喂养知识指导,在分娩后12 h至出院前每天观察和评估婴儿吸吮、乳头疼痛及皲裂情况,产后6个月电话随访婴儿喂养情况。 结果 全程干预组、产后干预组和对照组的乳头皲裂发生率分别为10.53%、21.28%和25.56%,3组间比较差异有统计学意义(P<0.05)。3组间乳头皲裂的严重程度差异无统计学意义(P>0.05)。3组产妇乳头明显疼痛分别为17例(17.89%)、30例(31.91%)和35例(38.89%),3组间乳头疼痛程度差异有统计学意义(P<0.05)。 结论 加味玉屏风散煎汤涂抹乳头,于孕37周始至产后7 d的连续使用,能有效降低乳头皲裂的发生率,也能有效减轻婴儿吸吮造成的乳头疼痛,间接提高了6个月内的纯母乳喂养率。