Evaluating the educational environment in a residency programme in Singapore: can we help reduce burnout rates?

INTRODUCTIONThe educational environment (EE) reflects the quality of a residency programme and has an association with burnout. Studying the EE allows for interventions to target specific weaknesses. We aimed to measure the EE of an internal medicine residency programme in Singapore, compare the perceptions between genders, residency grades and levels of work experience, and identify specific areas of weaknesses for intervention in hopes of reducing residency burnout rates in Singapore.METHODSThis study took place between October and December 2017. We adopted a mixed methods approach, quantitatively using the Postgraduate Hospital Educational Environment Measure (PHEEM), and qualitative exploration using semi-structured focus group discussion.RESULTSA total of 136 (88.9%) out of 153 residents responded. Our total PHEEM scores (112.23 ± 16.71), along with the scores for all three subscales, were higher than those of institutions in previous studies. There were no differences in overall PHEEM and subscale scores between genders, residency grades or levels of work experience. However, there were differences for individual questions, which were explored in the focus group discussion. Senior residents juggling heavier workloads, responsibilities and examinations appeared to be most prone to burnout. We identified three recurring themes that contributed to a poor EE in our programme: excessive workload, poor faculty relationships and differing unmet needs.CONCLUSIONAlthough our programme had a good EE, there were also areas of weaknesses revealed by specific questions, possibly contributing to burnout. We hope to implement interventions to these areas and subsequently assess for longitudinal changes in EE and burnout rates.     

Two instances of Chinese herbal medicine poisoning in Singapore

Datura metel L. (Yangjinghua) is a toxic herb that contains anticholinergic compounds. Inappropriate consumption of this herb could result in anticholinergic poisoning. Clinical features of such poisoning have not been previously described. We report two such cases. Both patients had taken brews of Datura metel L., and developed poisoning soon afterwards. Prominent clinical features included confusion, dilated pupils, absence of sweating, and the absence of sluggish bowel sounds. No flushing of the face or skin was detected in either case. Both patients recovered fully within 12 hours with supportive measures, and no gastric elimination or antidote was used. The different names ascribed to Datura metel L. in chinese medicine can be confusing; this confusion resulted in the poisoning of one of our patients. The clinical features of Datura metel L. poisoning and concerns over inappropriate uses of herbal medicine are discussed.     

Cytochemical, cytogenetic, immunophenotypic and tumorigenic characterization of two hairy cell lines

Two cell lines (EH and HK) were derived from two patients with hairy cell leukemia (HCL). Both patients exhibited a clinical picture characteristic of HCL, including splenomegaly, cytopenias, and tartrate- resistant acid phosphatase (TRAP)-positive "hairy" lymphocytes in blood and marrow. EH and HK were demonstrably of B lineage, as judged by cytochemistry and immunophenotype, including expression of B1, B2, and LEU-12 antigens and of monoclonal surface immunoglobulins (slgs). Monoclonality was confirmed by clonal karyotype abnormality demonstrated in cell line HK. HCL parentage suggested by cytochemistry and electron microscopy was confirmed by the immunophenotypic observation that HCL lines expressed antigens alpha S-HCL1, alpha S- HCL3, and cCLLa. While alpha S-HCL1 and alpha S-HCL3 are nonspecific, their co-expression is characteristic of HCL cells. The cCLLa is a novel 69-kd membrane HCL-associated polypeptide antigen not shared by circulating normal T or B lymphocytes nor by malignant cells from unrelated lymphoid or nonlymphoid malignancies. The doubling time of EH and HK was 24 and 36 hours, respectively. While HK included a small subset of Epstein-Barr virus (EBV) nuclear antigen-positive cells, EH cells were homogeneously negative for the presence of this antigen. Both cell lines were consistently implantable in irradiation- preconditioned immunodeficient mice giving rise to primary tumors and widespread metastasis.     

P-selectin glycoprotein ligand-1 (PSGL-1) is a ligand for L-selectin in neutrophil aggregation

In inflammation, activated neutrophils adhere to endothelial cells and aggregate with one another. While beta 2-integrin and L-selectin are essential for aggregation, their ligands remain to be identified. We have previously shown that L-selectin mediates a carbohydrate-dependent interaction in aggregation (Simon et al: J Immunol 149:2765, 1992; Rochon et al: J Immunol 152:1385, 1994). We have suggested that the L- selectin counter-structure is a mucinlike protein and proposed that aggregation occurs through a two-step process involving L-selectin, beta 2-integrin, and their distinct counter-structures (Bennett et al: J Leuk Biol 58:510, 1995). A candidate ligand for L-selectin is P- selectin glycoprotein ligand-1 (PSGL-1), a mucinlike protein on neutrophils that binds P-and E-selectin. Using flow cytometry we show that the number and size of neutrophil aggregates is reduced with Fab fragments of PL1, an anti-PSGL-1 monoclonal antibody that blocks the interaction between P-selectin and PSGL-1 (Moore et al: J Cell Biol 128:661, 1995). In addition, monoclonal antibodies to L-selectin and PSGL-1 were used simultaneously to modulate the availability of these adhesion molecules on individual cell populations. The inhibition of aggregation by these antibodies is consistent with L-selectin and PSGL- 1 being counter-structures. We suggest that L-selectin and PSGL-1 support a collisional cell-cell interaction that represents the first step in neutrophil aggregation.     

Immunochemical characterization of fibrinogen, fibrin I, and fibrin II in human thrombi and atherosclerotic lesions

Arterial thrombi and atherosclerotic lesions were analyzed immunochemically and examined histologically. The extent of in vivo proteolytic cleavage of the amino-terminal end of fibrinogen by thrombin and plasmin was determined and quantitated by specific radioimmunoassays. The samples were treated with cyanogen bromide (CNBr), and the total amount of fibrinogen and fibrin-derived protein was determined as NDSK, the NH2-terminal disulfide knot of fibrinogen. Thrombin-releasable fibrinopeptides A and B were used to quantitate fibrinogen and fibrin I. Previous plasmin cleavage of the B beta chain was inferred from the amount of B beta 1-42 and B beta 15-42 in undigested NDSK. The results obtained in both acute and organized thrombi indicate that approximately 60% of the total protein (as determined by amino acid analysis) was fibrinogen-derived and that 70% to 80% of the fibrinogen-derived material was fibrin II. These findings support the hypothesis that fibrin II as distinct from fibrin I is the predominant component in a thrombus. In samples from normal and atherosclerotic aortas, fibrinogen-derived protein comprised less than 10% of the total protein. Samples from grossly normal aortas contained only fibrinogen and fibrin I. Fibrinogen concentration decreased and fibrin II concentration increased with increasing severity of the lesions, suggesting that increased fibrin II formation is associated with progression of atheromas.     

p53 negatively regulates the osteogenic differentiation of vascular smooth muscle cells in mice with chronic kidney disease

Aim

To investigate the osteogenic differentiation of vascular smooth muscle cells (VSMCs) in mice with chronic kidney disease (CKD) and to evaluate the effects of p53 on the osteogenic differentiation of the VSMCs.

Methods

Experimental models of CKD-associated vascular calcification generated by five-sixth (5/6) nephrectomy (Nx) and a high-phosphate (HP) diet were used in p53+/+ and p53–/– mice. Following 5/6 Nx, aortic calcification, markers of osteogenic differentiation, VSMCs and p53 protein in aortic tissues were studied.

Results

Aortic calcification was observed after eight weeks following 5/6 Nx in mice of both genotypes, and expression of the markers of osteogenic differentiation in the VSMCs was increased. These changes were continuously observed up to 12 weeks after 5/6 Nx, and particularly after 5/6 Nx + HP. Compared with p53+/+ mice, aortic calcification in p53–/– mice was more severe (p < 0.001). Expression of the markers of osteogenic differentiation was noticeably increased (p < 0.001), while expression of the marker of VSMCs had decreased (p < 0.001). Statistical analysis demonstrated that the markers of osteogenic differentiation were negatively correlated with p53, and the marker of VSMCs was positively correlated with p53 (p < 0.001).

Conclusion

p53 has the potential to negatively regulate the osteogenic differentiation of VSMCs in CKD mice.     

Inhaled corticosteroids in obstructive airway disease

Inhaled corticosteroids play an important role in the management of obstructive airway disease, by suppressing airway inflammation that is central to the pathophysiology of these conditions. In asthma there is strong clinical evidence supporting the use of inhaled corticosteroids in mild, moderate, and severe persistent asthma to improve lung function, reduce exacerbations, and prevent death. In chronic obstructive pulmonary disease, inhaled corticosteroids improve symptoms, reduce frequency of exacerbations and hospitalizations, and should be considered in patients with moderate-to-severe airflow limitation who have persistent symptoms despite optimal bronchodilator therapy. Though the adverse effects of corticosteroids are less when given via inhalation than when given systemically, nevertheless, the adverse effects are important and need to be considered. Newer inhaled corticosteroids with better pharmacologic properties are being developed and will probably be available in the near future.     

Oyster-associated outbreaks of Norovirus gastroenteritis in Singapore

Outbreaks of gastroenteritis associated with the consumption of raw imported half-shelled frozen oysters occurred in Singapore between 16 Dec 2003 and 04 Jan 2004. A total of 305 cases were reported with clinical symptoms of diarrhoea (94%), abdominal cramps (72%), vomiting (69%) and fever (54%). The median incubation period was 30.8 h and the duration of illness was 2–3 days. The overall relative risk of oyster consumption was 14.1 (95% CI: 8.3–24.0, P<0.001). Stool and oyster samples tested negative for common bacterial pathogens, including Vibrio parahaemolyticus. However, stool samples were positive for the presence of Norovirus group II RNA via RT PCR while oyster samples indicated the presence of Norovirus particles by electron microscopy. The clinical and epidemiological features were suggestive of Norovirus gastroenteritis and were subsequently confirmed by laboratory tests of stools and implicated oysters. Steps have been taken to ensure that food outlets do not thaw frozen oysters and serve them raw.