[Burnout : Symptoms, diagnostics and treatment approaches]

Burnout syndrome is characterized by the triad of symptoms exhaustion, mental distance from work activities and a feeling of ineffectiveness. The syndrome is not an independent mental disorder but can be coded in the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as a problem related to difficulties in coping with life (Z73) and in ICD-11 as a qualifying diagnosis (QD85). This article discusses the prevalence and comorbidities of burnout syndrome, taking the methodological difficulties in conceptualizing and operationalizing the construct into account. In addition, it provides an overview of available measurement instruments and their validation. Furthermore, it discusses work-related and individual factors in the development of burnout syndrome as well as analysis of the effectiveness of treatment options.

Impairments in psychological functioning in refugees and asylum seekers

Refugees are at increased risk for developing psychological impairments due to stressors in the pre-, peri- and post-migration periods. There is limited knowledge on how everyday functioning is affected by migration experience. In a secondary analysis of a study in a sample of refugees and asylum seekers, it was examined how aspects of psychological functioning were differentially affected. 1,101 eligible refugees and asylum seekers in Europe and Türkiye were included in a cross-sectional analysis. Gender, age, education, number of relatives and children living nearby, as well as indicators for depressive and posttraumatic symptoms, quality of life, psychological well-being and functioning, and lifetime potentially traumatic events were assessed. Correlations and multiple regression models with World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 12-item version's total and six subdomains' scores ('mobility', 'life activities', 'cognition', 'participation', 'self-care', 'getting along') as dependent variables were calculated. Tests for multicollinearity and Bonferroni correction were applied. Participants reported highest levels of impairment in 'mobility' and 'participation', followed by 'life activities' and 'cognition'. Depression and posttraumatic symptoms were independently associated with overall psychological functioning and all subdomains. History of violence and abuse seemed to predict higher impairment in 'participation', while past events of being close to death were associated with fewer issues with 'self-care'. Impairment in psychological functioning in asylum seekers and refugees was related to current psychological symptoms. Mobility and participation issues may explain difficulties arising after resettlement in integration and exchange with host communities in new contexts.

A self-help app for Syrian refugees with posttraumatic stress (Sanadak): results of a randomized controlled trial

Background

Syrian refugees often develop posttraumatic stress as a result of the Syrian civil war and migration stressors. However, there is a lack of adequate treatments. The smartphone app Sanadak was developed and evaluated to provide cognitive behavioral therapy-based self-help in the Arabic language for Syrian refugees with posttraumatic stress.

Methods

In a randomized controlled trial, eligible individuals were allocated to the intervention group (IG; app) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis.

Results

Of 170 screened individuals (aged 18-65 years), 133 were eligible and randomized to the IG (n = 65) or CG (n = 68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff -0.90, 95%CI -0.24 to 0.47; P=.52) and after 4 months (Diff -0.39, 95%CI -3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS-stereotype agreement: d = 0.86, 95%CI 0.46 to 1.25; stereotype application: d = 0.60, 95%CI 0.22 to 0.99) and after 4 months (d = 0.52, 95%CI 0.12 to 0.92; d = 0.50, 95%CI 0.10 to 0.90).

Conclusions

Sanadak reduced mild to moderate posttraumatic stress in Syrian refugees, but not superior to the control condition. Therefore, Sanadak may not be suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach.

Impact of impaired renal function on kinetics of high-sensitive troponin I (hs-cTnI) following cardiac surgery

Background

Renal insufficiency might result in increased levels of cardiac troponin due to decreased elimination. Hence, the diagnostic utility of hs-cTnI might be lower in patients with impaired renal function. There is only scarce data on kinetics of high-sensitivity cardiac troponin I (hs-cTnI) following cardiac surgery with regard to renal function.

Purpose

The aim of this study was to assess the impact of impaired renal function on the kinetics of hs-cTnI following cardiac surgery differentiating between patients with and without postoperative myocardial infarction (PMI) and to analyze the prognostic value of hs-cTnI elevations in patients with impaired renal function.

Methods

We performed a retrospective analysis of all adult patients (>18 years) who underwent cardiac surgery at our hospital between Jan, 1st 2013 and May, 1st 2019.

Serial measurements of high-sensitive cardiac troponin I (hs-cTnI) were assessed from baseline up to 48 hours after surgery. Renal function was assessed based on estimated glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula with impaired renal function defined by GFR <60 ml/min. Postoperative myocardial infarction was defined by new vessel occlusion on angiography. Predictors of long-term all-cause mortality were assessed by cox regression analysis.

Results

A total of 14,465 patients were included (51.4% underwent coronary artery bypass grafting (CABG), 39.4% had valvular procedures and 9.2% thoracic aortic procedures).

Levels of hs-cTnI were higher in patients with impaired renal function in the overall collective (figure 1). However, in patients with postoperative myocardial infarction levels of hs-cTnI did not differ with regard to renal function (figure 2).

Cox regression analysis showed postoperative elevation of hs-cTnI to be a significant predictor of long-term all-cause mortality over a median follow-up of 3.0 years regardless of baseline kidney function (Hazards ratio 1.67, 95% Confidence interval [1.46–1.91], p<0.001).

Conclusion

Renal function had an impact on postoperative hs-cTnI kinetics only in patients with an uneventful postoperative course. In patients with postoperative myocardial infarction kinetics of hs-cTnI were not affected by baseline renal function. Moreover, elevated hs-cTnI levels were a significant predictor of all-cause mortality regardless of baseline renal function.

Funding Acknowledgement

Type of funding sources: None.

Usefulness of troponin in selecting patients for invasive coronary angiography after cardiac surgery

Background

Great uncertainty exists about the indication for invasive coronary angiography (ICA) in patients with suspected acute coronary syndrome following cardiac surgery.

Aim

The aim of this study was to define clinical criteria that best identify patients who benefit from ICA after cardiac surgery.

Methods

We performed a retrospective analysis of all patients who underwent cardiac surgery between January 2009 and May 2019 at our center. Exclusion criteria included pediatric patients as well as pacemaker, TAVR and LVAD implantation and heart transplantation procedures. The primary outcome was usefulness of ICA as defined by consequent PCI or re-operation due to ICA findings. ECG changes (ST-elevations) and high-sensitivity Troponin I (hsTrop I) were analyzed.

Results

48,136 patients were screened and after applying exclusion criteria 29,359 patients were finally included in the analysis (mean age 67.8±11.0 years, 31.1% females, Euroscore II 5.14±8.9%). A total of 1,171 patients (4%) underwent post-op ICA. The primary outcome occurred in 440 patients (1.5%) of which 290 underwent consequent PCI and 214 underwent consequent re-operation. Baseline characteristics are shown in table 1. Unadjusted analyses did not identify significant differences in the level of cardiac biomarkers between useful-ICA and unuseful-ICA groups.

In multivariate regression analysis, only ST-elevation on ECG predicted the primary outcome (OR 1.33, 95% CI 1.003–1.76).

Dichotomizing hsTrop I concentrations by applying the guideline-specified cut-off (>70x URL) resulted in correct classification of useful-ICA patients in 95.7%. However, the false-positive rate was also extremely high (83.6%) with a positive predictive value (PPV) of 1.6% and a negative predictive value (NPV) of 99.6% (accuracy 17.5%).

Using area under the curve (ROC) analysis following optimal cut-off values for hsTrop I were identified: in CABG patients a cut-off value of >650x URL (corresponding absolute value 17000 ng/L) was defined with a corresponding sensitivity of 83.3%, specificity of 83.6%, PPV of 8.9% and NPV of 99.6% (accuracy 83.6%). In non-CABG patients (i.e. valve or aortic procedures), the cut-off was about twice as high as that for CABG patients (1,350x URL or 35,000 ng/L) with a corresponding sensitivity of 84.1%, specificity of 89.2%, PPV of 5.9% and NPV of 99.9% (accuracy 89.1%).

Conclusion

Our study demonstrates that currently recommended cut-off concentrations of high-sensitivity troponin are not useful for guiding clinical decision-making in patients with suspected acute coronary syndrome following cardiac surgery, while substantially higher cut-off values might be useful. Those cut-off values critically depend on the type of cardiac surgery performed (CABG vs. non-CABG).

Troponin_Curves post-op

Funding Acknowledgement

Type of funding source: None

[Historical study of medical geography in Russia]

This article provides an overview of the change of topics in the medical-geographical studies in Russia. It highlights the conventional nature of this science, its dependence on political, ideological and scientific demands as well as institutional difficulties. It concludes that the goal of further historical research is to focus on the restoration of synchronous meanings of medical geography, its links with other disciplines and the elucidation of Russia's participation in the transnational project of medico-geographical research.

A head coil system with an integrated orbiting transmission point source mechanism for attenuation correction in PET/MRI

The combination of positron emission tomography (PET) and magnetic resonance imaging (MRI) provides a benefit for diagnostic imaging. Still, attenuation correction (AC) is a challenge in PET/MRI compared to stand-alone PET and PET-computed tomography (PET/CT). In the absence of photonic transmission sources, AC in PET/MRI is usually based on retrospective segmentation of MR images or complex additional MR-sequences. However, most methods available today are still challenged by either the incorporation of cortical bone or substantial anatomical variations of subjects. This leads to a bias in quantification of tracer concentration in PET. Therefore, we have developed a fully integrated transmission source system for PET/MRI of the head to enable direct measurement of attenuation coefficients using external positron emitters, which is the reference standard in AC. Based on a setup called the 'liquid drive' presented by Jones et al (1995) two decades ago, we built a head coil system consisting of an MR-compatible hydraulic system driving a point source on a helical path around a 24-channel MR-receiver coil to perform a transmission scan. Sinogram windowing of the moving source allows for post-injection measurements. The prototype was tested in the Siemens Biograph mMR using a homogeneous water phantom and a phantom with air cavities and a Teflon (PTFE) cylinder. The second phantom was measured both with and without emission activity. For both measurements air, water and Teflon were clearly distinguishable and homogeneous regions of the phantom were successfully reproduced in the AC map. For water the linear attenuation coefficient was measured as (0.096  ±  0.005) cm^-1 in accordance with the true physical value. This combined MR head coil and transmission source system is, to our knowledge, the first working example to use an orbiting point source in PET/MRI and may be helpful in providing fully-quantitative PET data in neuro-PET/MRI.

Pumpless Extracorporeal Lung Assist as Supportive Therapy in a Patient with Diffuse Alveolar Hemorrhage

Our 18-year old female patient suffered from microscopic polyangiitis. After invasive diagnostics, a diffuse alveolar hemorrhage occurred, leading to acute lung failure. In spite of differential ventilation, respiratory insufficiency and lactate-acidosis increased quickly. Due to the massive hemorrhage, a pumpless extracorporeal lung assist was implanted and, after six hours, low-dose heparinization was started. In response to this therapy, hypercapnia and acidosis improved quickly and were completely eliminated within 24 hours. Simultaneously, treatment with prednisolon and cyclophosphamid was started. After 7 days, the patient's conditions allowed weaning from the pumpless extracorporeal lung assist and after 9 days she was extubated.

In conclusion, the pumpless lung assist was shown to be a very practical option to treat the most serious forms of hypercapnia, especially for patients disposed to diffuse bleeding.

Cerebrospinal fluid lipocalin 2 in patients with clinically isolated syndromes and early multiple sclerosis

Background:

Lipocalin 2 (LCN2) may be involved in the immunopathogenesis of multiple sclerosis (MS) and might further impact on iron homoeostasis. Brain iron accumulates in MS; however, the association to iron-related proteins is still unsolved.

Objective:

To investigate cerebrospinal fluid (CSF) and serum LCN2, transferrin (Trf) and ferritin in early MS in relation to disease evolution and longitudinal brain iron accumulation.

Methods:

We analysed CSF and serum LCN2 by enzyme-linked immunosorbent assay (ELISA) and Trf and ferritin by nephelometry in 55 patients (45 clinically isolated syndrome (CIS), 10 MS, median clinical follow-up 4.8 years) and 63 controls. In patients, we assessed sub-cortical grey matter iron by 3T magnetic resonance imaging (MRI) R2* relaxometry (median imaging follow-up 2.2 years).

Results:

Compared to controls serum ( p < 0.01), CSF ( p < 0.001) LCN2 and CSF Trf ( p < 0.001) levels were reduced in the patients. CSF LCN2 correlated with CSF Trf ( r = 0.5, p < 0.001). In clinically stable patients, CSF LCN2 levels correlated with basal ganglia iron accumulation ( r = 0.5, p < 0.05). In CIS, higher CSF LCN2 levels were associated with conversion to clinically definite MS ( p < 0.05).

Conclusion:

We demonstrate altered LCN2 regulation in early MS and provide first evidence for this to be possibly linked to both clinical MS activity and iron accumulation in the basal ganglia.

[Heart and combined heart-lung transplantation. Indications, chances and risks]

Orthotopic heart transplantation (HTX) is nowadays the worldwide accepted gold standard for the treatment of terminal heart failure. The main indications for HTX are non-ischemic dilatative (54%) and ischemic (37%) heart failure. In the acute phase after HTX the survival rate is approximately 90%. Good short and long-term results with survival rates ranging from 81% after 1 year to more than 50% after 11 years demonstrate that there is currently no real treatment alternative to HTX for treatment of end-stage heart failure. In the case of irreversible pulmonary hypertension in combination with end-stage heart failure or complex congenital heart syndromes, a combined heart and lung transplantation (HLTX) is necessary. Compared with HTX the short-term survival of HLTX is reduced, mostly for technical reasons. Improved long-term results after HTX and HLTX are a result of highly specialized transplantation units and effective immunosuppression. However, a major problem is the shortage of organ donors in Germany and the resulting long waiting times for patients with frequently occurring blood groups of up to 10 months for transplantation. The consequence of the latter is the ever increasing number of implanted cardiac assist devices in patients not only as a bridge to transplant but also as destination therapy.

Extra cellular matrix remodelling after heterotopic rat heart transplantation: gene expression profiling and involvement of ED-A+ fibronectin, alpha-smooth muscle actin and B+ tenascin-C in chronic cardiac allograft rejection

Chronic cardiac rejection is represented by cardiac allograft vasculopathy (CAV) and cardiac interstitial fibrosis (CIF) known to cause severe complications. These processes are accompanied by remarkable changes in the cardiac extra cellular matrix (cECM). The aim of our study was to analyse the cECM remodelling in chronic rejection and to elucidate a potential role of ED-A domain containing fibronectin (ED-A(+) Fn), alpha smooth muscle actin (ASMA) and B domain containing tenascin-C (B(+) Tn-C). A model of chronic rejection after heterotopic rat heart transplantation was used. Allografts, recipient and control hearts were subjected to histological assessment of rejection grade, to real-time PCR based analysis of 84 genes of ECM and adhesion molecules and to immunofluorescence labelling procedures, including ED-A(+) Fn, ASMA and B(+) Tn-C antibodies. Histological analysis revealed different grades of chronic rejection. By gene expression analysis, a relevant up-regulation of the majority of ECM genes in association with chronic rejection could be shown. For 8 genes, there was a relevant up-regulation in allografts as well as in the corresponding recipient hearts. Association of ASMA positive cells with the grade of chronic rejection could be proven. In CAV and also in CIF there were extensive co-depositions of ED-A(+) Fn, ASMA and B(+) Tn-C. In conclusion, chronic cardiac allograft rejection is associated with a cECM remodelling. ASMA protein deposition in CAV, and CIF is a valuable marker to detect chronic rejection. Interactions of VSMCs and Fibro-/Myofibroblasts with ED-A(+) Fn and B(+) Tn-C might functionally contribute to the development of chronic cardiac rejection.

Efficacy of a strategy to prevent neonatal early-onset group B streptococcal (GBS) sepsis

BACKGROUND

Existing guidelines recommend different strategies to prevent early-onset neonatal GBS sepsis. In 1997, using our own data on incidence and risk factors, we established a new prevention strategy which includes GBS screening at 36 weeks' gestation and intrapartum antibiotic prophylaxis (IAP) in women with positive or unknown GBS colonization with at least one risk factor. The present study evaluates the efficacy of the new prevention strategy.

METHODS

Retrospective study of the incidence of early-onset GBS sepsis among all live births at the University Women's Hospital Basel between 1997 and 2002. Additional analysis of delivery and post partum period of all GBS sepsis cases, including GBS screening, risk factors during labor (prematurity, rupture of membranes (ROM) <12 h, intrapartum signs of infection), and IAP. Comparison of this group's characteristics G2 (9,385 live births, using the new strategy) with the previous group, G1 (1984-1993, 16,126 live births, without GBS screening or routine IAP) was performed.

RESULTS

The incidence of early-onset GBS sepsis was reduced from 1/1000 (G1) to 0.53/1000 (G2). We observed a significant reduction of overall intrapartum risk factors in cases of GBS sepsis.

CONCLUSION

This study suggests that our new prevention strategy is effective in reducing the incidence of early-onset GBS sepsis in neonates. In comparison, implementation of the CDC's prevention strategy might have prevented 2 additional cases in 9385 live births. However, this would have required treating a much larger number of pregnant women with IAP with consequential increasing costs, side effects and complications.

[Late results after nerve transplantation on the upper extremities]

PURPOSE

The purpose of this retrospective study was to determine the influence of the type of injury, the time elapsed after the injury, the blood supply to the operation area, the size of the graft, and the applied treatment method on the late results.

METHOD AND MATERIAL

In the study period from 1985 through 2000, nerve transplantations had been performed in 281 patients. There were 204 men and 77 women. Reconstructions were applied on the median nerve in 59 patients, ulnar nerve in 48, median and ulnar nerves in 23, radial nerve in ten, and digital nerves in 141 patients. 188 patients presented for late follow-up (66.9%).

RESULTS

Evaluation was made according to the Highet scheme. In patients with median nerve transplantation M(3) or better results were seen in 69%, with M(3) being 45.2%. S(3) or better was observed in 64.3%, with S(3) being 47.6%. In patients after ulnar nerve transplantation M(3) or better result was achieved in 56.8%, M(3) being 19%. S(3) or better result was seen in 32.4%, S(3) being 27%. In patients who underwent median and ulnar nerve transplantations M(3) or better result was seen in 36.8%, M(3) being 26.3%. S(3) was in 42.1%, while S(4) did not occur. In patients after radial nerve transplantation M(3) or better effect resulted in 87.5%, M(3) being 12.5%. In patients with digital nerve transplantation S(3) or better result occurred in 57.4 %, S(3) being 47.6%.

CONCLUSION

The best result can be achieved with nerve suturing, performed as an optimum from all aspects. However, as far as the surgical technique is concerned, results of using interfascicular grafts are more advantageous than epineural nerve suture based on compromises. In ideal circumstances, transplantation of a nerve graft less than 2 cm is of the same value as a good primary suture. If a nerve graft is longer than 2 cm, and negative local factors are accumulating due to the type of injury, late results will gradually deteriorating. The final outcome definitely depends on the patient's age and the time elapsed from the injury to the operation.

Lipid hydroperoxides and free radical scavenging enzyme activities in preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome: no evidence for circulating primary products of lipid peroxidation

OBJECTIVE

Preeclampsia is reportedly accompanied by increased plasma lipid peroxidation. However, to date the assays that have been applied to measure lipid peroxides have been relatively nonspecific. A highly specific high-performance lipid chromatographic-chemiluminescence technique was used here to measure lipid hydroperoxides in plasma and red blood cells of patients with preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.

STUDY DESIGN

Lipid peroxidation products, both lipid hydroperoxides and thiobarbituric acid reactive substances (TBARS), and free radical scavenging enzyme activities were measured in either plasma or erythrocytes of patients with normal pregnancies (n = 36), preeclampsia (n = 28), or HELLP syndrome (n = 10).

RESULTS

Whereas lipid hydroperoxides were undetectable (<0.02 micromol/L), plasma TBARS and glutathione peroxidase activity in plasma and erythrocytes were significantly increased in patients with HELLP syndrome. There were no differences in glutathione transferase and reductase activities or superoxide dismutase activity between the groups.

CONCLUSIONS

We were unable to corroborate results of studies that suggested that increased TBARS are representative of circulating plasma lipid hydroperoxides in preeclampsia. However, elevated glutathione peroxidase activity and TBARS are in line with increased oxidative stress in preeclampsia.

High-throughput functional annotation of novel gene products using document clustering

Gene products differentially expressed in healthy vs. diseased tissues may be considered drug targets since the change in their expression level can be related to the cause and progression of the disease studied. A significant portion of the proteins produced by these genes will be unknown and consequently their function must be characterised. The experimental elucidation of biochemical function must be supported by computational tools which can help predicting the possible function of a given protein from its amino acid sequence. We have designed a high-throughput system which automatically analyses amino acid sequences deduced from differentially represented cDNA clones. The system attempts to assign a biological function to protein sequences by carrying out searches in sequence databanks and by locating functionally relevant motifs in the query sequences. The results delivered by the various prediction methods consist of the annotations of matching sequences and/or motifs, which are free-format texts written by humans and therefore may describe the same concept with synonymous words. It is desirable to present the results in such a way that the annotations describing the same biological function are grouped together. To this end we devised an algorithm that enables the hierarchical clustering of free-format documents based on their contents. The system is capable of detecting and flagging conflicting annotations, and will speed up the interpretation of the function prediction results.

Force field based conformational analysis of RNA structural motifs: GNRA tetraloops and their pyrimidine relatives

The protocol of conformational analysis applied here to ribonucleotide oligomers combines conformational search in the space of torsion angles and energy minimization using the AMBER4.1 force field with a continuum treatment of electrostatic solute-solvent interactions. RNA fragments with 5'-GGGCGNNAGCCU-3' sequences commonly fold into hairpins with four-membered loops. The combinatorial search for acceptable conformations using the MC-SYM program was restricted to loop nucleotides and yielded roughly 1500 structures being compatible with a double-stranded stem. After energy minimization by the JUMNA program (without applying any experimental constraints), these structures converged into an ensemble of 74 different conformers including 26 structures which contained the sheared G-A base pair observed in experimental studies of GNRA tetraloops. Energetic analysis shows that inclusion of solvent electrostatic effects is critically important for the selection of conformers that agree with experimentally determined structures. The continuum model accounts for solvent polarization by means of the electrostatic reaction field. In the case of GNRA loop sequences, the contributions of the reaction field shift relative stabilities towards conformations showing most of the structural features derived from NMR studies. The agreement of computed conformations with the experimental structures of GAAA, GCAA, and GAGA tetraloops suggests that the continuum treatment of the solvent represents a definitive improvement over methods using simple damping models in electrostatic energy calculations. Application of the procedure described here to the evaluation of the relative stabilities of conformers resulting from searching the conformational space of RNA structural motifs provides some progress in (non-homology based) RNA 3D-structure prediction.

Nurses on-line: career mobility for registered nurses

The demands of a dynamic health care environment have altered the roles and responsibilities of nurses, creating employment situations where distinctions across educational levels are becoming increasingly important. The 1995 Pew Foundation Report projected that, in the next decade, there would exist a shortage of registered nurses with baccalaureate and higher degree preparation. This deficit creates a unique opportunity to provide innovative approaches to career mobility for registered nurses. Constraints related to juggling the demands of home life, child rearing, and employment have been obstacles for diploma and associate degree nurses wishing to continue their education. Web-based instruction offers exciting possibilities for a new paradigm in nursing education that takes advantage of both the interactivity and substantial resources of the internet. On-line registered nurse completion programs offer flexible, cost-effective, and easily accessible alternatives to traditional education. This article describes the application of adult learning theory for use in re-engineering courses for on-line instruction. Hardware and software needs, technical support, development of an instructional model, teaching-learning considerations, and program evaluation also are discussed.