The use of an object: exploring physician burnout through object relations theory

The crisis of physician burnout has been widely and repeatedly reported across the mainstream press and medical journals around the world, in the closing years of the second decade of the 21st century. Despite multiple systematic reviews and commentary on the scale of this 'global epidemic', understandings of both the phenomenon and the most effective interventions remain limited. Practice-based medical humanities represents the collaborative sharing of conceptual tools for understanding illness and clinical practice and the shouldering of responsibility for mapping the shape of care, in all its local, national and global contexts, thinking-with rather than critique on the profession and its practices. In keeping with this approach, this article offers a new perspective on the contemporary crisis of physician burnout by exploring the objectification of the clinician's body within the systems and practice of healthcare. Within the context of medical humanities' scholarship, discussions of objectification usually navigate towards a discussion about patient identity and its potentially reductive objectification within the frameworks of biomedical science. However, this article crosses the cultural divide between clinician and patient, and comes to focus on the objectification of the clinician herself, using object relations theory from the field of psychoanalysis to excavate the psychodynamics of care and their impact on clinicians, and the systems of healthcare in which care is delivered.

'Capable of being in uncertainties': applied medical humanities in undergraduate medical education

Numerous medical schools have been updating and modernising their undergraduate curricula in response to the changing health needs of today's society and the updated General Medical Council competencies required for qualification. The humanities are sometimes seen as a way of addressing both of these requirements. Medical humanities advocates would argue that the humanities have a vital role to play in undergraduate medical education, allowing students to develop the critical tools required by the 21st-century clinician to deliver the best person-centred care. While we endorse this view, we contend that such training must be taught authentically to have maximal impact. This article arises from a collaboration between Imperial College London and Birkbeck, University of London, which aimed to embed the humanities into Imperial's undergraduate medical curriculum. Here, we use a teaching session on graphic medicine and narrative as a case study to illustrate how the humanities can be a powerful tool for students to explore professional clinical complexity and uncertainty when taught in a transdisciplinary way. In this session, uncertainty operated on several different levels: the introduction of unfamiliar concepts, materials, and methods to students, transdisciplinary approaches to teaching, and the complexities of real-life clinical practice. Further, we argue that to manage uncertainty, medical students must cross from a scientific training based on positivist understandings of evidence and knowledge, to one which foregrounds multiplicity, nuance, interpretive critical thinking, and which understands knowledge as contingent and contextually produced. In facilitating such learning, it is crucial that the teaching team includes experts from both medical and humanities fields to scaffold student learning in an intellectually dynamic way, drawing on their disciplinary knowledge and wide range of personal professional experiences.

Volume replacement after trauma: an update

Traditionally, fluid therapy in trauma patients favoured liberal replacement of intravascular fluids to correct fluid loss and optimise macro- and microcirculation. This narrative review examines the background for the changed approach to volume therapy, discusses important clinical studies and points out open questions for future research. Evidence is emerging that low volume resuscitation and permissive hypotension may be associated with improved outcomes. Crystalloids are safe as first line fluids. Colloids have no advantage over crystalloids and may be detrimental in patients with traumatic brain injury. Synthetic colloids may prolong bleeding and increase need for blood products. The role of hypertonic saline is unclear, as recent large-scale trials have been stopped for futility and some safety concerns.

Molecular biology on the ICU. From understanding to treating sepsis

Mounting evidence suggests that beside well established factors, such as virulence of pathogens or site of infection, individual differences in disease manifestation are a result of the genetic predisposition of the patient on an Intensive Care Unit (ICU). Specific genetic factors might not only predict the risk to acquire severe infections but also to develop organ dysfunction or ultimately to die. Thus, the advent of molecular techniques allowing screening for a wide variety of genetic factors, such as single nucleotide polymorphisms in genes controlling expression of important mediator systems in patients as well as their purposeful targeting in animal models of sepsis, are revolutionizing understanding of pathophysiology in the critically ill. Molecular tools are about to challenge ''state-of-the-art'' diagnostic tests such as blood culture as they not only increase sensitivity but dramatically reduce time requirements to identify pathogens and their resistance patterns. Similarly, knowledge of genetic factors might in the near future help to identify ''patients at risk'', i.e. those with a high likelihood to develop organ dysfunction or to guide therapeutic interventions in particular regarding resource-consuming and/or expensive therapies (''theragnostics''). While therapeutic options in molecular intensive care medicine, such as stem cells in the treatment of organ failure or therapeutic gene transfer are possible along the road and might become an option in the future, recombinant DNA technology has already a well defined role in the production of recombinant human proteins from insulin to activated protein C.

[When safety becomes a danger. Penetrating trauma by side impact protection]

We report the case of a penetrating injury of the abdomen by an iron bar of a side impact protection after a traffic accident. The iron bar of the side impact protection entered the lateral thigh, penetrated the pelvis and retroperitoneum and left the body lateral of the spine at the L4 level. The patient was fixed by the iron bar to the car seat. The mechanism of the accident, the patient's symptoms and the initial treatment of the patient are described and discussed.

Clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass: retrospective study

This retrospective study evaluates our experience with clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass. Twenty-three of 3,600 consecutive patients suffered from splanchnic malperfusion. Symptoms developed between day 2 and 6 postoperatively in 18 of 23 patients. Four of 23 patients had no abdominal symptoms. Laboratory evaluation revealed significantly higher serum lactate and creatine phosphokinase levels in the 18 symptomatic patients compared with those of a control group. Arteriography was performed in 20 cases and revealed nonocclusive splanchnic hypoperfusion. Risk factors for development of mesenteric ischemia include arrhythmias and low cardiac output. Patients with angiographically proven nonocclusive mesenteric ischemia were treated with intra-arterial bolus injection and subsequent intra-arterial infusion of tolazoline combined with heparin sodium. The overall mortality rate was 30% (7 of 23). Infusion therapy with tolazoline and heparin seems to be a successful treatment modality for clinically diagnosed mesenteric ischemia.

Clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass: retrospective study

This retrospective study evaluates our experience with clinically diagnosed nonocclusive mesenteric ischemia after cardiopulmonary bypass. Twenty-three of 3,600 consecutive patients suffered from splanchnic malperfusion. Symptoms developed between day 2 and 6 postoperatively in 18 of 23 patients. Four of 23 patients had no abdominal symptoms. Laboratory evaluation revealed significantly higher serum lactate and creatine phosphokinase levels in the 18 symptomatic patients compared with those of a control group. Arteriography was performed in 20 cases and revealed nonocclusive splanchnic hypoperfusion. Risk factors for development of mesenteric ischemia include arrhythmias and low cardiac output. Patients with angiographically proven nonocclusive mesenteric ischemia were treated with intra-arterial bolus injection and subsequent intra-arterial infusion of tolazoline combined with heparin sodium. The overall mortality rate was 30% (7 of 23). Infusion therapy with tolazoline and heparin seems to be a successful treatment modality for clinically diagnosed mesenteric ischemia.

Heparin and the nonanticoagulant N-acetyl heparin attenuate capillary no-reflow after normothermic ischemia of the lung

BACKGROUND

Ischemia-reperfusion injury of the lung frequently occurs after cardiopulmonary bypass, after pulmonary thromboendarterectomy, and especially after lung transplantation. Heparin is known to be protective in ischemia-reperfusion injury, but the risk for bleeding disorders may restrict its use in a variety of diseased conditions. Therefore, we tested the efficiency of nonanticoagulant N-acetyl (NA) heparin to protect from postischemic reperfusion injury of the lung.

METHODS

Pentobarbital-anesthetized, mechanically ventilated Lewis rats were heparinized (100 IU/kg) before insertion of catheters. Additionally, animals received either heparin (200 IU/kg; n = 7), NA heparin (1.1 mg/kg; n = 7), or saline (control, n = 7) before ischemia. After normothermic ischemia for 50 minutes, the left lung was reperfused for 120 minutes, or until the death of the animal. The nonischemic right lung was excluded after 10 minutes of reperfusion.

RESULTS

Survival rate at 120 minutes of reperfusion was 7 of 7 and 6 of 7 in the heparin and the NA-heparin group, but 0 in 7 in the control group (p < 0.01). At 30 minutes of reperfusion, PaO2, blood flow through the ascending aorta and mean systemic blood pressure were also significantly higher in the heparin and the NA-heparin group when compared with the control group (p < 0.05). Pulmonary vascular resistance was significantly lower in the heparin and the NA-heparin groups, and histologic examination of the lungs from these groups confirmed reperfusion of nutritive alveolar capillaries by the presence of red blood cells. Lack of red blood cells in the alveolar capillaries of lung specimens from the control group indicated failure of capillary reperfusion.

CONCLUSIONS

Heparin and NA heparin exert similar protection against capillary no-reflow after normothermic ischemia of the lung. This implies that the protective effect of heparin is mediated by properties different from its anticoagulant activity. Thus the nonanticoagulant N-acetyl heparin may pose a safe new therapeutic approach in lung ischemia-reperfusion injury without increasing the risk of hemorrhagic complications.

Model of chronic systolic and diastolic dysfunction after cryothermia-induced myocardial necrosis in rats

BACKGROUND AND PURPOSE

Left ventricular dysfunction following myocardial infarction is the most important predictor of adverse prognosis. Novel treatment options in infarction require an appropriate experimental model with a standardized, hemodynamically relevant myocardial injury. We evaluated a cryoinjury model in rodents that allows quantitative analysis of systolic and diastolic dysfunction.

METHODS

Anesthetized, orally intubated, and ventilated Lewis rats (n = 12) underwent sternotomy. Myocardial necrosis was induced by use of a standardized cryolesion to the obtuse margin of the left ventricle, freezing for 3 minutes to -160 degrees C. Left ventricular performance was analyzed at day 120 after cryoinjury. Sham-operated animals (n = 10) served as controls.

RESULTS

Cryoinjured animals behaved normally and gained weight up to day 120. Average heart weight of cryoinjured animals significantly exceeded that of controls. Left ventricular systolic pressure and systolic, diastolic, and mean aortic pressures were lower 4 months after cryoinjury, whereas left ventricular end-diastolic pressure was significantly increased. Cryoinjured animals had reduced aortic blood flow, as well as impaired maximal left ventricular dP/dt during aortic occlusion and aortic occlusion-provoked peak systolic pressure. Analysis of maximal rates of isovolumic pressure decrease revealed significant reduction in peak negative dP/dt in cryoinjured animals. Finally, time constants of isovolumic pressure decline were significantly prolonged in cryoinjured animals.

CONCLUSION

Standardized cryothermia induces a myocardial lesion that results in highly reproducible impairment of left ventricular performance 120 days after cryothermia. The model is ideally suited to test novel therapeutic strategies for myocardial dysfunction.

Evidence against a role of physiological concentrations of estrogen in post-myocardial infarction remodeling

OBJECTIVES

The purpose of this study was to examine whether endogenous estrogen deficiency induced by ovariectomy affects chronic left ventricular dysfunction post-myocardial infarction (MI).

BACKGROUND

Epidemiologic findings suggest that mortality of postmenopausal women is increased after MI, but the underlying mechanisms are unknown.

METHODS

Rats were either not ovariectomized (non-OVX), ovariectomized (OVX) or ovariectomized and treated with subcutaneous 17-beta-estradiol (E2) pellets (OVX + E2). Two weeks later, animals were sham-operated (Sham) or left coronary artery ligated (MI). Eight weeks later, in vivo echocardiographic and hemodynamic measurements were performed. Thereafter, hearts were isolated and perfused isovolumically.

RESULTS

Mean infarct size was similar among the three MI groups. Ovariectomy decreased serum E2 levels (11 +/- 4 vs. 49 +/- 11 pg/ml in non-OVX, p < 0.01) and increased body weight. These changes were reversed by E2 replacement. The degree of cardiac hypertrophy was similar for all groups post-MI. Left ventricular diameters were increased post-MI (8.9 +/- 0.4 in non-OVX + MI vs. 6.7 +/- 0.2 mm in non-OVX + Sham hearts, p < 0.0001), but OVX or OVX + E2 replacement did not alter left ventricular diameters in post-MI and Sham hearts. Left ventricular fractional shortening was severely impaired post-MI (19 +/- 2% vs. 50 +/- 3 in non-OVX + Sham hearts, p < 0.0001) with no influence of hormonal status. Left ventricular end-diastolic pressure, measured in vivo, was increased in all MI groups without significant differences between groups. Pressure-volume curves, obtained in perfused hearts, demonstrated a right and downward shift with reduced maximum left ventricular developed pressure post-MI (75 +/- 6 vs. 108 +/- 3 mm Hg in non-OVX + Sham hearts, p < 0.001) and were also unaffected by either OVX or E2 replacement.

CONCLUSIONS

Chronic endogenous estrogen deficiency does not have major effects on the development of cardiac hypertrophy, dysfunction and dilation post-MI.

Single dose aztreonam in treating gonorrhoea

Of 108 consecutive patients with urogenital gonorrhoea treated with a single 1 g intramuscular dose of aztreonam, 102 were suitable for evaluation. There was 100% cure at urogenital sites but treatment failed at three of 14 (21%) rectal or pharyngeal sites. In vitro resistance to aztreonam was not noted.