Understanding Burnout Among US Radiation Oncology Residents

PURPOSE/OBJECTIVE(S)

Burnout is a significant concern among medical residents in the United States, including those in radiation oncology. This study aims to understand the extent of burnout among radiation oncology residents and identify modifiable factors within program structure and benefits that may help improve overall wellness and reduce burnout.

MATERIALS/METHODS

A Qualtrics-based survey was administered to US radiation oncology program directors and coordinators, utilizing contact information gathered in FREIDA, with a request to forward to all residents. The survey included questions on benefits and program structure as well as the Maslach Burnout Inventory. Data was analyzed using descriptive statistics.

RESULTS

To date, 82 of 736 residents (11.1%) completed the survey with representation from all PGY-levels. Median participant age was 31, and 53% identified as male. 20% of surveyed residents feel emotionally drained from work a few times a week and 6% feel emotionally drained daily. 59% feel burned out from work at least a few times a month, with 6% feeling burned out daily. Despite this, 85% feel they are positively influencing other people's lives through their work at least weekly and 77% feel they have accomplished many worthwhile things in this job at least weekly. 65% have salaries between $60,000-$74,999, and 35% have the opportunity to moonlight for supplemental income. 49% have 3 weeks of vacation and 48% have 4 weeks. 27% reported their department had funded wellness events. 61% reported dual coverage rotations, with 40% requiring coverage of multiple attendings in one day. 65% reported protected academic time on all rotations, and 7% have no protected academic time. 48% of respondents have 12 months of research time. 85% and 36% of those with research and protected academic time, respectively, can complete this off-site. Respondent concerns include the job market (62%), declining personal fertility in residency (46%), and cost of living (40%). The most reported ways to decrease stress and anxiety were exercise (35%), a strong support system (34%), and spirituality (10%). Increased salary was identified as the top benefit that could improve wellness by 41 residents, while retirement matching (32), paid gym memberships (23), a personal wellness stipend (30), and free/subsidized childcare (16) were also ranked among the top 5 benefit changes that could improve wellness. Increased mid-level support (16), more protected academic time during the week (15), and flexibility with work location during academic/research time (13) were the top aspects of program structure that were reported as opportunities to improve wellness.

CONCLUSION

Burnout is prevalent among US radiation oncology residents, and changes to residency programs and expanded institutional benefits are strongly perceived as the key components to improved resident wellness. This study highlights the need for further investigation into the root causes of burnout and the development of evidence-based strategies.

Assessment of the efficacy of a Crisis Intervention Team (CIT): experience in the Esplugues Mental Health Center (Barcelona)

AIM

Crisis Resolution Teams (CRT) have shown positive clinical and service-use results in various countries but evidence in the south of Europe is scarce. The aim is to assess the impact of the Crisis Intervention Team (CIT) in Spain with respect to the course of symptomatology and mental health services use in patients served.

METHODS

Prospective observational cohort study. Assessment of the psychopathological severity (HoNOS scale) of the clinical course (CGI scale) and use of medical services.

RESULTS

A positive clinical course was observed following the intervention. The mean difference in HoNOS (Health of the Nation Outcome Scales) scores between baseline and discharge was 7 points (p < 0.05). On discharge, more than 60% of patients had improved their symptomatology according to the CGI scale (Clinical Global Impression) and most were discharged due to improvement or goal achievement. A tendency to reduction in the number of admissions to acute units and day hospital was observed, along with fewer emergency room visits. In contrast, an increase in the number of admissions to subacute units was seen. During the intervention, the median number of visits to the center was 15 and the median duration of care provision by the CIT was 39 days.

CONCLUSIONS

The CIT intervention promotes patients' clinical improvement and has a positive impact in terms of reducing acute hospitalizations and emergency room visits.

Survivorship of wild caught Mepraia spinolai nymphs: The effect of seasonality and Trypanosoma cruzi infection after feeding and fasting in the laboratory

Chagas disease is caused by Trypanosoma cruzi. Vector survival is an important variable affecting vectorial capacity to determine parasite transmission risk. The aims of this study are to evaluate vector survival under fasting/starvation conditions of wild-caught Mepraia spinolai after feeding and fasting, the pathogenicity of T. cruzi infection, the parasite burden and seasonal variation in parasite discrete typing units (DTU). The survivorship of M. spinolai nymphs after two continuous artificial feedings was evaluated, assessing their infection with microscopic observation of fecal samples and PCR. Later, insects were fasted/starved until death. We performed qPCR analyses of parasite load in the fecal samples and dead specimens. T. cruzi genotyping was performed using conventional PCR amplicons and hybridization tests. Infection rate was higher in M. spinolai nymphs in summer and spring than in fall. Parasite burden varied from 3 to 250,000 parasites/drop. Survival rate for starved nymph stage II was lower in insects collected in the spring compared to summer and fall. TcII was the most frequent DTU. Mainly metacyclic trypomastigotes were excreted. We conclude that M. spinolai infection rate in nymphs varies among seasons, suggesting higher transmission risk in warmer seasons. However, nymphs stage II collected in spring are more sensitive to starvation compared to other seasons. TcII in single or mixed infection does not seem relevant to determine vector pathogenicity. These results of vector survivorship after fasting/starvation are important to determine the competence of M. spinolai as a vector of T. cruzi, since they excrete metacyclic trypomastigotes and the parasitism with T. cruzi seems to be poorly pathogenic to the vector under a severe fasting/starvation condition.

Comparison of clinical and cognitive characteristics of a Mexican adult clinical population with and without ADHD

Introduction. Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting approximately 5% of the world population, with symptoms that may persist into adulthood. Despite the findings on the clinical course of this disorder, information regarding comorbidity patterns, psychosocial and executive functioning in adult life in those with and without ADHD in Latin American samples is scarce. Objective. The aim of this study is to compare the comorbidity pattern, psychosocial, and executive functioning of adults with and without ADHD from a clinical sample. Method. One hundred and fifty-one patients between 20 and 45 years, with screened positively on ASRS-V1.1, were invited to continue an evaluation process as part of clinical research program (PROMETEO): 1) K-SADS-PL Mx interview, 2) MINI-Plus interview, ASRS-V1-1 18 item version, BRIEF self-reported questionnaire, SCQA-ADHD, and 3) Individual case review by clinical expert in ADHD. Results. Individuals in the ADHD group had a higher average of comorbid disorders (2.5 SD 1.1 vs. 1.3 SD 1.0 respectively, F = .439; t = -6.621; df = 149; p < .001), more likelihood of procrastinating (OR = 6.5; 95% CI[2.6, 16.2]; z = 4.0) and were more likely to present difficulties in both the behavior regulation index (OR = 104.9; 95% CI[31.8, 345.7]; z = 7.65) and the metacognitive index (OR = 94.79; 95% CI[29.10, 308.76]; z = 7.56) compared to the non-ADHD group, regardless of gender. Discussion and conclusions. Our results indicate that the ADHD adult group presented with more comorbidity, and worse psychosocial and executive functioning than non-ADHD adults.

Minicircle classes heterogeneity within the TcIII and TcIV discrete typing units of Trypanosoma cruzi

The taxon Trypanosoma cruzi, causative agent of Chagas disease, is composed of several discrete typing units (DTUs) named TcI-TcVI, and Tcbat. The history of the taxon T. cruzi is known, even though several controversial aspects remain as the relationships between TcIII and TcIV. We analyzed cloned T. cruzi stocks pertaining to the seven DTUs by filter hybridization tests of PCR amplicons from minicircle variable regions and kinetoplast DNA probes. Minicircle DNA blots from the cloned stocks and filter hybridization with one TcI, one TcII, one TcV, one TcVI, three TcIII, one TcIV from North America and one TcIV kinetoplast DNA probes from South America revealed minicircle variable region cross-reaction in some T. cruzi DTUs probed. TcIII was heterogeneous in minicircle class composition, even though two TcIII probes revealed that a small fraction of minicircles cross-hybridized with the minicircles from the TcIII, TcV and TcVI DTUs. The minicircles of TcIV from North America cross-reacted only with TcIV from North America but not with TcIV stocks from Brazil and Bolivia. The results on minicircle cross-hybridizations are discussed in the context of RNA editing, mitochondrial function in T. cruzi DTUs.

Prevención Cuaternaria: Ética Médica, Evaluación y Eficiencia en los Sistemas de Salud

La prevención Cuaternaria consiste en desarrollar cuidados de salud y de ejercer la medicina, priorizando los cuidados centrados en la persona. Su marco conceptual se sustenta en aspectos éticos y filosóficos centrales en el ejercicio de la medicina, en aspectos epistemológicos y de carácter social. Su objeto es proteger fundamentalmente a los pacientes, pero también a los integrantes del equipo de salud, de los excesos de la medicalización y de los excesos o prácticas innecesarias o dañinas. El presente artículo es el resultado de la síntesis de los documentos de trabajo, discusión y propuestas llevadas adelante por un amplio grupo de comprometidos profesionales de CIMF, con interés particular sobre la Prevención Cuaternaria. Los materiales se produjeron en forma colaborativa por medio de un largo y complejo proceso de trabajo a distancia, realizado durante los foros preparatorios de la VI Cumbre Iberoamericana de Medicina Familiar y Comunitaria. A estos materiales se sumaron los documentos de trabajo elaborados durante la misma cumbre en San José de Costa Rica, en el mes de abril de 2016. El cometido de este artículo es difundir el estado de desarrollo y de compromiso actual con este enfoque y el destacado impulso que ha tenido en Iberoamérica en los últimos cinco años. Por su relevancia, se pretende estimular una mayor difusión del concepto: la implementación de contenidos relacionados con él en la formación y en el nivel académico. A nivel político promover su consideración en la toma de decisión, en políticas de salud pública. Difundir a nivel poblacional y promover la elaboración de contenidos de calidad. Ofrecer pistas de reflexión y herramientas concretas para su aplicación.

[Prognostic implications of folliculo-stellate cells in pituitary adenomas: relationship with tumoral behavior]

INTRODUCTION

Despite progress in understanding its pathogenesis, there has not yet been found any independent predictive marker of aggressive behavior of pituitary adenomas, to facilitate the treatment and monitoring of patients.

AIM

To analyze the expression of folliculo-stellate cells by immunostaining with S-100 protein, in a series of patients with pituitary adenomas followed for at least seven years.

PATIENTS AND METHODS

A retrospective study of 51 patients diagnosed with a pituitary adenoma between 2006 and 2008 was performed, according to current criteria established by the World Health Organization. The S-100 expression in folliculo-stellate cells was immunohistochemically evaluated, correlating it with clinico-radiological and histopathological tumor parameters and post-operative progression/recurrence.

RESULTS

Of 51 tumors, 40 were classified as typical and 11 as atypical pituitary adenomas. Most typical pituitary adenomas showed positive folliculo-stellate cells for S-100 (mean: 3.93%); atypical had little/no cell S-100 positive (mean: 0.83%). There were no significant differences in the expression of S-100 with respect to age or sex of the patient, size, invasiveness or post-operative tumor recurrence.

CONCLUSIONS

In our study group, with the exception of non-functioning adenomas immunopositive for prolactin, with the lowest and highest average of all subtypes in both groups (typical 0.25% vs atypical 9.24%; p = 0.0028), the predictive factor of tumor aggressiveness for pituitary adenomas, is not represented by a low value of S-100 in folliculo-stellate cells, not allowing select patients for intensive post-operative treatment.

Trypanosoma cruzi diversity in infected dogs from areas of the north coast of Chile

As part of a multi-site research program on the eco-epidemiology and control of Chagas disease in northern Chile, we sought to identify the Trypanosoma cruzi discrete typing units (DTUs) infecting rural and peridomestic dogs, using direct methods without grown of the parasite in the laboratory and thus to assess the use of this species as a sentinel of the disease in well-defined endemic areas of T. cruzi in Chile. Infected dogs (35) from three villages were included in the study. The studied villages were Caleta Río Seco and Caleta San Marcos, both in the Tarapacá Region, and La Serena in the Coquimbo Region. These villages were selected based on previous evidence of Mepraia infection reports of the Chilean Ministry of Health. Amplicons from nested-PCR positive samples were used as targets to determine the infective T. cruzi DTUs circulating in blood using PCR-DNA blotting and hybridization assays with five specific DNA probes (TcI, TcII, TcIII, TcV and TcVI). Results of hybridization with dog samples from Caleta Rio Seco showed single infections in 2 out of 16 and mixed infections in 14 out of 16. TcVI was the most frequent DTU found in this area. A highlight is that for the first time the presence of TcIII is reported in this area. Samples from Caleta San Marcos showed single infections in 5 out of 9 and mixed infections in 4 out of 9. TcVI was the most frequent DTU found in this area. Samples from La Serena showed single infections in 5 out of 10 and mixed infections in 2 out of 10; we were unable to genotype the other 3 samples. Our results indicate that infection by T. cruzi DTUs in dogs is not homogeneously distributed but rather specific to each region of our country, as demonstrated by the differences in the T. cruzi DTU distribution in some localities.

Birth Control and Low-Income Mexican-American Women: The Impact of Three Values

Nineth-nine Mexican-American women who were identified as either high or low acculturated responded to questionnaires assessing the relationship between birth control attitudes, knowledge, and usage, and the values ascribed to motherhood, male dominance, and sexual expression. Using a multiple regression analysis, a significant positive relationship was found for both high and low acculturated women with respect to their attitudes toward birth control and the values ascribed to motherhood, male dominance, and sexual expression. Relative to birth control use, a significant positive relationship was found between this variable and the values ascribed to motherhood, male dominance, and sexual expression for the low but ntot the high acculturated women. Finallh, no significant relationship was found between birth control knowledge and the aforementioned values. It should be noted that the differences between the low and high acculturated women persisted even while holding their socioeconomic level constant.

Mid-infrared nonlinear optical response of Si-Ge waveguides with ultra-short optical pulses

We characterize the nonlinear optical response of low loss Si(0.6)Ge(0.4) / Si waveguides in the mid-infrared between 3.3 μm and 4 μm using femtosecond optical pulses. We estimate the three and four-photon absorption coefficients as well as the Kerr nonlinear refractive index from the experimental measurements. The effect of multiphoton absorption on the optical nonlinear Kerr response is evaluated and the nonlinear figure of merit estimated providing some guidelines for designing nonlinear optical devices in the mid-IR. Finally, we compare the impact of free-carrier absorption at mid-infrared wavelengths versus near-infrared wavelengths for these ultra-short pulses.

On the prediction of Hodgkin lymphoma treatment response

PURPOSE

The cure rate in Hodgkin lymphoma is high, but the response along with treatment is still unpredictable and highly variable among patients. Detecting those patients who do not respond to treatment at early stages could bring improvements in their treatment. This research tries to identify the main biological prognostic variables currently gathered at diagnosis and design a simple machine learning methodology to help physicians improve the treatment response assessment.

METHODS

We carried out a retrospective analysis of the response to treatment of a cohort of 263 Caucasians who were diagnosed with Hodgkin lymphoma in Asturias (Spain). For that purpose, we used a list of 35 clinical and biological variables that are currently measured at diagnosis before any treatment begins. To establish the list of most discriminatory prognostic variables for treatment response, we designed a machine learning approach based on two different feature selection methods (Fisher's ratio and maximum percentile distance) and backwards recursive feature elimination using a nearest-neighbor classifier (k-NN). The weights of the k-NN classifier were optimized using different terms of the confusion matrix (true- and false-positive rates) to minimize risk in the decisions.

RESULTS AND CONCLUSIONS

We found that the optimum strategy to predict treatment response in Hodgkin lymphoma consists in solving two different binary classification problems, discriminating first if the patient is in progressive disease; if not, then discerning among complete and partial remission. Serum ferritin turned to be the most discriminatory variable in predicting treatment response, followed by alanine aminotransferase and alkaline phosphatase. The importance of these prognostic variables suggests a close relationship between inflammation, iron overload, liver damage and the extension of the disease.

Nonlinear optical response of low loss silicon germanium waveguides in the mid-infrared

We have investigated the nonlinear optical response of low loss Si(0.6)Ge(0.4) / Si waveguides in the mid-infrared wavelength range from 3.25- 4.75μm using picosecond optical pulses. We observed and measured the three and four-photon absorption coefficients as well as the Kerr nonlinear refractive index. The dynamics of the spectral broadening suggests that, in addition to multiphoton absorption, the corresponding higher order nonlinear refractive phenomena also needs to be included when high optical pulse intensities are used at mid-infrared wavelengths in this material.

FT-IR and FT-Raman spectra of 6-chlorouracil: molecular structure, tautomerism and solid state simulation. A comparison between 5-chlorouracil and 6-chlorouracil

A Raman and IR study of the biomolecule 6-chlorouracil was carried out in the solid state. The unit cell found in the crystal was simulated as a tetramer form by density functional calculations. Specific scale factors and scaling equations deduced from uracil molecule were employed in the predicted wavenumbers of 6-chlorouracil. The scaled wavenumbers were used in the reassignment of the IR and Raman experimental bands. Good reproduction of the experimental wavenumbers is obtained and the % error is very small in the majority of cases. A comparison between the molecular structure and charge distribution of 6-chlorouracil and 5-chlorouracil molecules was presented. The effect of the hydration with the PCM model in the molecular structure and charges was discussed. The optimum tautomers of 6-chlorouracil were optimized and analyzed. Six of them were related to those of uracil molecule. The effect of the halogen substitution in the sixth position of the pyrimidine ring in the stability of the different tautomers was evaluated. HOMO and LUMO orbital energy analysis were carried out.

Common variant in VEGFA and response to anti-VEGF therapy for neovascular age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of visual impairment in aging populations in industrialized countries. Here we investigated whether the genotype of vascular endothelial growth factor A (VEGFA) gene is associated with response to anti-VEGF therapy. 223 eyes with neovascular AMD were treated with intravitreal anti-VEGF therapy. Responders were defined as patients who had an improvement in best corrected visual acuity (BCVA) of at least 5 letters or one line on the EDTRS visual acuity chart along with resolution of intraretinal or subretinal fluid over 12 months. Patients who did not meet the definition of responders were classified as poor-responders. The vision of responders (n = 148) improved while the vision of poor-responders (n = 75) worsened (P<0.001). Responders on average had a decrease in central foveal thickness (CFT), while poor-responders had an increase in CFT (P <0.001). Compared with the responder group, the poor-responder group had a higher frequency of the risk (T) allele (Allelic P = 0.019) and TT genotype (P = 0.002 under a recessive model) for the VEGFA-rs943080 polymorphism. VEGFA expression was 1.8-fold higher in cells with the VEGFA rs943080 TT genotype than in cells with the VEGFA rs943080 CC genotype (P = 0.012). Age, gender, smoking, diabetes mellitus, and hypertension did not play a significant role in treatment response, but BMI was found to be significantly different between responders and poorresponders (P = 0.033). In conclusion, we demonstrated a potential pharmacogenetic relationship between the VEGFA gene and treatment response to anti-VEGF therapy.The studies are registered at ClinicalTrials.gov under the identifiers NCT00474695 (http://clinicaltrials. gov/ct2/show/NCT00474695) and NCT01464723 (http://clinicaltrials.gov/ct2/show/NCT01464723).

Congenital co-infection with different Trypanosoma cruzi lineages

Variability of mixed Trypanosoma cruzi congenital infection in Chile in twenty one congenital samples of Chagas disease is reported. Recognition of infecting strains was performed by minicircle hybridization tests. Seven newborns with double infection were found. Trypanosoma cruzi TcII and TcV lineages were the most frequent in single and mixed infections. With these results we pretend to understand the epidemiological significance of the T. cruzi lineages for which the placenta does not seem to represent an actual barrier in congenital infections.

Simulation of a tetramer form of 5-chlorouracil: the vibrational spectra and molecular structure in the isolated and in the solid state by using DFT calculations

A Raman and FT-IR study of the biomolecule 5-chlorouracil in the solid state was carried out. The unit cell found in the crystal was simulated as a tetramer form by density functional calculations. They were performed to clarify the assignments of the experimentally observed bands in the spectra. Calculations in the monomer form and comparisons with the experimental data in Ar matrix were also carried out. The error in the calculated frequencies was analyzed and reduced by using scaling equations and scaling factors deduced from the uracil molecule. The calculations with the B3LYP method and with the 6-31G(d,p) and 6-311+G(2d,p) basis set, appear in general to be useful, when combining with a scaling equation procedure or with the specific scale factors, for interpretation of the general features of the IR and Raman spectra. The scaled values were used in the reassignment of the IR and Raman experimental bands. Comparison of the results with those determined in uracil and 5-halogenated derivatives were performed. The substitution at 5-position of the uracil ring by a chlorine atom has a little effect on the geometric parameters.

Caracterização bromatológica e agronômica de genótipos de milho para produção de silagem

O objetivo deste trabalho foi avaliar as características bromatológicas e agronômicas dos genótipos de milho para a produção de silagem dos cultivares do Ensaio Centro Superprecoce da Rede Nacional de Genótipos de Milho, bem como avaliar se a base genética (híbridos simples, duplos, tripos, intervarietais e variedades cultivadas) ou a dureza dos grãos (duro, semiduro e dentado mole) alteram a indicação de cultivares de milho para silagem. O experimento foi realizado na área experimental da Universidade Tecnológica Federal do Paraná (campus Dois Vizinhos). Os trinta e dois genótipos avaliados foram colhidos quando os grãos encontravam-se no estádio pastoso a farináceo, ensilados em microssilos de PVC e desensilados após 53 dias. Avaliou-se a relação entre as bases genéticas, a dureza do grão e as características individuais dos genótipos quanto à aptidão para a produção de silagem. Não se verificaram diferenças significativas entre os contrastes formados entre as bases genéticas, bem como a dureza dos grãos, para os caracteres estudados. Porém, foi possível identificar genótipos superiores para a produção de silagem pela produção de matéria seca pelos genótipos AS 1555 YG, AS 1572 YG, 30A37, 30A77, 20A78, Dx 908, Dx 603, 2A550, 2B433, AL2007A, Embrapa 1F640, PRE 22T10, PREXT0109, PRE 22D11, DKB330 YG (Test).

Caracterização agronômica de genótipos de milho para a produção de silagem

O objetivo deste trabalho foi avaliar às características agronômicas e a produtividade de seis genótipos de milho de ciclo super precoce quanto à produção de silagem no município de Dois Vizinhos, Paraná. O experimento foi conduzido na área experimental da Universidade Tecnológica Federal do Paraná. A altura média diferiu entre os cultivares, variando de 1,62 (Al-Piratininga) a 0,90 m (BMX 739). O híbrido AGN30A03 apresentou menor resistência ao acamamento de plantas e ao quebramento do colmo. Os genótipos BMX 739, CD 304, PRE22T11 e Al-Piratininga obtiveram as maiores produtividades de massa verde (638,81; 455,18; 620,98; 460,12 g planta-1, respectivamente). A variedade Al-Piratininga apresentou número de espigas planta-1 (1,11) superior ao das demais. Entre os materiais avaliados, o genótipo BMX 739, se destacou pelo rendimento de matéria seca ensilável por área e pela participação percentual de espiga (29 %) e grãos (26 %) na fitomassa.

Solid state simulation of tetramer form of 5-aminoorotic acid: the vibrational spectra and molecular structure study by using MP2 and DFT calculations

The Raman and IR spectra of the biomolecule 5-aminoorotic acid in the solid state were simulated by a dimer and tetramer forms, with the special interest in the interactions that involve the NH and NH(2) groups. The unit cell expected in the crystal was simulated as a tetramer form by density functional calculations. They were performed to clarify wavenumber assignments of the experimentally observed bands in the spectra. Correlations with the molecule of uracil were made, and accurate scaling procedures deduced by us were employed in the calculated wavenumbers of 5-aminoorotic acid. Good reproduction of the experimental wavenumbers is obtained and the % error is very small in the majority of cases. This fact confirms our simplified solid state model. The scaling leads to a reassignment of the IR and Raman experimental bands. The NBO atomic charges and several thermodynamic parameters were also calculated.

[Primary lung paraganglioma. A case report]

Primary lung paragangliomas are rare. They are 1-2% of the paragangliomas, and most of them occur in patients of 43-61 years. They clinically appear as solitary tumors and are in general asymptomatic. These tumors show a nesting pattern (Zellballen) of chief polygonal cells locked by fibrovascular trabeculae with subtenticular cells. The main cells have uniform nuclei with granular eosinophilic cytoplasm, and they are positive for neuroendocrinal markers (Neuron Specific Enolase, sinaptofisine and cromogranine A). Sustentacular cells are positive for protein S-100 and neurofibrilar protein. A differential diagnosis with the carcinoid tumor can be very difficult. The surgical treatment is mandatory , specially high blood pressure and the chances of malignization.