Long working hours, emergency calls, a never ending stream of patients and prolonged stress are factors that are common in the lives of doctors. In countries with a low doctor-patient ratio like India, doctors often experience overwhelming workload and excessive pressure. Factors such as lack of safety and vulnerability to violence further adds to this stress. Even before the coronavirus outbreak challenges healthcare providers like never before, physicians were experiencing a high rate of burnout. Several studies have pointed this out in recent years. A small but powerful indicative study published in the Indian Journal of Psychiatry in 2018 suggested that a significantly higher proportion of doctors in Indian setting experience stress, depression, and burnout. Out of the 445 responders in the study, 30.1% were found to have depression and 16.7% reported having suicidal thoughts. More than 90% of the participants reported some level of burnout.
The coronavirus outbreak has hugely magnified this problem, exacerbating the burnout rate in doctors and other healthcare staff particularly those involved in treating COVID 19 patients. Burnout is a condition where an individual experiences overwhelming mental and physical exhaustion owing to excessive stress. It not just affects the mental and physical health of the individual but also impacts his/her job related outcomes.
The COVID 19 burnout in doctors
In China, a cross-sectional study published in JAMA Network Open Journal in March 2020 found that the coronavirus outbreak had a devastating impact on the mental health of healthcare workers. Out of the 1257 respondents, 50.4% were found to have symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety and 71.5% reported distress. The researchers concluded that working in the frontline was an independent risk factor for worse mental health outcomes.
Doctors at the frontlines of the pandemic are facing extremely challenging working conditions. Long grueling working hours, constant emergencies, witnessing a high death rate and a persistent struggle to save lives not just cause physical exhaustion but also result in an emotional and mental turmoil. In countries where severely ill patients exceeded the healthcare capacity to treat, doctors had to actually choose whom to treat and whom to let die. Absence of a clear treatment route is another major work challenge.
Wearing PPEs for long hours is itself a major challenge. Once your PPE is on your ability to eat, drink water or even go to the washroom is restricted. The grueling heat makes long hours of wearing PPEs worse. However, the most significant challenge is the threat from the disease itself. Being in the midst of patients every day puts doctors at a high risk of caching the infection themselves. By first week of May, over 500 doctors, nurses and paramedics had already been infected by Coronavirus in the country. An AIIMS doctors was applauded for putting himself at significant risk when he removed his goggled and face shield to be able to clearly see and re-intubate a seriously ill patient. This tells us how doctors are putting themselves at risk during this global pandemic. As doctors get infected and result in a further depletion of workforce, the remaining physicians face an even greater workload.
Apart from all the above concerns, one major concern for doctors and healthcare staff is the threat of carrying the infection to their home and families.
How to address the burnout crisis
As much as it is important to ensure the safety of doctors, it is equally important to help them address the mental and physical outcomes of burnout. Governments, healthcare providers and hospitals must initiate a series of measures to help address this burnout crisis.
Adequate availability of protective equipment
Strict adherence to properly wearing PPEs has been found to be effective in minimizing infection rate among doctor and healthcare workers. It is extremely important therefore that governments and hospitals ensure adequate supply and sufficient availability of PPEs for doctors. Adequate supply of PPEs and addressing the shortage concerns also allays the mental stress and fear among doctors. It is also important to ensure that doctors do not have to wear the same protective equipment for more than 8-10 hours.
Access to counseling and mental health experts
The World Health Organization has advised doctors to take extra care of their health by consuming healthy food, taking adequate rest and staying active. The body has also recommended de-stressing and avoiding smoking or drugs. Hospitals must ensure that doctors have regular access to counseling support to advocate healthy living. They must also have access to mental health experts to give them a proper outlet for their mental and emotional turmoil.
Offering alternative stay arrangements
Governments and private healthcare providers must also arrange for alternative accommodation for doctors and other healthcare staff members to allow them stay away from their families during the time they are treating COVID 19 patients. This takes off the extra pressure and concern about carrying the virus home.
Reduce burden by adding to the manpower
With the number of patients rising steeply every day, we need to find innovative ways to have sufficient backup resource of doctors. In this situation, it makes sense to train final year MBBS and PG medical students in critical care and keep them ready to be deployed in case the need arises.
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STUDY FINDS LIVING NEAR OIL, GAS WELLS INCREASES AIR POLLUTION EXPOSURE
Stanford researchers have observed higher levels of air pollutants within 2.5 miles of oil and gas wells, likely worsening negative health outcomes for residents.
The findings of the study were published in the journal ‘Science of The Total Environment’.
The scientists analysed local air quality measurements in combination with atmospheric data and found that oil and gas wells are emitting toxic particulate matter (PM2.5), carbon monoxide, nitrous oxide, ozone and volatile organic compounds (VOCs). The findings will help researchers determine how proximity to oil and gas wells may increase the risk of adverse health outcomes, including preterm birth, asthma and heart disease.
“In California, Black and Latino communities face some of the highest pollutions from oil and gas wells. If we care about environmental justice and making sure every kid has a chance to be healthy, we should care about this. What’s novel about our study is that we’ve done this at a population, state-wide scale using the same methods as public health studies,” said lead author David Gonzalez, who conducted research for the study in Stanford’s Emmett Interdisciplinary Program in Environment and Resources (E-IPER).
The findings align with other smaller-scale studies that have measured emissions from a handful of wells. At least two million Californians live within one mile of an active oil or gas well.
“It’s really hard to show air quality impacts of an activity like oil and gas production at a population scale, but that’s the scale we need to be able to infer health impacts,” said senior study author Marshall Burke, an associate professor of Earth system science at Stanford’s School of Earth, Energy and Environmental Sciences (Stanford Earth).
The research has revealed that when a new well is being drilled or reaches 100 barrels of production per day, the deadly particle pollution known as PM2.5 increases by two micrograms per cubic meter about a mile away from the site.
A recent study published in ‘Science Advances’ found that long-term exposure to one additional microgram per meter cubed of PM2.5 increases the risk of death from COVID-19 by 11 per cent.
“We started in 2006 because that’s when local agencies started reporting PM2.5 concentrations. We’re very concerned about the particulate matter because it’s a leading global killer,” said Gonzalez.
The team evaluated about 38,000 wells that were being drilled and 90,000 wells in production between 2006 and 2019. They developed an econometric model incorporating over a million daily observations from 314 air monitors in combination with global wind direction information from the National Oceanic and Atmospheric Administration (NOAA) to determine if the pollutants were coming from the wells. They analysed locations with air quality data of before and after a well was drilled.
Ranking healthfulness of foods from first to worst: Study
A new tool has been developed by scientists at the Friedman School of Nutrition Science and Policy at Tufts to help consumers, food companies, restaurants, and cafeterias choose and produce healthier foods and officials to make sound public nutrition policy.
The findings of the study were published in the journal ‘Nature Food’. Food Compass is a new nutrient profiling system, developed over three years, that incorporates cutting-edge science on how different characteristics of foods positively or negatively impact health. Important novel features of the system include:
1. Equally considering healthful vs. harmful factors in foods (many existing systems focus on harmful factors);
2. Incorporating cutting-edge science on nutrients, food ingredients, processing characteristics, phytochemicals, and additives (existing systems focus largely on just a few nutrients); and
3. Objectively scoring all foods, beverages, and even mixed dishes and meals using one consistent score (existing systems subjectively group and score foods differently).
“Once you get beyond ‘eat your veggies, avoid soda,’ the public is pretty confused about how to identify healthier choices in the grocery store, cafeteria, and restaurant,” said the study’s lead and corresponding author, Dariush Mozaffarian, dean of the Friedman School.
The new Food Compass system was developed and then tested using a detailed national database of 8,032 foods and beverages consumed by Americans. It scores 54 different characteristics across nine domains representing different health-relevant aspects of foods, drinks, and mixed meals, providing for one of the most comprehensive nutrient profiling systems in the world.
The characteristics and domains were selected based on nutritional attributes linked to major chronic diseases such as obesity, diabetes, cardiovascular problems, and cancer, as well as the risk of undernutrition, especially for mothers, young children, and the elderly.
Food Compass was designed so that additional attributes and scoring could evolve based on future evidence in such areas as gastrointestinal health, immune function, brain health, bone health, and physical and mental performance; as well as considerations of sustainability.
Potential uses of Food Compass include encouraging the food industry food purchasing incentives for employees through worksite wellness, health care, and nutrition assistance programs; supplying the science for local and national policies such as package labelling, taxation, warning labels, and restrictions on marketing to children and enabling restaurants and school, business, and hospital cafeterias to present healthier food options.
Each food, beverage, or mixed dish receives a final Food Compass score ranging from 1 (least healthy) to 100 (most healthy). The researchers identified 70 or more as a reasonable score for foods or beverages that should be encouraged. Foods and beverages scoring 31-69 should be consumed in moderation. Anything scoring 30 or lower should be consumed minimally.
Across major food categories, the average Food Compass score was 43.2. The lowest-scoring category was snacks and sweet desserts (average score 16.4).The highest scoring categories were vegetables (average score 69.1), fruits (average score 73.9, with nearly all raw fruits receiving a score of 100), and legumes, nuts, and seeds (average score 78.6). Among beverages, the average score ranged from 27.6 for sugar-sweetened sodas and energy drinks to 67 for 100per cent fruit or vegetable juices.
STUDY FINDS LARGE DOSES OF INTENSIVE THERAPY BETTER FOR CHILDREN WITH CEREBRAL PALSY
Scientists report that children with cerebral palsy benefited most from 60 hours of Constraint-Induced Movement Therapy (CIMT) over four weeks.
The findings of the study were published in the journal ‘Pediatrics’.The study also showed that intensive therapy did not add stress for families. The findings could have far-reaching impacts on the treatment of children’s movement disorders.
The study by researchers at Virginia Tech’s Fralin Biomedical Research Institute at VTC, UVA Children’s, The Ohio State University, and Nationwide Children’s Hospital, has shown that higher doses of CIMT therapy — 20 three-hour sessions over four weeks — yield significant and lasting improvement in the use of their arms and hands, especially in everyday functional activities.
The Children with Hemiparesis Arm-and-hand Movement Project (CHAMP) study is the first to compare different dosage levels of the same type of CIMT intervention for similar children.
The study was funded by the National Institutes of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development.
“CHAMP provides new findings that are practically useful for clinicians and families in choosing treatment likely to produce meaningful benefits for children with hemiparetic cerebral palsy,” said Sharon Landesman Ramey, Distinguished Research Scholar at the Fralin Biomedical Research Institute and professor of psychiatry, psychology, and neuroscience at Virginia Tech, who led the study and is the paper’s corresponding author.
The study focused on children with hemiparetic cerebral palsy (HCP), the most common childhood neuromotor disorder. Cerebral palsy affects one to four children per 1,000 in the United States, and about 40 per cent of these children will develop hemiparesis — impaired voluntary control on one side of the body, according to the Centers for Disease Control and Prevention.
The study group included 118 children with HCP, two to eight years old, at three sites — Roanoke and Charlottesville in Virginia and Columbus, Ohio. CHAMP randomised and assigned children to different CIMT treatment groups that varied in their dosage level (30 versus 60 hours in four weeks) and the type of constraint used (cast versus splint). These treatment groups were compared with a Usual and Customary Treatment group — that later was offered a form of CIMT as an ethical option for study participation.
The form of CIMT therapy, known as ACQUIREc, was developed by co-principal investigators Stephanie DeLuca and Ramey, who also co-direct the Fralin Biomedical Research Institute at VTC Neuromotor Research Clinic, along with Karen Echols and other colleagues at the University of Alabama at Birmingham.
The CHAMP study found that the higher intensity therapy sessions — three hours a day, five days a week for four weeks — significantly improved upper arm and hand abilities while a lower dosage of 30 hours per month (2.5-hour sessions, three days a week for four weeks) produced fewer gains. The children’s early improvements continued for at least six months after higher-intensity CIMT.
The therapy can be life-changing for children. Kim Hindery, whose daughter, Abigail, 6, was part of the study in Ohio, witnessed a dramatic difference during and then after the therapy.
“I could literally see her brain changing. I’ll never forget when she looked up at her hand and goes, ‘Oh!’ — just mesmerised, like, ‘It exists!’ Being able to see a light bulb go off in your child’s head that you never thought you would see go off is priceless,” Hindery said.
Those benefits are well-known to DeLuca who has overseen the delivery of ACQUIRE therapy to more than 500 children.
“The therapists are trained to ensure each child has many successes in every therapy session,” said DeLuca, who is an associate professor at the research institute and in paediatrics and neuroscience at Virginia Tech.
“The child sees and feels their improvement and becomes an active partner in the therapy. ACQUIRE therapy increases children’s willingness to tackle new and difficult activities,” DeLuca added.
The study shows parents who worried about the intensity of the therapy and use of the cast that they should have little concern. The study also unexpectedly showed that Usual and Customary Treatment benefited children more than it did in the past, which Landesman Ramey said should be reassuring to parents whose children receive other forms of therapy.
Patients below 40 should avoid knee replacement surgeries, say experts
Doctors have warned that knee replacement surgeries in osteoarthritis patients less than 40 years of age can do more harm than good.
Osteoarthritis in young people may be caused by surgical removal of an injured meniscus, C-shaped cartilage in the knee, or injury to the articular cartilage (chondro) and the bone under it, or insufficiency of the ligament. This disturbs the alignment of the knee by placing abnormal stresses on the cartilage of the affected compartment, thus causing pain and difficulty in walking.
According to doctors, there are other procedures that can be used to avoid knee surgeries.
“Simpler technically demanding procedures like cartilage regeneration surgeries are done with the help of keyhole made into the joint and cartilage harvested and grown in the lab. These procedures can manage early degenerative changes that happen only in half the need to start with mostly the inner side. If treated on time, they can give almost like natural cartilage growing there and can avoid knee replacement surgery,” said Dr Shubhang Aggarwal, Senior Joint Replacement Surgeon, and Director, NHS Hospital, Jalandhar.
“The need for knee replacement surgery in young arthritic patients who have degenerative changes in one compartment of the knee joint is overemphasised. Even though we do robotic surgery which gives a perfect alignment and ensures that the implants which are put in last up to 30 years, still, it is advisable that in very young patients especially with osteoarthritis alternate methods of treatment even if they are surgical should be considered.” He added
Dr Vivek Mahajan, senior orthopaedic at Indian Spinal Injuries Centre, said, “Usually in younger patients, the cause of knee pain is due to meniscal tear or ligament injury or cartilage damage which if neglected can lead to osteoarthritis in future. These injuries should be addressed in time and can be managed by simple arthroscopy or keyhole surgery which can prolong the life of knee joint.”
Some of the experts also suggest that degenerative or inflammatory arthritis at a young age would be treated by non-operative treatment like weight reduction therapies, physiotherapy etc.
“As far as a knee replacement is considered, it is usually recommended in the older age group. Generally, the procedure is offered after the age of 60. That does not mean that patients below 40 should continue to suffer even if they have significant pain because of arthritis. Inflammatory arthritis such as rheumatoid arthritis can damage the joint at a relatively young age and cause serious disability. This may need a knee replacement at an early age,” said Dr Yash Gulati, Senior Consultant Orthopaedics, Joint Replacement and Spine, Indraprastha Apollo Hospitals, New Delhi.
FIRST CHILDREN-FRIENDLY COVID-19 VACCINATION CENTRE COMES UP IN DELHI
One of the private imaging centres in Delhi has become the first Covid-19 vaccination centre for children in India. The centre would cater to children above 2 years to 18 years and their vaccination process.
The new children-friendly Covid-19 vaccination centre has been given a catchy look and feel. The centre has been painted with cartoons and animal themes in a way that will help to reduce the injection fear among the children. It also has paintings of popular cartoons like Motu-Patlu, dinosaurs etc on the wall. This kids’ vaccination centre is getting a lot of praise from the residents and Children are also coming to see the centre.
“If we see demographic distribution then the age group of 0-18 years isn’t less. We can’t leave them unvaccinated, because diseases in children are not severe but still, they are potential carriers,” said Dr Sameer Bhati, Director, Star Imaging and Path Labs.
The purpose behind opening this centre is to engage children post-vaccination when they will be under observation and to remove fear from their minds.
Dr Bhati further said, “The anxiety and fear that parents have for children regarding vaccination, and engaging children post-vaccination is important. We have given it a catchy look in a way that can engage children in other activities after vaccination.”
The guidelines for Covid-19 vaccination for children who come under comorbidities is still pending. It’s expected that these guidelines may come soon after the complete clearance of DCGI to Bharat Biotech’s Covaxin for children. The Drugs Controller General of India (DCGI) has already given clearance to Zydus Cadila’s DNA vaccine ZyCoV-D for those above 12-18 years.
“The comorbid group in children is also at high risk. The obesity group is also at high risk. According to the latest studies, we are waiting for Covid-19 vaccination guidelines for children who come under comorbidities. SEC has recommended Covaxin also,” he added.
How Covid-19 could bring adverse complications for pregnant women
Assessing 2,471 women in the third trimester of their pregnancy, close to their delivery, researchers found “significant differences” for symptomatic covid positive patients including higher rates of gestational diabetes, lower white blood cell counts, and heavier bleeding during delivery, whilst respiratory complications were witnessed in their babies.
The peer-reviewed findings were published in The Journal of Maternal-Fetal and Neonatal Medicine. The study finds an increased risk of poorer outcomes for the newborns and symptomatic women with COVID-19, which adds further weight to the argument for pregnant women to be vaccinated for the virus.
Thankfully in the group of patients — which included 172 Covid positive women (56 of whom were symptomatic)– monitored at the Mayanei Hayeshua Medical Center in Israel, only one person needed mechanical ventilation, and there were no maternal deaths.
They show, lead Dr Elior Eliasi stated that COVID-19 in the third trimester of pregnancy “has clinical implications, albeit at lower rates than expected once asymptomatic patients are taken into account.”
The analysis found that there was no significant increase in cesarean delivery in women, who were COVID-19 positive and the incidence of preterm deliveries was not significantly different among the three groups (healthy, covid positive asymptomatic, covid positive symptomatic). Most pregnancy and delivery outcomes were similar between COVID-19-positive and -negative parturients (a woman about to give birth; in labour).
Dr Eliasi said, “However, There were significant differences between the COVID-19-positive and healthy controls included higher rates of GDM (gestational diabetes), low lymphocyte counts (white blood cell count) which were significantly lower, postpartum hemorrhage (bleeding during birth), and neonatal respiratory complications.”
“Our findings support the importance of vaccinating all pregnant women at all stages of pregnancy,” he added.
The study looked at births at the hospital between 26 March and 30 September 2020. A total of 93 per cent of women admitted to the labour ward during this period were negative for COVID-19. Of the COVID-19-positive patients, 67 per cent were asymptomatic.
On average the increase risk of incidence of adverse outcomes was 13.8 per cent higher for asymptomatic covid patients and 19.6 per cent higher for those symptomatic.
“More data is now needed to better delineate the differences between pregnancy outcomes seen in certain populations, potentially related to different viral characteristics (subtypes, viral load), patient epigenetics, or other factors. Additionally, the effects of maternal infection on the fetus both in terms of symptomatic maternal illness and vertical viral transmission remain to be further investigated,” the authors stated.
Limitations of this study include it being retrospective; whilst another is that the sample includes a relatively healthy population admitted to just a single community hospital. “Therefore,” the authors stated their findings, “may not be generalizable to all populations.”
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