Objectives: To ascertain which factors are most significant in a general practitioner's decision to stay in rural practice and whether these retention factors vary in importance according to the geographical location of the practice and GP characteristics. Design: National questionnaire survey. The method of paired comparisons was used to describe the relative importance of the retention items. Setting: Non‐metropolitan Australia, September 2001. Participants: A stratified sample of all rural GPs practising during April–June 2001. Main outcome measures: A rank ordering of factors influencing how long GPs stay in rural practice, and an index of their relative perceived importance. Results: Professional considerations — overwhelmingly, on‐call arrangements — are the most important factors determining GP retention in rural and remote areas. Rural doctors consistently ranked on‐call arrangements, professional support and variety of rural practice as the top three issues, followed by local availability of services and geographical attractiveness. Proximity to a city or large regional centre was the least important factor. Retention factors varied according to geographical location and GPs' age, sex, family status, length of time in the practice, and hospital duties. Conclusions: A broad, integrated rural retention strategy is required to address on‐call arrangements, provide professional support and ensure adequate time off for continuing medical education and recreation.

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We have treated 37 patients with intractable pain (35 with cancer-related pain) by continuous intrathecal morphine infusion via implanted pump. These patients were carefully selected according to specific criteria, and each demonstrated a significant reduction in pain following a test dose of intrathecal morphine. All patients had good pain relief from intrathecal morphine infusion, even with pain located in cervical dermatomes. Systemic narcotics could be withdrawn from most patients. Significant side effects were rare and typically self-limited. Many patients required gradually increasing doses, seemingly related to disease progression. Two patients with non-malignant pain have had variable dose requirements over 28 and 44 months without clear tolerance. In these patients we observed a reduction in side effects associated with systemic opioids when continuous intrathecal opioid infusion was instituted. Intrathecal opioid administration may have fewer complications than ablative pain relief procedures. In properly selected patients, this method offers an effective alternative for pain relief.

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BackgroundProgression from nonsevere sepsis—i.e., sepsis without organ failure or shock—to severe sepsis or shock among emergency department (ED) patients has been associated with significant mortality. Early recognition in the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes. We sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic shock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis.MethodsThis is a retrospective cohort of patients presenting to a single urban academic ED from November 2008 to October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the ED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure <90 mmHg upon triage, an initial whole blood lactate level ≥4 mmol/L, or one or more of a set of predefined signs of organ dysfunction upon initial assessment. Disease progression was defined as the development of any combination of the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on predefined potential predictors of disease progression and outcome measures of disease progression were collected by a query of the electronic medical record and via chart review. Logistic regression was used to assess associations of potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension, or death.ResultsIn this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial serum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40–9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED triage (OR 4.59; 95 % CI 1.57–13.39; p < 0.01) were independently associated with disease progression to severe sepsis or shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation.ConclusionsIn our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg independently predict early progression to severe sepsis or shock among ED patients with presumed sepsis.

Sixteen adult captive bald eagles (Haliaeetus leucocephalus) underwent a complete bilateral ocular examination to assess normal ocular parameters and describe ophthalmic lesions. Tear production was measured with the Schirmer tear test 1 and intraocular pressure was measured with applanation tonometry. The menace response was normal bilaterally in 13 of 16 eagles. Two birds had normal menace responses despite having fundic lesions, and 2 birds with an inconsistent or absent menace response did not have appreciable ophthalmic lesions. Mean (SD) tear production was 14 +/- 2 mm/min (range, 8-19 mm/min). Mean intraocular pressure was 21.5 +/- 1.7 mm Hg (range, 15-26 mm Hg). At least 1 ocular lesion was present in 50% of examined eyes. Cataracts, the most common lesion observed, were present in 8 eyes of 5 birds. Three of 4 known geriatric birds were or had been affected with bilateral cataracts. Overall, ocular lesions are common in captive bald eagles, and cataracts appear to be more prevalent in geriatric bald eagles. An obvious positive menace response is present in most visual birds but may be absent in some eagles that are either normal or that do not have appreciable ophthalmic lesions. Applanation tonometry and the Schirmer tear test 1 can be performed easily on adult bald eagles and provide reproducible results.

Background: Burnout has become endemic in medicine, across all specialties and levels of training. Grit, defined as "perseverance and passion for long-term goals," attempts to quantify the ability to maintain sustained effort throughout an extended length of time. Our objective is to assess burnout and well-being and examine their relationship with the character trait, grit, in emergency medicine residents.Methods: In Fall 2016, we conducted a multicenter cross-sectional survey at five large, urban, academically affiliated emergency departments. Residents were invited to anonymously provide responses to three validated survey instruments; the Short Grit Scale, the Maslach Burnout Inventory, and the World Health Organization-5 Well-Being Index.Results: A total of 222 residents completed the survey (response rate = 86%). A total of 173 residents (77.9%) met criteria for burnout and 107 residents (48.2%) met criteria for low well-being. Residents meeting criteria for burnout and low well-being had significantly lower mean grit scores than those that did not meet criteria. Residents with high grit scores had lower odds of experiencing burnout and low well-being (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.46-0.85; and [OR] = 0.33, 95% CI = 0.16-0.72, respectively). Residents with low grit scores were more likely to experience burnout and more likely to have low well-being (OR = 6.17, 95% CI = 1.43-26.64; and OR = 2.76, 95% CI = 1.31-5.79, respectively).Conclusion: A significant relationship exists between grit, burnout, and well-being. Residents with high grit appear to be less likely to experience burnout and low well-being while those with low grit are more likely to experience burnout and low well-being.

The objectives of this study were to determine reference intervals, perform longitudinal analyses, and determine the index of individuality (IoI) of 8 hematologic, and 13 biochemical and electrophoretic variables for a group of captive bald eagles (Haliaeetus leucocephalus). Reference intervals were determined from blood samples collected during annual wellness examinations for 41 eagles (23 male and 18 female) with ages ranging between 6 and 43 years (18.7 +/- 7.4, mean +/- SD) at the time of sample collection. Longitudinal analyses and IoI were determined for measured hematologic, biochemical, and protein electrophoretic variables, both individually and as a group, for a subset of 16 eagles (10 male and 6 female) during a 12-year period. This smaller group of eagles ranged in age between 2 and 20 years at the start of the study period, and between 14 and 32 years (21.9 +/- 5.0, mean +/- SD) at the end of the study period. Significant increases with age within the group of 16 eagles were observed only for red blood cells, percent heterophils, total protein, and beta-globulin protein fraction, while albumin:globulin decreased significantly with age. A low IoI (> or = 1.4) was determined for all hematologic and biochemical variables except gamma globulins, which had high IoI (< or = 0.6) for 3 individuals within the subset of 16.