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The tragic death of an anaesthetic trainee driving home after a series of night shifts prompted a national survey of fatigue in trainee anaesthetists. This indicated that fatigue was widespread, with significant impact on trainees' health and well-being. Consultants deliver an increasing proportion of patient care resulting in long periods of continuous daytime duty and overnight on-call work, so we wished to investigate their experience of out-of-hours working and the causes and impact of work-related fatigue. We conducted a national survey of consultant anaesthetists and paediatric intensivists in the UK and Ireland between 25 June and 6 August 2018. The response rate was 46% (94% of hospitals were represented): 84% of respondents (95%CI 83.1-84.9%) contribute to a night on-call rota with 32% (30.9-33.1%) working 1:8 or more frequently. Sleep disturbance on-call is common: 47% (45.6-48.4%) typically receive two to three phone calls overnight, and 48% (46.6-49.4%) take 30 min or more to fall back to sleep. Only 15% (14.0-16.0%) reported always achieving 11 h of rest between their on-call and their next clinical duty, as stipulated by the European Working Time Directive. Moreover, 24% (22.8-25.2%) stated that there is no departmental arrangement for covering scheduled clinical duties following a night on-call if they have been in the hospital overnight. Overall, 91% (90.3-91.7%) reported work-related fatigue with over half reporting a moderate or significantly negative impact on health, well-being and home life. We discuss potential explanations for these results and ways to mitigate the effects of fatigue among consultants. [ABSTRACT FROM AUTHOR]

Long daytime and overnight shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. The Working Time Regulations (1998) implemented the European Working Time Directive into UK law, and in August 2009 it was applied to junior doctors, reducing the maximum hours worked from an average of 56 per week to 48. Despite this, there is evidence that problems with inadequate rest and fatigue persist. There is no official guidance regarding provision of a minimum standard of rest facilities for doctors in the National Health Service, and the way in which rest is achieved by trainee anaesthetists during their on-call shift depends on rota staffing and workload. We conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK. We achieved a response rate of 59% (2231/3772 responses), with data from 100% of NHS trusts. Fatigue remains prevalent among junior anaesthetists, with reports that it has effects on physical health (73.6% [95%CI 71.8-75.5]), psychological wellbeing (71.2% [69.2-73.1]) and personal relationships (67.9% [65.9-70.0]). The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% (55.0-59.1) stating they had experienced an accident or near-miss when travelling home from night shifts. We discuss potential explanations for the results, and present a plan to address the issues raised by this survey, aiming to change the culture around fatigue for the better. [ABSTRACT FROM AUTHOR]

The article describes how 27 large UK financial institutions (FIs) sought to acquire an information and influence advantage from the relationships they enjoyed with investee companies in their portfolio. The financial institutions invested much time and effort cultivating these links and contacts. The primary aim of this relationship investment decision was to produce added value in stock selection and asset allocation decisions. The resulting fund performance was the means for financial institutions to satisfy a fiduciary duty to supply their clients with their preferred mix of return, diversification and liquidity. This problem area is investigated by using financial institutional case data to describe FI behaviour when interacting with their relationship investee companies. The article ends by analysing the case data and case structures through the perspective of finance theory. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim of this study was to define a classification in the WOMAC score after total knee arthroplasty (TKA) according to patient satisfaction. The secondary aims were to describe patient demographics for each level of satisfaction., Methods: A retrospective cohort consisting of 2589 patients undergoing a primary TKA were identified from an established arthroplasty database. Patient demographics, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and short form (SF) 12 scores were collected pre-operatively and 1 year post-operatively. In addition, patient satisfaction was assessed at 1 year with four responses: very satisfied, satisfied, dissatisfied or very dissatisfied. Receiver operating characteristic (ROC) curves were used to identify values in the components and total WOMAC scores that were predictive of each level of satisfaction, which were used to define the categories of excellent, good, fair and poor., Results: At 1 year, there were 1740 (67.5%) very satisfied, 572 (22.2%) satisfied, 190 (7.4%) dissatisfied and 76 (2.9%) very dissatisfied patients. ROC curve analysis identified excellent, good, fair and poor categories for the pain (> 78, 59-78, 44-58, < 44), function (> 72, 54-72, 41-53, < 41), stiffness (> 69, 56-69, 43-55, < 43) and total (> 75, 56-75, 43-55, < 43) WOMAC scores, respectively. Patients with lung disease, diabetes, gastric ulcer, kidney disease, liver disease, depression, back pain, with worse pre-operative functional scores (WOMAC and SF-12) and those with less of an improvement in the scores, had a significantly lower level of satisfaction., Conclusion: This study has defined a post-operative classification of excellent, good, fair and poor for the components and total WOMAC scores after TKA. The predictors of level of satisfaction should be recognised in clinical practice and patients at risk of a lower level of satisfaction should be made aware in the pre-operative consent process., Level of Evidence: III.