New medicine for the new millennium: a time for change?

Health care is under scrutiny. Demand exceeds supply and funding is insufficient. Rationing is a reality while providers feel persecuted. Yet patients remain patient--and continue to suffer. What can be done to improve the present situation?     

Electives: isn’t it time for a change?

Objectives  Medical student electives are memorable learning experiences, of which approximately 40% are spent in developing countries. Students often have laudable motivation but are rarely helped to learn most effectively or contribute meaningfully whilst away. Each year an estimated 350 years of elective time is spent in developing countries (by students from the UK alone), which represents substantial opportunity.
Methods  We conducted a literature search prior to developing an alternative approach towards electives based upon educational and ethical principles.
Results  Despite their anecdotal value there has been little empirical research conducted into electives. From our review we identified four key learning domains (Clinical Knowledge and Skills, Attitudes, Global Perspectives, Personal and Professional Development) and two broader issues (Institutional Benefits and Moral/Ethical Considerations). Potentially beneficial and more structured alternatives are emerging and improvements appear possible through institutional collaborations and greater planning in order to maximise the educational experience, opportunities to contribute and minimise the risks involved in electives.
Conclusions  Electives are a highlight of clinical training but probably often represent missed opportunities. There are both educational and moral reasons for seeking more considered approaches to reduce the 'medical tourism' that can result from the current largely ad hoc arrangements.     

Reviewing the value of clinical audit: is now the time for a change?

Many different activities have been defined for the effective use of clinical audit. Proposes a method of linking the practice and outcome of audit with the Trust business people, setting out criteria methodology and background following a two-year research study.     

Haemochromatosis: a time for guidelines?

Hereditary haemochromatosis is an autosomal recessive metabolic abnormality which causes excessive absorption of dietary iron. Iron accumulation leads to potentially fatal damage to organs such as the heart, liver and pancreas. Normal life expectancy can be restored simply by therapeutic venesection. Discovery of the gene, HFE, has rekindled interest in pathogenesis, management and screening strategies.     

How do teleconsultations for remote trauma management change over a period of time?

We obtained follow-up information about the new patients seen at a minor accident and treatment service (MATS) staffed by emergency nurse practitioners (ENPs). A previous study, of 150 teleconsultations in a six-month period starting in April 1996, was used for comparison. In the present series, 150 teleconsultations occurring in a four-month period starting in April 1999 were studied; the patients constituted 5.6% of the 2658 new attenders or 3.8% of the 3936 total attenders. In comparison with the study three years before, falling teleconsultation rates were partly offset by increasing numbers of attenders and an extension of the ENPs' roles and skills. Teleconsultation rates rose when the number of consultant-run clinics was curtailed and ENP-run clinics replaced some of them. Eligibility to request and report more radiographs reduced the need for teleconsultations, and subsequently teleconsultations for help with interpretation of radiographs fell as the ENPs became more experienced. Specialty residents trusted ENP judgement and accepted telephoned direct admission of cases to their wards. Fewer teleconsultations were required for soft-tissue injuries. Telemedicine is an excellent educational tool.     

The treatment of overdose--time for a change?

To determine emergency management of overdose relating to gastrointestinal decontamination procedures in Scottish Accident & Emergency (A & E) Departments. A postal questionnaire was sent to the 28 main A & E Departments in Scotland. There was a 75% response rate. Nineteen departments(90%) continue to perform gastric lavage, with the majority carrying out this procedure more than one hour post-ingestion of commonly presenting overdoses. Sixteen departments (76%) regularly administer activated charcoal and four (19%) use syrup of ipecacuanha. Twenty departments (95%) had access to Toxbase. The majority of respondents (86%) feel there is a need for standardisation of treatment in acute overdose. Despite the availability of guidelines provided by the UK National Poisons Information Service and the Position Statements, there is no consensus in the actual management of acute overdose among Scottish A&E departments.     

Depression and cardiovascular mortality: a role for n-3 fatty acids?

BACKGROUND: Recent studies indicate that depression plays an important role in the occurrence of cardiovascular diseases (CVDs). The underlying mechanisms are not well understood. OBJECTIVE: We investigated whether dietary intake of the n-3 fatty acids (FAs) eicosapentaenic acid and docosahexaenoic acid could explain the relation between depressive symptoms and cardiovascular mortality. DESIGN: The Zutphen Elderly Study is a prospective cohort study conducted in the Netherlands. Depressive symptoms were measured in 1990 with the Zung Self-rating Depression Scale in 332 men aged 70-90 y and free from CVD and diabetes. Dietary factors were assessed with a cross-check dietary history method in 1990. Mortality data were collected between 1990 and 2000. Logistic and Cox regression analyses were performed, with adjustment for demographics and CVD risk factors. RESULTS: Compared with a low intake (x: 21 mg/d), a high intake (x: 407 mg/d) of n-3 FAs was associated with fewer depressive symptoms [odds ratio: 0.46; 95% CI: 0.22, 0.95; P for trend = 0.04] at baseline and no significant reduced risk of 10-y CVD mortality [hazard ratio (HR): 0.88; 95% CI: 0.51, 1.50]. The adjusted HR for an increase in depressive symptoms with 1 SD for CVD mortality was 1.28 (95% CI: 1.03, 1.57) and did not change after additional adjustment for the intake of n-3 FAs. CONCLUSION: An average intake of approximately 400 mg n-3 FA/d may reduce the risk of depression. Our results, however, do not support the hypothesis that the intake of n-3 FAs explains the relation between depression and CVD.     

Nurse education: a time for new solutions?

Notes the worsening situation with regard to nursing shortages. Considers responses such as the commission of increased places on Project 2000 courses and the introduction of NVQ III staff. Points to this success, particularly with regard to the latter of these solutions, but notes a lack of career progression for such entrants. Suggests that there is a strong case for development of a better career path for NVQ III staff, and looks to education and training consortia in this respect.     

Symposium on 'nutritional adaptation to pregnancy and lactation'. Pregnancy as a time for dietary change?

It is thought that nutrition during pregnancy plays a key role in the well-being of the mother and the newborn infant, and further influences health during childhood and adulthood. Pregnancy is a time of increased nutritional requirements, but many of these requirements will be met by adaptive physiological changes that occur during gestation, with little need to alter maternal dietary intake. A modest increment of food which provides 0.8 MJ/d (above prepregnant requirements) during the third trimester is considered adequate to meet the needs of fetal and maternal growth, and to satisfy the small increase in requirements of many macro- and micronutrients. However, requirements for vitamin D and folic acid increase substantially, and should be met primarily by supplementation. Food selection may also be altered to avoid a range of food-borne diseases and toxic constituents. There are a number of psycho-social reasons why pregnancy might be considered a good time for promoting changes in dietary behaviour for the health of the wider family. However, pregnancy may be a bad time to promote dietary change if it is perceived to involve slimming, if nutritional requirements are greatest before pregnancy, or if dietary changes made are harmful. There is little evidence to support educational interventions as successful at changing dietary behaviour during pregnancy. Pregnancy may be best viewed as an opportunity for maintaining good dietary selections and for building knowledge for future action, and should not be seen as the only opportunity for promoting dietary change within the life course.