Alfentanil or fentanyl during isoflurane–based anaesthesia for day–care knee arthroscopy?

Forty patients agreed to participate in a study to compare whether fentanyl or alfentanil used as analgesic is associated with quicker recovery following anaesthesia for outpatient arthroscopy procedure. Psychomotor tests including choice reaction time (CRT), perceptive accuracy test (PAT) and finger tapping test (FTT) were done prior to induction of anaesthesia with propofol (2–3 mg–kg^-1). Patients were then divided into two groups: Group F (fentanyl) received 0.1 mg fentanyl prior to start of surgery and thereafter 0.05 mg every 30 min during the procedure. Group A (alfentanil) received 0.5 mg alfentanil prior to the onset of surgery and 0.25 mg every 15 min thereafter. Anaesthesia was then maintained using isoflurane (0.5–2%) in oxygen and air (Fio₂ 0.33) during spontaneous respiration with a face mask in a Bain's system. Psychomotor tests were repeated every 45 min postoperatively. Clinical recovery, visual analogue pain intensity score (VAS) and time to discharge home were also assessed by a nurse blind to the method used. Patients in Group A returned to baseline values on the FTT after 90 min while those in Group F did not return to baseline values until 135 min after the end of the operation. Clinical recovery and time to discharge home ("home ready") were also significantly longer in Group F. There was no difference in recovery as seen in the PAT and CRT between the groups. Also, there was no difference in the incidence of side effects and the pain intensity (VAS) scores were similar in the two groups at all time periods. We conclude that recovery following alfentanil is quicker compared to fentanyl when anaesthesia is based on isoflurane.     

Effects of cadaver dissection on the attitudes of medical students

Summary: Summary. A study was conducted to determine whether the attitudes of medical students to death and caring changed during the 3 months following exposure to cadaver dissection. All first-year students were invited to complete a questionnaire immediately before their initial cadaver dissection experience, after 6 weeks, and after a further 3 months. The questionnaire reflected attitudes to death, violent death, death of someone known to the respondent and caring when someone known to the respondent is seriously injured. Ethnicity and previous exposure to dying has no effect on responses, but overall men students' reactions were significantly less than for women ( P < 0.001). The responses given on the final part of the questionnaire after 3 months were significantly lower than those to most questions in the first part of the questionnaire. The exceptions were those questions where the subject in the given scenario was known to the respondent, where reactions were rated significantly greater ( P < 0.001) in the follow-up questionnaire and can be explained on the basis that they were a personal referent.
Students rapidly develop a coping mechanism which enables them to view cadaver dissection as an occupation quite divorced from living human beings. During these early months of training solicitude decreases for those who die who are unknown to them, but concern for personal referents increases. Educators should be aware of the dramatic change of attitudes among students and the process of professionalization which might influence their caring of future patients.     

Public health medicine and drinking water in Scotland

The prevention of the spread of disease by drinking water relies on a tripartate arrangement among the supplier, the regulator and their medical advisers. This paper describes the role of Public Health Medicine in Scotland in preventing a ‘significant risk to health’ from potable water. The legislative framework is highlighted. The rationale of water monitoring is examined and the role of Consultant in Public Health Medicine. The concept of Significant Medical Risk Values is introduced and their derivation, uses, and levels presented.     

The potential of an anaesthesiologist–manned ambulance service in a rural/urban district

The use of anaesthesiologists in prehospital emergency care is controversial. We wanted to assess the impact of an anaesthesiologist and a short time interval from acceptance of a mission to take–off at survival rates in a rural/urban emergency medical service. Prospectively registered data for 991 consecutive patients through a 12–month period were retrospectively evaluated by an independent foreign expert. Of all primary missions, 3.3% were considered probably lifesaving from site of injury to receiving hospital. Of these, the lifesaving result in 50% were dependent on both the qualifications of the anaesthesiologist and a short response time. Survival from hospital admission to discharge was 44%. All patients were discharged to their own homes, able to live a fully functional life. The consistent use of anaesthesiologists compared to less qualified personnel and the maintaining of response times below presently required minima doubles the potential for lives saved in services comparable to the one studied.     

Independent learning among general practice trainees: an initial survey

Self-directed learning is a natural way for adults to learn. Vocational training for general practice is a preparation for unsupervised clinical work that will be supported, in the main, by continuing medical education. This study uses the Self-Directed Learning Readiness Scale to investigate factors influencing readiness for such learning among a sample of general practice trainees. Three principal factors emerged from analysis: enjoyment and enthusiasm for learning; a positive self-concept as a learner and a factor suggesting the possibility of a 'reproducing' orientation to learning. These factors may reflect approaches to learning in general rather than these adopted for professional learning, but offer helpful pointers for the development of both vocational training and of continuing medical education.     

Supportive employment for individuals with chronic schizophrenia: the case for a National Health Service community-based sheltered workshop

A pilot project was established from 1992 to 1994 to provide people with chronic schizophrenia living in Dundee, Scotland, with a National Health Service sheltered workshop that would be fully integrated into the local business community. Of the 43 clients who attended the sheltered workshop, 38 agreed to take part in the project. Typical attenders were single, middle-aged men with schizophrenia. Twenty-five per cent had spent more than two years in hospital; 75% had been unemployed for more than five years. The clients' use of National Health Service day facilities more than halved while attending the workshop. Their hospital readmission rates were low (16%) compared with the local readmission rates for people with schizophrenia in Dundee (86%). A training approach based on the general principles of social skills training contributed to positive vocational outcomes for one-third of the workshop clients. The findings suggest that the onus of responsibility for providing work for many individuals with schizophrenia remains with the National Health Service, and in particular, occupational therapy. Occupational therapy staff must assess their clients effectively and provide quality training leading to opportunities for paid employment. These results have implications for the training of occupational therapy staff and also for the staffing structure in sheltered workshops. Copyright © 1997 Whurr Publishers Ltd.     

Clinical problem-solving using video simulation: an investigation

This paper examines the use of videotape simulation as a research method for the exploration of clinical problem-solving, the challenges posed and the strategies employed to overcome the difficulties encountered are discussed. The simulation forms part of a larger comparative study of outcomes of pre-registration nurse education programmes, commissioned by the English National Board for Nursing, Midwifery and Health Visiting.