Can general internal medicine be taught in general practice? An evaluation of the University College London model

There is national and international interest in increasing the community-based component of undergraduate medical education, but more research is needed on its potential, practicability and effectiveness. The objective of the study was to examine the feasibility and efficacy of general practitioners teaching basic clinical skills to first year clinical medical students in the community. The structure and methods of evaluation of the programme are described. Evaluation tools included semi-structured interviews of general practitioner tutors; student questionnaires; assessment of student performance; and costs of the programme. The great majority of the students found the programme enjoyable (81 out of 81, 100%) and educational (79 out of 81, 97%). Students' perfomance in the end of rotation Objective Structured Clinical Examination suggested that clinical skills are acquired at least as well in the community as in hospital. Tutors identified the personal benefits of this teaching as development of their own clinical skills and the stimulation of teaching. The programme has been successfully expanded from 24 students to 230 students annually and has demonstrated that community-based teaching can usefully contribute to undergraduate medical education in the area of clinical skills teaching. Key practical issues for schools contemplating similar initiatives are presented.     

Leg ulceration and ethnicity: a study in west London

Little is known of the influence race has on the development of leg ulceration, with most studies being performed in almost exclusively white populations. As part of a wider audit of leg ulcer services, health care professionals were contacted to give details of age, sex and ethnic background of all patients who attended for treatment of leg ulceration over a one year period in an area of west London. West London Health Care Trust provides services to a population of 275000 of whom 53000 have an ethnic background from the Indian subcontinent (South Asian).In all, 280 patients were identified, of whom 264 (94%) had details of age and sex. This gave a crude ascertainment rate of 1.02 per 1000 population. Of the 264 patients, five were classified as South Asians, with one patient classified as Afro-caribbean. The Mantel Haenzsel test demonstrated a significantly higher proportion of whites suffering from leg ulceration than South Asians, giving an odds ratio of 4.43, with 95% confidence intervals between 1.94 and 10.13 (P=0.0004). The expected frequency of South Asian patients should be 23, based on rates from the white population, of which 13 would be women and 10 men. Only five South Asian men were identified, and no Asian women with leg ulceration.Reasons for this low ascertainment are two-fold. Either there is a real difference between the white and South Asian populations, or South Asian patients are not presenting for treatment. Further work must be performed to determine whether this is an effect of low prevalence, or unmet need in the community.     

Do hot spots of deprivation predict the rates of suicide within London boroughs?

INTRODUCTION: The ecological associations between suicide rates and different indices of deprivation within London have been investigated at least for half a century. In the present study, the association between rates of suicide with newly developed hot spots of deprivation index within London boroughs have been studied taking into account the results of the spatial dependency between suicide rates in nearby boroughs. METHODS: Suicide data were provided by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. The hot spots index of deprivation and the population counts were provided by the Department of the Environment, Transport and the Region (DETR) and Office for the National Statistics (ONS), respectively. RESULTS: The results show that there is no strong spatial dependency between suicide rates in the London boroughs, the 'hot spots' index of deprivation predicts the rates of suicide in males 30-49, better than other age and sex groups. The rate of suicide decreases with decreasing deprivation as indicated by the 'hot spots' index. CONCLUSION: These findings suggest that at the London boroughs the 'hot spots' index of deprivation (together with other socio-economic and social fragmentation indices) should be considered as a potential explanatory variable to explain the effects of age on rates of suicide in men and women.     

A genome-wide association study of suicide severity scores in bipolar disorder

BackgroundSuicide claims one million lives worldwide annually, making it a serious public health concern. The risk for suicidal behaviour can be partly explained by genetic factors, as suggested by twin and family studies (reviewed in (Zai et al. 2012)). Recently, genome-wide association studies (GWASs) of suicide attempt on large samples of bipolar disorder (BD) patients from multiple sites have identified a number of novel candidate genes. GWASs of suicide behaviour severity, from suicidal ideation to serious suicide attempt, have not been reported for BD.MethodsWe conducted a GWAS of suicide behaviour severity in three independent BD samples:212 small nuclear families with BD probands from Toronto, Canada, 428 BD cases from Toronto, and 483 BD cases from the UK. We carried out imputation with 1000 Genome Project data as reference using IMPUTE2. Quality control and data analysis was conducted using PLINK and R. We conducted the quantitative analyses of suicide behaviour severity in the three samples separately, and derived an overall significance by a meta-analysis using the METAL software.ResultsWe did not find genome-wide significant association of any tested markers in any of the BD samples, but we found a number of suggestive associations, including regions on chromosomes 8 and 10 (p < 1e-5).ConclusionsOur GWAS findings suggest that likely many gene variants of small effects contribute collectively to the risk for suicidal behaviour severity in BD. Larger independent replications are required to strengthen the findings from the GWAS presented here.     

Studies of HBV replication during acute hepatitis followed by recovery and acute hepatitis progressing to chronic disease

The serologic and viral profiles of 24 patients who presented with acute hepatitis B virus (HBV) infection were studied. Although in rare cases, HBV-DNA was detectable before hepatitis B surface antigen (HBsAg) and e antigen (HBeAg), in the majority the viral proteins appeared first. In acute hepatitis followed by recovery, as IgM anti-HBc (hepatitis B core antigen) titres rose, the level of HBV replication fell and serum transaminases became elevated. In patients progressing to chronic HBV infection, IgM anti-HBc titres rose early, viral replication was initially low but continued to rise as the serum transaminase levels became elevated. 7S IgM anti-HBc, although present in the phase of established chronic HBV infection, was not found in the early phase of the chronic infection. Thus this antibody appears to be a consequence of, rather than a causative factor in, chronic HBV infection.     

Calcium-channel blockers and beta blockers: advantages and disadvantages of combination therapy in chronic stable angina pectoris

In electrophysiologic studies we have previously shown that the calcium-channel blockers nifedipine, verapamil, and diltiazem have different actions on the atrioventricular node: nifedipine has no evident effect at a dose of 7.5 micrograms/kg of body weight intravenously, whereas verapamil (0.15 mg/kg) and diltiazem (0.25 mg/kg) both prolong the AH interval significantly and terminate or slow reciprocating atrioventricular tachycardia involving the atrioventricular node alone or in association with an accessory pathway. None of the calcium-channel blockers tested influenced intraventricular conduction, but all increased the sinus rate. Since these properties suggested that it would be safer to combine nifedipine, rather than verapamil and diltiazem, with beta-adrenergic blockers in the treatment of ischemic heart disease, we tested this combination for efficacy and safety. Our previous results have now been reviewed, and they show that according to both subjective and objective criteria, nifedipine adds benefits to the action of propranolol in the management of chronic stable angina pectoris. No adverse effects were seen in our series, and beneficial influences were noted in patients with elevation of blood pressure. Side effects reported by others and said to arise from the interaction between nifedipine and beta blockers are analyzed, and prudence is suggested before the combination, or indeed any negative inotropic agent, is given to patients with impaired left ventricular function. The previous reports cannot be taken to indicate that nifedipine has a greater tendency to produce adverse effects in this combination than does the beta-adrenergic blocker.     

Measuring Stigma in Chronic Pain: Preliminary Investigation of Instrument Psychometrics,Correlates, and Magnitude of Change in a Prospective Cohort Attending Interdisciplinary Treatment

Chronic pain is a potentially stigmatizing condition. However, stigma has received limited empirical investigation in people with chronic pain. Therefore, we examined the psychometric properties of a self-report questionnaire of stigma in people with chronic pain attending interdisciplinary treatment. Secondarily, we undertook an exploratory examination of the magnitude of change in stigma associated with interdisciplinary treatment in a prospective observational cohort. Participants attending interdisciplinary treatment based on acceptance and commitment therapy completed the Stigma Scale for Chronic Illness 8-item version (SSCI-8; previously developed and validated in neurological samples), and measures of perceived injustice, pain acceptance, and standard pain outcomes before (n = 300) and after treatment (n = 247). A unidimensional factor structure and good internal consistency were found for the SSCI-8. Total SSCI-8 scores were correlated with pain intensity, indices of functioning, and depression in bivariate analyses. Stigma scores were uniquely associated with functioning and depression in multiple regression analyses controlling for demographic factors, pain intensity, pain acceptance, and perceived injustice at baseline. SSCI-8 total scores did not significantly improve after treatment, although an exploratory subscale analysis showed a small improvement on internalized stigma. In contrast, scores on perceived injustice, pain acceptance, and pain outcomes improved significantly. Taken together, these data support the reliability and validity of the SSCI-8 for use in samples with chronic pain. Further research is needed optimize interventions to target stigma at both the individual and societal levels.PerspectiveThis study supports the use of the SSCI-8 to measure stigma in chronic pain. Stigma is uniquely associated with worse depression and pain-related disability. Research is needed to identify how to best target pain-related stigma from individual and societal perspectives.     

Dietary change for macular health of older people: Eating for Eye Health,a pilot community kitchens intervention

Background

Dry age-related macular degeneration (AMD) is a leading cause of untreatable, progressive central vision loss, social isolation, and disability in older people. Evidence suggests that diet (eg, the Mediterranean dietary pattern or increased oral carotenoid intake) might protect against dry AMD progression. The aim of this pilot study was to test the feasibility of a participant-informed community kitchens intervention (Eating for Eye Health project) to implement dietary behaviour change, to benefit macular health of older adults.

Straddling and overriding atrioventricular valves: morphology and classification.

Fifty-seven hearts are described in which either the orifice or tension apparatus of an atrioventricular (A-V) valve was related to both sides of a septum in the ventricular mass. In most of the hearts both the orifice overrode the septum and the tension apparatus straddled the septum. In some hearts straddling of the tension apparatus was present in the absence of overriding of the anulus while in two hearts the anulus overrode in the absence of straddling. Hearts were observed in which the chamber receiving all of one valve and the straddling portion of the other valve had either right or left ventricular morphologic features, and in each type the chamber receiving only part of the straddling valve was found either to the right or the left. When the straddling valve was morphologically a tricuspid valve it always straddled the posterior part of a septum that never extended to the crux; when it was morphologically a mitral valve it always straddled the anterior part of a septum that did extend to the crux. This arrangement was found irrespective of the relations of the chambers.Four basic groups were therefore defined: straddling of the mitral and tricuspid valves in the setting of A-V concordance and discordance, respectively. However, the degree of override of the straddling valve was frequently such that the A-V connection present was double inlet ventricle rather than concordance or discordance. Indeed, in each group a series of anomalous hearts was found between the extremes of concordance or discordance and double inlet. In categorizing the A-V connections, these series were divided at their mid points. The hearts with double inlet connections were considered univentricular hearts and their chambers described accordingly. In each series hearts were found with unequally committed common valves that were virtually identical to the hearts with straddling right or left valves. They were therefore included in the study as were two hearts in which both right and left valves straddled. Examination of the conduction tissues in examples of each series showed that the position of the connecting node depended on whether or not the septum extended to the crux, anterior systems being found when it did not and either anterior or regular systems when it did, the latter variation depending on the A-V connection present. The study shows that straddling or overriding valves can be easily catalogued if attention is paid to the A-V connection and the morphologic features and relations of the ventricular chambers.