To identify the current familiarity and use of Web 2.0 technologies by medical students and qualified medical practitioners, and to identify the barriers to its use for medical education.
A semi‐structured online questionnaire survey of 3000 medical students and 3000 qualified medical practitioners (consultants, general practitioners and doctors in training) on the British Medical Association's membership database.
All groups had high familiarity, but low use, of podcasts. Ownership of digital media players was higher among medical students. There was high familiarity, but low use, of other Web 2.0 technologies except for high use of instant messaging and social networking by medical students. All groups stated that they were interested in using Web 2.0 technologies for education but there was lack of knowledge and skills in how to use these new technologies.
There is an overall high awareness of a range of new Web 2.0 technologies by both medical students and qualified medical practitioners and high interest in its use for medical education. However, the potential of Web 2.0 technologies for undergraduate and postgraduate medical education will only be achieved if there is increased training in how to use this new approach.
education; Web 2.0 technologies
Shared medical appointments or group visits have proven to be a promising way of providing planned care to older and chronically ill patients with two powerful added attractions—patient peer support and improved practice efficiency
There is good evidence that timely restoration of coronary blood flow in obstructed infarct related arteries is a significant determinant of both short and long term mortality and morbidity. This is irrespective of whether it is achieved using fibrinolytic therapy or percutaneous coronary intervention (PCI). Despite the clear advantages of primary PCI, it is thrombolysis that remains the main reperfusion strategy in the UK. Recent data have highlighted mortality benefits when antiplatelet treatment and anticoagulation are used as adjuncts to thrombolysis. Moreover, of those who receive thrombolysis, 60% proceed to coronary arteriography within 6 months of their index event. Recent studies have been published clarifying the timing of coronary arteriography in patients who receive thrombolysis as reperfusion therapy.
acute myocardial infarction; clopidogrel; enoxaparin; percutaneous coronary intervention; ST elevation myocardial infarction; STEMI; thrombolysis
Gene therapy for cancer is a rapidly evolving field with head and neck squamous cell cancer being one of the more frequently targeted cancer types. The number of clinical trials in the UK is growing and there is already a commercially available agent in China. Various gene therapy strategies along with delivery mechanisms for targeting head and neck cancer are reviewed.
head and neck; squamous cell; cancer; gene therapy; gene
The implementation of modernising medical careers (MMC) has resulted in some specialties being allocated very inexperienced trainees such as ophthalmology. We aim to describe the process of implementation of MMC and how it may affect the service provision in smaller specialities such as ophthalmology. A methodical approach in a district hospital setting was used to provide early core training to such trainees involving managerial support. The quality of service provided by newer trainees can be enhanced by providing early structured training during induction to create an atmosphere of enthusiasm and continued learning. This example can be used in other units and specialties.
approved training; foundation training; modernising medical careers; ophthalmology; specialist training
amyloid; pathological; talus; talar; fractures
Endovascular aneurysm repair (EVAR) is increasingly being employed as an alternative to open surgical repair for patients with abdominal aortic aneurysms. The surveillance of patients post‐EVAR has traditionally been carried out with regular computed tomographic scans which have in part been responsible for the high costs associated with this procedure. Duplex has been proposed as an alternative, but researchers have so far been unable to devise a standardised protocol for this surveillance. This review aims to provide a clear understanding of currently employed imaging modalities and discuss future surveillance possibilities for this patient group.
abdominal aortic aneurysm; endovascular aneurysm repair; stent‐graft
To determine the incidence and character of drink spiking in an urban population of patients within the UK presenting to an emergency department concerned they had consumed a deliberately contaminated drink.
Prospective case series determining the presence and quantity of sedative and illicit drugs, and ethanol in biological samples (blood and urine) obtained from consenting patients >18 years of age presenting to a large inner city London emergency department alleging they had consumed a spiked drink within the previous 12 h.
Biological samples were obtained from 67 (blood) and 75 (urine) of 78 study participants. 82% of participants were female, mean age 24 years. Mean time from alleged exposure to biological sampling was 5.9 h (range 1–12 h). Ethanol was detected in 89.7% of participants. Mean serum ethanol concentration was 1.65 g/l (range 0.04–3.1 g/l); 60% of participants had a serum ethanol concentration associated with significant intoxication (>1.5 g/l). Illicit drugs were detected in 12 (15%) participants; 7 denied intentional exposure (3 methylenedioxymethamphetamine, 3 cannabis, 1 γ‐hydroxybutyrate). Medicinal drugs were detected in 13 participants; only 1 exposure was unexplained (benzodiazepine). Overall illicit or medicinal drugs of unexplained origin were detected in 8 (10%) participants. Unexplained sedative drug exposure was detected in only 2 (3%) participants.
Use of sedative drugs to spike drinks may not be as common as reported in the mainstream media. A large number of study participants had serum ethanol concentrations associated with significant intoxication; the source (personal over‐consumption or deliberate drink spiking) is unclear.
spiked drink; illicit drugs; ethanol; poisoning; unlawful
Biliary tract infection is a common cause of bacteraemia and is associated with high morbidity and mortality. Few papers describe blood culture isolates, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.
To determine the proportion of bacteraemias caused by biliary tract infection and to describe patient demographics, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.
Prospective cohort study.
Biliary tract infection that caused bacteraemia was defined as a compatible clinical syndrome and a blood culture isolate consistent with ascending cholangitis. Patients aged 16 years and over were included in the study. From June 2003 to May 2005, demographic and clinical data were collected prospectively on all adult patients with bacteraemia. Radiological and endoscopic retrograde cholangiopancreatography findings were collected retrospectively.
In 49 patients, the biliary tract was the site of infection for 39/592 (6.6%) community‐acquired and 19/466 (4.1%) hospital‐acquired episodes of bacteraemia. Three patients had mixed bacteraemias, and four had recurrent bacteraemia. The proportion of patients presenting with a structural abnormality was 34/49 (69%), and, of these structural abnormalities, 18/34 (53%) were pre‐existing or newly diagnosed malignancies. Gram‐negative organisms caused 55/58 (95%) episodes of bacteraemia. The most common Gram‐negative organisms were Escherichia coli (34/55; 62%) and Klebsiella pneumoniae (14/55; 26%). Of the E coli isolates, 6/34 (18%) were extended spectrum β‐lactamase producers or multiply drug resistant. Thirty‐day mortality was 7/49 (14%). There was no difference in time taken to administer an effective antibiotic to survivors and non‐survivors (0.86 vs 1.05 days, respectively, p = 0.92). Of the seven who died, four died from septic shock within 48 h of admission caused by “susceptible” Gram‐negative organisms. Two others died from disseminated malignancy.
The proportion of bacteraemias caused by biliary tract infection was 5.5%. The most common infecting organisms were E coli and K pneumoniae. There was a strong association with choledocholithiasis and malignancies, both pre‐existing and newly diagnosed. Death was uncommon but when it occurred was often caused by septic shock within 48 h of presentation.
biliary tract infection; cholangitis; bacteraemia; mortality; clinical outcomes
To investigate the prevalence of complicating and concurrent morbidities in older diabetic patients and to evaluate to what extent their occurrence affects the burden of disease and use of medical healthcare.
Cross‐sectional analysis of retrospectively obtained data on comorbidities and use of medical healthcare. Healthcare registration systems were used to retrieve data on 300 patients with diabetes aged ⩾60 years who, according to the severity of their disease and intensity of care required, were treated in a regional general practitioner (GP), diabetes nurse specialist (DNS) or medical specialist (MS) practice.
Complicating and concurrent morbidities were often found irrespective of the type of practice involved. After adjustments for differences in sex, age and glycosylated haemoglobin (HbA1c), the extent of complicating comorbidities showed sequential increases in patients managed by GP, DNS and MS (mean number of 3.6, 4.7 and 6.7, respectively; ptrend<0.001). However, the mean number of concurrent comorbidities was similar across all three settings (2.1, 1.8 and 2.0, respectively). Both complicating and concurrent comorbidities were similarly associated with the extent of drug use (β = 0.49 (95% CI 0.40 to 0.58) and β = 0.57 (95% CI 0.52 to 0.72), respectively) and the number of consultations with specialists other than the main care giver (β = 1.19 (95% CI 1.15 to 1.24) and β = 1.21 (95% CI 1.14 to 1.28), respectively). However, the mean number of different specialists involved in a patient's care per additional concurrent comorbidity was twice as high as per any additional complicating comorbidity (β = 0.60 (95% CI 0.48 to 0.71) vs β = 0.31 (95% CI 0.24 to 0.39)).
The use of healthcare facilities by older patients with diabetes is substantial, irrespective of the complexity of the disease and the kind of practice involved. The common manifestation of complicating and concurrent comorbidities and their varying complexity in individual patients requires a patient‐oriented rather than a disease‐oriented approach and vocational training programmes for care givers that are tailored to the complexity of multiple chronic diseases.
healthcare; chronic diseases; diabetes; comorbidity
To audit the safety of differing protocol‐driven early‐discharge policies, from two sites, for low‐risk acute upper gastrointestinal (GI) bleeding and determine if default early (<24 h) in‐patient endoscopy is necessary.
All patients with low‐risk acute upper GI bleeding presenting to two separate hospital sites in Leeds from August 2002 to March 2005 were identified. Both hospitals operate nurse‐led process‐driven protocols for discharge within 24 h, but only one includes default endoscopy. Relevant information was obtained from patients' notes, patient administration systems, discharge letters and endoscopy records.
120 patients were admitted to site A and 74 to site B. Median length of stay on the clinical decisions unit was 12.6 h at site A and 9.4 h at site B (p = 0.045). Oesophagogastroduodenoscopy was performed on 89/120 (74%) patients at site A compared with only 7/74 (9%) at site B (p<0.001). Six of 120 (5%) patients from site A were admitted to hospital for further observation compared with 6/74 (8%) from site B (p = 0.38). Of the remaining patients, all were discharged within 24 h, and 8/114 (7%) at site A vs 17/68 (25%) at site B were given hospital clinic follow‐up (p<0.001). None of the 194 patients had further bleeding or complications within 30 days.
Patients admitted with a low‐risk acute upper GI bleeding can be managed safely by a nurse‐led process‐driven protocol, based on readily available clinical and laboratory variables, with early discharge <24 h. Avoiding in‐patient endoscopy appears to be safe but at the price of greater clinic follow‐up.
discharge protocol; emergency medicine; endoscopy; gastrointestinal haemorrhage
Learning curves are often referred to in the context of medical education and training, though their trajectories and natures are a matter of debate. The origins of this concept derive from industry and its relevance to contemporary medicine and surgery remains controversial. We describe the history, derivation, character and possible mechanisms to deal with the implications of learning curves in the current climate of clinical governance and modernising medical careers.
education; learning; training
We present here a patient with end stage renal failure who received two weeks antimalarial prophylaxis at full dose leading to life threatening toxicity with severe acute megaloblastic anaemia, symptomatic pancytopenia and exfoliative dermatitis. Prompt recognition and treatment can rapidly reverse these fatal effects but more importantly, education of patients before travel is imperative in preventing such events.
antimalarials; end stage renal failure; exfoliative dermatitis; megaloblastic anaemia; pancytopenia
There is now an inverse correlation between the number of women entering medicine and the availability of flexible working
flexible working; junior doctors; National Health Service; women
Cancer patients with venous thromboembolism (VTE) pose particular management challenges since they have an increased risk of bleeding and recurrent thrombosis compared to the non‐cancer population. Also, as the disease progresses so do the hazards of anticoagulation, and patients in the palliative stages of their cancer could be viewed as a separate disease group with respect to diagnosis and management. As the focus from curative treatment moves towards symptom control, physicians face several challenges in providing the most appropriate care. Palliative care patients have rarely been included in research on VTE and the supporting evidence needs to be extrapolated cautiously. Quality of life aspects of VTE and their management may be a more appropriate outcome measure in this stage of disease than radiological end points. This paper looks at the challenges facing professionals in the management of VTE in the advanced cancer patient.
cancer; hospice; low molecular weight heparin; LMWH; palliative care; venous thromboembolism
Transcranial Doppler sonongraphy is a non‐invasive, non‐ionising, inexpensive, portable and safe technique that uses a pulsed Doppler transducer for assessment of intracerebral blood flow. This article deals with the principles and technique of transcranial Doppler sonography. It gives a brief overview of its use in evaluation of intracranial steno‐occlusive disease, subarachnoid haemorrhage, and extracranial diseases (including carotid artery disease and subclavian steal syndrome). The role of transcranial Doppler in detection of microembolic signals and evaluation of right to left shunts is also dealt with. Finally, its use in acute stroke is briefly outlined.
stroke; transcranial Doppler ultrasoound
Psoriasis is an inflammatory skin disease that affects 1–3% of Caucasian populations and may be persistent, disfiguring and stigmatising. There is a range of severity, but even when the affected body surface area is relatively limited the impact on day‐to‐day activities and social interactions may be significant. An understanding of the psychological burden and an appreciation that many patients are currently dissatisfied with their management has driven the development of more effective treatment. In recent years psoriasis has been the focus of intense investigation resulting in an improved understanding of the immunopathogenesis, and the development of new, targeted biological treatments.
biological; pathophysiology; psoriasis