bluuebunny/crossref_metadata_2025 huggingface dataset:
Staff development in UK medical schools
Authors: Towle Angela
Published: November 2023

A conference held a few years ago brought together medical teachers, educationists, and staff developers from UK medical schools to highlight key issues in effecting change through staff development based on the presentation of case studies and the sharing of ideas and experience (Towle 1993). Using information from the conference report and personal experience in three medical schools, I have attempted to summarize below the main issues in staff development in medical education in the UK, some key experiences so far and the lessons which have been learned.
Medical education into the next century
Authors: Rees Lesley , Jolly Brian
Published: November 2023

In Chapter 1 a rationale that will govern our vision of medical education in the next century was portrayed. In this chapter we summarize, using examples from our own experience, the most notable trends that have taken place in medical education. We will attempt to locate them in the context of other changes that have engulfed the medical world in general, and the UK in particular. The most notable of these, and the most pressing for many engaged in the continual process of curriculum change are the widespread developments associated with the publication by the GMC (1993) of the document Tomorrow’s doctors. By 1999 most schools will have implemented new curricula, but it is sobering and even disenchanting to acknowledge that many of the young doctors produced by these new systems will not emerge until 2005 and, indeed, will have ceased practising before the century is halfway through. Hence, in a rapidly evolving environment, the challenge of the future will not be in how to manage change but in how to perpetuate it.
Stimulation to relieve pain
Authors: Coniam S W , Diamond A W
Published: November 2023

The development of scientific medicine meant that efforts to relieve pain were concentrated on the pharmacological approach, or attempts to block the neuronal pathways associated with pain using local anaesthetics or destructive lesions. However, older methods of treating pain and disease-including acupuncture, electric shock, vibration and massage, poultices, and painful stimuli such as cupping and scarifying-had aimed at stimulating part of the nervous system. Because such methods could not be explained by the scientific knowledge of the last century, they generally fell out of favour with the medical establishment.
Musculoskeletal pain
Authors: Coniam S W , Diamond A W
Published: November 2023

The largest group of patients presenting with symptoms of pain suffer from some form of musculoskeletal pain. Some causes of musculoskeletal pain and disability are related to clearly defined diseases, for example inflammatory disease such as rheumatoid arthritis, or well recognized metabolic or degenerative conditions such as osteoarthritis or osteoporosis.
General aspects of regional anaesthesia in children and babies
Authors: Peutrell J M
Published: November 2023

Regional techniques are usually combined with light general anaesthesia in children. Regional blocks provide prolonged and reasonably predictable postoperative pain relief which is particularly advantageous for children having day-case surgery. Additional analgesia (e.g. non-steroidal anti-inflammatory drugs or paracetamol) can be given to obtain adequate blood concentrations before the block has worn off.
Topical anaesthesia of skin and mucous membranes
Authors: Peutrell J M
Published: November 2023

The epidermis is a stratified epithelium without nerve endings or blood vessels. It consists of several distinct layers. The outer horny layer of skin is called the stratum comeum and over most of the body surface is 75-100 µ,mthick. It is a dense layer consisting of cells containing mainly keratin and extracellular tissue with a high lipid content. The dermis is a vascular layer with specialized pain receptors (nociceptors) lying at, or, just above the dermo epidermal junction.Cutaneous pain receptors are probably formed from free nerve endings. They are of two principal types:
Nerve blocks for dental surgery
Authors: Ball I
Published: November 2023

A careful painless injection technique is one of the most import ant aspects of administering dental local analgesia to children because, unlike adults, it is rare that a hurt child who becomes frightened and distraught will allow one to continue with treatment, let alone permit a second attempt at such an injection. Equally important is a simple straightforward explanation to the child to reassure him or her about the procedure, avoiding reference to frightening or emotive words such as needle or injection. It is usually sufficient to tell the child that the tooth and face will ‘go to sleep but wake up later’. Because of the disconcerting sensation it is also good practice to reassure the child by showing him with the aid of a mirror that although his face feels different his appearance remains unaltered.
Penile block
Authors: Peutrell J M
Published: November 2023

AnatomyThe nerve supply to the penisThe penis is supplied by sensory nerves from the lumbosacral plexus and autonomic fibres from the inferior hypogastric plexus:(1) the two dorsal nerves of the penis innervate the glans and the distal two-thirds of the body of the penis;(2) the ilioinguinal and genitofemoral nerves supply the base of the penis;(3) autonomic fibres accompany either the dorsal nerves or the blood vessels.The dorsal nerves of the penis (S2-S4) arise as terminal branches of the pudenda nerves. They run along the ischial ramus and then the lower border of the pubic ramus. They enter the subpubic space (see below) by passing between the perineal membrane and the inferior pubic ligament.
Percutaneous intervention in ischaemic heart disease
Authors: Banning Adrian P
Published: November 2023

Charles Dotter and Melvin Judkins were the first physicians to attempt to use catheters for a therapeutic purpose when they used a coaxial system of catheters in patients with peripheral arterial disease in 1964 (1). The term ‘transluminal angioplasty’ was coined but, despite initially encouraging results, application of the technique was limited by problems with puncture site haematoma and distal emboli. Andreas Gruentzig, trained by Zeitler in Germany, continued to refine the angioplasty technique in peripheral arteries and in 1974 he developed a double lumen catheter with a distensible PVC balloon which revolutionized angioplasty. This catheter applied circumferential pressure to the stenosis rather than the axial pressure of the previous catheters and it also created a smaller puncture site, thus reducing procedural complications. By 1976, Gruentzig had successfully miniaturized the catheter and he was performing coronary angioplasty in dogs and in human cadavers.
Systemic effects of cardiopulmonary bypass
Authors: Dunning John J
Published: November 2023

Without cardiopulmonary bypass, cardiac surgery as we know it today would not be possible. Yet the very technology which enables the surgeon to perform complex surgery on the heart is itself damaging and exerts effects on the patient which manifest themselves in every system of the body. Although temporary dysfunction of various systems is usual, most of the systemic side effects are well tolerated and rapid postoperative correction is the rule. However, under certain circumstances the systemic effects on one or more organ systems may be more pronounced, resulting in distressing symptoms and iatrogenic conditions which are difficult to correct.
Myocardial protection
Authors: Pepper John
Published: November 2023

The concept of placing new grafts to bypass obstructions in coronary arteries is attractively simple. The objective of every operation should be a technically perfect result without producing myocardial damage. Currently only a minority of surgical patients present with normal left ventricular function; most have damaged ventricles but the damage may in part be reversible. Until recently the attention of surgeons had fallen almost exclusively on the myocyte but it is becoming clear that protection of the coronary endothelium and the specialized conduction tissue are also important in the pursuit of a perfect result. From the practical viewpoint the prerequisites for optimal protection are uniform and adequate distribution of a protective agent, excellent visualization of the operative field, a simple technique that does not distract the surgeon, and optimal protection of the brain and kidneys.
Myocardial reperfusion injury
Authors: Gorman Robert C , Gardner Timothy J
Published: November 2023

Early in the history of cardiac surgery, it was recognized that some patients who underwent technically successful operations suffered from a syndrome of low cardiac output in the early postoperative period. It was also apparent that the perioperative mortality was increased in these patients. Autopsy and clinical studies in the late 1960s and early 1970s documented that myocardial necrosis (particularly in the subendocardial region) was common after cardiac surgery. This intraoperative loss of myocytes was believed to be the cause of the low cardiac output syndrome. The fact that myocardial necrosis occurred in patients with normal coronary arteries suggested that better intraoperative protection of the myocardium would improve operative results.
Anaesthesia for coronary artery bypass surgery
Authors: Feneck R O , Duncan F
Published: November 2023

Although the first coronary artery bypass graft operation was performed by Sabiston in 1962 (1), delay in publishing the report has led to some confusion as to who carried out the first successful procedure. Garret (2), Favaloro (3), and Johnson (4) have all been credited as pioneers of the technique. However, others rapidly followed and by the end of the 1970s coronary artery bypass graft (CABG) surgery was commonly undertaken in hospitals throughout the world, and was certainly the most common major surgical procedure requiring admission to an intensive care unit for postoperative care. The early literature on cardiac anaesthesia is a little clearer.
Perioperative care and recovery
Authors: Grebenik Catherine R
Published: November 2023

Thorough preoperative assessment of the patient undergoing surgery for ischaemic heart disease is a vital part of management. It enables intercurrent diseases to be evaluated and treated, provides a guide for anaesthetic care, allows assessment of the likelihood of postoperative complications, and permits planning for the type of postoperative care required.
Ventricular fibrillation with intermittent aortic cross clamping in coronary heart surgery
Authors: Wright Ravi Pillai ,J E C
Published: November 2023

Ventricular fibrillation induced either by electrical stimulation or by cooling is a long established technique used for surgery on the heart. Indeed, its use was widespread before the advent of a variety of solutions, both crystalloid and containing blood, that are currently used to arrest the heart and provide protection by hypothermia. The technique continues to be used in the setting of surgery for ischaemic heart disease by a small minority of surgeons in the world. The technique relies upon short periods of acute myocardial ischaemia, interrupted by normal coronary perfusion. Traditionally it is believed that as long as the periods of ischaemia are sufficiently short (6-12 minutes) complete myocardial recovery is obtained during the period of reperfusion. The practice of this technique has been supported more recently by the latterly observed myocardial protection effects of ischaemic preconditioning.
Technical aspects of coronary artery surgery
Authors: Pillai Ravi , Wright J E C
Published: November 2023

Since the description of the use of saphenous vein for coronary artery bypass grafting by Favaloro in 1967 the procedure has been widely adopted across the world. Today it is the most common adult cardiac surgical operation. Its relative simplicity has led to the massive increase in the number of centres performing cardiac surgery in several countries. The fact that ischaemic heart disease is responsible for the largest number of deaths in most western countries has ensured that coronary artery surgery, as well as other interventional procedures for treating ischaemic heart disease, has occupied a position of importance alongside preventive measures as far as allocation of resources are concerned.
Cardiac transplantation for ischaemic heart disease
Authors: Murday Andrew
Published: November 2023

Cardiac transplantation offers patients with end-stage cardiac disease the prospect of increased life expectancy and a return to a good functional life. This prospect is available only at some risk to the potential transplant recipient. Cardiac transplantation carries a relatively high operative mortality. In addition to this there is a considerable practical burden for the recipient and their supporters resulting from continued dependency upon immunosuppressive drugs and the concomitant frequent hospital attendance for the supervision of these regiments. There is also the ongoing risk of postoperative morbidity resulting from the dual hazards of rejection and infection. Finally, there is a definitive time-limited prognosis following cardiac transplantation.
What is pain?
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

Pain is felt by all human beings on occasions. Usually it is of a minor nature (such as a headache or muscle strain) and improves quickly without pharmacological intervention. Rarely it is severe, usually following injury or after a surgical operation, and intensive pharmacological efforts may be needed to relieve the pain and distress. Thus we are all familiar with what pain is. In scientific terms pain has been defined by the International Association for the Study of Pain (IASP) as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage., or described in terms of such damage’. A painful stimulus is a protective response for the individual. Those with diminished or altered pain sensitivity may sustain severe joint injury and deformity or other tissue damage like burns because of the lack of pain sensation.
Principles of analgesic drug administration
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

This section briefly introduces important pharmacological terms which apply to the following chapters on analgesic drug use and administration. The terms have been subdivided under their respective headings—pharmacokinetic terms and pharmacodynamic terms. Pharmacokinetic terms refer to how the body deals with the drug (that is, how the drug is absorbed, metabolized, and eliminated); pharmacodynamic terms describe the effects of the drug on the body (for example, how the drug binds to its receptor and produces effects).
Intramuscular administration of analgesics
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

The commonest, current practice, on most hospital wards, is to prescribe an analgesic drug on an ‘as required’ basis. Generally opioid analgesics are administered by the intramuscular route with a dosage interval varying from four to six hours. Many studies have reported the poor quality of analgesia provided by these standard regimes. Intramuscular administration has gained acceptance because it is relatively simple to perform and does not require nurses with specialist training or medical staff. The ‘as required’ prescription has achieved popularity for reasons which include the following.
Opioid infusions
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

The standard prescription of intermittent analgesic drug regimens commonly leads to inadequate pain control. Improvement may be achieved using some form of continuous analgesic drug administration technique. This may have several advantages including: avoidance of troughs in plasma drug concentrations (resulting in pain) which occur with intermittent dosage schedules; avoidance of high-peak plasma concentrations (causing adverse effects) after bolus administration. Continuous intravenous infusions should result in a constant level of analgesia for the duration of the infusion, avoiding periods of inadequate pain relief and periods of excessive sedation from intermittent high concentrations of drug by the administration of repeated bolus doses.
Patient-controlled analgesia (PCA) systems
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

The development and introduction of PCA systems into clinical practice has endeavoured to provide a method of analgesia which will bypass any difficulties relating to inappropriate dosing schedules, unpredictable drug absorption, or patient variability. It is a system that also avoids dependence upon the nurses or doctors to provide analgesic medication. These people may be unavailable at times or occupied with other tasks; reliance upon them for analgesia may therefore be a factor in the failure of current regimes to provide satisfactory analgesia. With the PCA systems the patient is in control of their analgesia all the time. Not only does the PCA system provide improved analgesia, it also allows patients to feel in control of their pain.
Spinal anaesthesia
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

The earliest reported use of spinal anaesthesia in man was by August Bier, in 1898, who injected cocaine intrathecally. The technique was further developed and used widely with newer local anaesthetic agents. Fears of neurological complications following spinal anaesthesia led to a decline in its popularity in the UK in the 1950s. These fears have since been felt to be unjustified. Spinal anaesthesia is now recognized as a safe and effective technique. It is principally used to provide anaesthesia for surgical procedures below the umbilicus, particularly for orthopaedic and urological operations. With most of the currently available local anaesthetic agents for spinal use, the blockade produced is of relatively short duration and provides little postoperative analgesia. Techniques using the insertion of catheters into the subarachnoid space can offer analgesia by continuous administration of local anaesthetic providing a prolonged block. Since the catheters must be inserted intrathecally and may give a portal of entry for bacteria this technique is not, so far, widely used.
Pain control in special situations
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

Analgesia for the obstetric patient is unusual in that the doctor must consider two patients the fetus and the mother and the effects the chosen method of analgesia will have on both. It is also a situation in which the patient may herself express a preference for particular methods of analgesia. Analgesia may be required for labour, following operative procedures performed during pregnancy such as cervical cerclage (Shirodkar suture) and after Caesarean section. Any techniques used during labour should produce efficient relief from pain whilst maintaining consciousness between contractions and good patient co-operation. It should not influence the process of labour. Respiratory depression, particularly of the neonate, should be minimal. Pain relief in labour is a major topic and, other than a brief review, is beyond the scope of this book. Interested readers are referred to the additional reading list for this chapter.
The acute pain service
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

For many years acute pain has been managed primarily by junior medical and nursing staff, many of whom have received minimal training to equip them for the task. It is not surprising that numerous studies of hospital patients have shown that acute pain is often poorly controlled, despite many advances in the drugs and techniques available to us. Management of chronic and terminal pain has developed enormously over the last 25 years, with many patients now receiving psychological, pharmacological, and physical treatments in multidisciplinary pain clinics and hospices. There is now widespread acceptance that these conditions are best managed by staff with specialist training.
Case studies in-pain management
Authors: Park Gilbert , Fulton Barbara , Senthuran Siva
Published: November 2023

The patient studies in this chapter have been chosen to illustrate commonly encountered problems in the accident and emergency department as well as those in the medical and surgical wards. Techniques such as regional blockade and the administration of epidural opioids may not be widely available and staff should seek help if unsure about the practice in their particular unit. In all instances it is important to maintain attention to the patient’s general condition and specifically to ensure an adequate airway, oxygenation, and the correction of hypovolaemia or other cause of shock in the individual patient, as necessary.
Patient assessment: structure and content
Authors: Faulkner Ann , Maguire Peter
Published: November 2023

The aim of an initial assessment is to establish which problems concern the patient, whether they be physical, social, psychological, or spiritual. The health professional should interview in a way which engenders trust and promotes compliance with advice and treatment. Beginning the interview; assessing the current problems and their impact; and ending the interview form three distinct parts of the assessment.
Breaking the news to patients
Authors: Faulkner Ann , Maguire Peter
Published: November 2023

Once a diagnosis of cancer seems possible or certain the doctor or nurse has to determine how much a patient wishes to know about his or her diagnosis, investigation, and treatment. This has to be done in a way that facilitates psychological adaptation and ensures compliance with advice and treatment.
Recognizing and handling difficult situations
Authors: Faulkner Ann , Maguire Peter
Published: November 2023

Many cancer patients have concerns which may pose problems for health professionals, especially when the cause of the concern is not made clear. If difficult situations arise as a result of the patient’s, or relatives’, fears and worries, it can leave health professionals with the feeling that they are somehow responsible for the patient’s emotional state. In this chapter, some difficult situations which commonly occur will be described, and useful strategies for coping with them will be contrasted with less effective, but more common techniques.
Injuries to children
Authors: Morton N S
Published: November 2023

The priorities are assessment of the airway while neck control is carried out, assessment of breathing and the circulation while controlling bleeding, assess ment of the level of consciousness and an overall assessment for other injuries. This scheme can be carried out very quickly and is easily remembered as an alphabetical list: The details of this scheme are similar to the rapid assessment of anycritically ill child but you must assume the cervical spine is injured until proven otherwise and you must actively look for injuries other than the most obvious.
Paediatric Ventilatory Care
Authors: Kerr M
Published: November 2023

The first breath marks the most radical change which will ever take place in the respiratory system. The adjustment from a fluid-filled to an air-filled lung is dramatic, but it is only the first of many adaptations which will take place as the lungs mature. The aetiology and clinical course of respiratory failure in infants and children is often quite unlike that seen in adults. The response to ventilatory support may also differ according to age. An understanding of the immature respiratory system can help explain these clinical differences and allow ventilatory management to be tailored to the needs of the patient.
Nursing Aspects of Paediatric Intensive Care
Authors: Macnab R
Published: November 2023

In this chapter, general principles of paediatric intensive care nursing are outlined, and a detailed discussion of the particularly important nursing issues is presented. Nursing assessment of critically ill infants and children, the nursing care of children in pain, the organization of nursing care, intensive support for parents and other family members and the provision for the dying child in the paediatric intensive care unit (PICU) are covered.
Legal and ethical aspects of paediatric intensive care
Authors: Morton N S
Published: November 2023

The legal and ethical framework for decision-making in paediatric intensive care is more complex than in adult practice. Although the primary duty of care is to the child, the decisions usually involve parents or guardians acting as advocates for the child. It is important that good lines of communication are established as soon as possible between the paediatric intensive care unit staff and the parents or guardians because changes in the child’s condition can happen very rapidly. The paediatric intensive care unit environment is complex and fraught with risks. Interventions must often be immediate before informed consent can be obtained. Allocations of intensive care resources, consent to treatment, withholding or withdrawing intensive care, diagnosis of brain death, organ donation and medical accidents all give problems. Each case must be considered individually with the overriding principle of acting at all times in the best interests of the child within the prevailing locally determined medical, social and legal rules.
Communication
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

Until recently, hospital consultants formed a more powerful and prestigious part of the medical establishment in the UK than GPs, but this is changing. General practitioners are closer to the ‘consumers’ than hospital doctors, and their patterns of referral for secondary care can have a more direct influence on which services are provided by which hospital or other provider. Their opinion is being sought and they are being wooed by other sections of the health service in an unprecedented manner. In turn, decision-making and power are also being shared with nurses, pharmacists, and other health professionals, who are being given prescription rights, formalized advisory roles and direct access to patients. Registers of practitioners of complementary medicine are being established; managerial power and numbers are increasing. The advent of fund-holding practices means that, for the first time in almost 50 years, there is a significant financial component to the doctor-patient interaction. Even without fund-holding there may be a perception by patients that treatment is being withheld because of cost.
Catastrophes and potential catastrophes in infants
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

Avoidable death and avoidable brain damage haunt any doctor treating babies and children. Disabilities are discussed in Chapter 8 and we are concerned in this chapter mainly with sudden infant death and with symptoms in babies that may mean life-threatening illness. However, many potentially fatal conditions can also lead to disabilities if the child survives. One of the challenges of general practice is to be able to pick out the child who has a major life-threatening disease from the majority, who have relatively minor self-limiting conditions.
Practising prevention
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

The aims of health promotion are to abolish avoidable child death and disease, to manage disability and resultant handicap, to mitigate the effects of deprivation and poor parenting, and to encourage healthy habits for children to take into adult life. Its aims do not include an over-dependence on medication or an exaggerated concept of what medicine can solve. They do include a positive attitude to life and the ability to make the most of one’s resources and opportunities.
Psychosocial problems of childhood
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

The General Practitioner is a doctor who provides personal, primary and continuing medical care to individuals and families ... His diagnosis will be composed in physical, psychological and social terms. (Royal College of General Practitioners 1969) Doctors always need to ask not only ‘what is the matter with the patient?’ but also ‘why is this child being brought to me at this moment?’ A rise in the frequency with which a parent brings the small child with upper respiratory tract infections is one indication of increased stress within the family. Not only do mothers in such circumstances have a lower threshold for consulting, but children living in stressed families are also more likely to develop minor infections. An out of hours call to see a minimally sick child who could well have been brought to the surgery during the day may be another indication of a stressed or disorganized family. Equally, the manner in which a child’s physical problems are presented is an important indicator of family tensions. Perhaps one minor symptom after another is revealed to the GP, who is left with a feeling that, even if the consultation had gone on for another hour, the mother still would not have had the chance to express all her anxieties about the child.
Children with disabilities, and school health services
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

The World Health Organization has defined impairment as a pathological process affecting normal physiology or anatomy, disability as reduced ability to perform normal functions resulting from an impairment, and handicap as the consequence or disadvantage for an individual resulting from a disability or an impairment. Until the last decade mental handicap was defined by comparing a child’s intellectual ability to that of his peers. Intelligence tests were a standardized means of measuring a child’s mental age from which IQ could be calculated, by dividing the mental age by the real age and multiplying by 100. Thus the general development of a 10-year-old child with an IQ of 20 was equivalent to that of a child of 2 years. IQ scores formed the basis for planning for an individual’s educational needs.
Infectious diseases
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

If the ill child wants to stay in bed, fine. Otherwise there is no reason why he should not sit in a chair, or lie on the sofa watching TV. Some parents of young children find it helpful to put aside a box of toys that are only brought out if their child is unwell. Teenagers may enjoy quietly listening to their personal stereo. Sick children feel ill at ease and behave in a more dependent, immature way they may feel more comfortable sleeping in the parents’ room for a night or two, or vice versa. Previously clean and dry toddlers may revert to wearing nappies.
Other respiratory disorders
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

Respiratory disease and otitis media account for 40 per cent of consultations by children under five years (Morbidity statistics from general practice 1986). This is not surprising considering that, on average, children have 12 acute respiratory infections in their first two years of life. Parental smoking is important. In a large British study involving 13 000 children under five years, maternal smoking during pregnancy was associated with a significantly increased risk of the child being admitted to hospital with a lower respiratory tract infection. ‘Bronchitis’ was most likely in children of mothers who smoked, surprisingly even if this was only in the antenatal period. Paternal smoking did not have a significant influence on the amount of serious respiratory disease.
Anaemia and bruising
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

A constant supply of oxygen is needed by the tissues and it is the function of haemoglobin to combine reversibly with oxygen, allowing the red blood cells to pick up the gas from the lungs and release it in the capillary bed. Interestingly, a litre of blood after leaving the lungs contains the same volume of oxygen as a litre of air-200 mL. Because of the different haemoglobin values at different ages (Table 17.1), it is important for the GP to know the normal range, making it less likely that he will treat a child for a non-existent anaemia. Haemoglobin concentration at birth is high by adult standards (16-18 g/dL). It initially falls rapidly and then more gradually to a low at two months of age, when the normal range is about 10.5-14.5 g/dL. After that there is a gradual rise throughout child hood but the haemoglobin concentration remains below adult values until adolescence.
Fits and faints
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

One of the most frightening experiences for any parent, is to witness their child having a convulsion, particularly its first. They have visions of a dead or braindamaged child, and it is common for him to be rushed directly to the Accident and Emergency department of the nearest hospital, bypassing the GP. A fit is usually unpredictable, and the child may have appeared reasonably well a few minutes before: Jimmy was the 14-month-old baby of French parents. He was brought to the surgery with a fever and an upper respiratory tract infection. The GP told the mother that the child was not seriously unwell, had a self-limiting illness, and only needed paracetamol. A few hours later a very angry mother rang from the hospital. Jimmy had a convulsion five minutes after she had left the surgery. The parents had taken him directly to the hospital, where he was now better. However, she never wanted to see the doctor again, who was obviously quite unable to realize how sick her child had been.
Recurrent pains
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

Complaints of aches and pains at one site or another, recurring over several months or years, are common in childhood. Often they seem to peter out or, at least, the family becomes able to cope with the symptom at a domestic level, once the doctor has guessed or established the family’s specific fear, and has been able to reassure them that the pains are not, for example, appendicitis, leukaemia or a brain tumour. Other family members may have dysmenorrhoea, indigestion, or migraine. The abdomen and head and limbs seem to be the most common sites for recurrent pains in children; chest pains or chronic backache are rarer. Although, in most patients, there is no physical cause to account for the pain, careful assessment is necessary. Chronic backache, unlike the others, is more usually a symptom of some underlying organic pathology in a child. It, and limb pains are discussed in Chapter 21.
Congenital disorders and genetic disease
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

Genetics is becoming more and more relevant to primary care. The aim of this chapter is to put this major development which affects existing and future babies and children, into context. Practice staff have an important role in educating and counselling carriers of common recessively inherited conditions (haemoglobin disorders, cystic fibrosis), in providing information to those offered testing elsewhere, and in referring carrier couples for genetic counselling. Many women attending for family planning advice intend to have a baby in the near future. This may be an ideal opportunity for preconception counselling. Antenatal care often includes several screening tests often inadequately explained. Being alert to the genetic components of handicap or chronic disease is important, so that the need to refer parents of children affected by these conditions for genetic advice is not overlooked. All members of a primary health care team who come into contact with parents or potential parents must be able to give basic genetic information. However, it may be advisable for larger practice teams to arrange for one member, perhaps a health visitor or practice nurse, to receive additional training in this area.
Perversion as a regulator of self-esteem
Authors: Rosen Ismond
Published: November 2023

Regulation of self-esteem is a major function of the perversions. Patients seeking help for the relief of their perversions, simultaneously complain of feelings of inadequacy, with under or over self-assertion, as evidence of a disordered narcissistic economy. Perverse fantasies or actions function as a source of intense pleasure that elevates self-esteem. Conversely, following perverse acts patients may complain of feelings of shame and guilt that diminishes their self-esteem.
The gender disorders
Authors: Stoller Robert J
Published: November 2023

Most psychoanalysts, following Freud (1905), believe all psychopathology, not just the sexual deviations, results-by such mechanisms as castration anxiety and penis-envy in the oedipal conflict-from disturbances in the development of gender-identity, that is, of masculinity and femininity. This discussion, however, will be restricted to the gross aberrations of masculinity and femininity: primary and secondary transsexualism, transvestism, certain types of homosexuality, inter-sexuality, and certain aspects of psychosis.
Childhood gender-identity disorders
Authors: Loeb Loretta
Published: November 2023

It is important in formulating the aetiology of adult male transsexualism to know how similar symptoms develop in childhood. I have observed transsexual symptoms in two male children whom I had in psychoanalysis. I did not have to speculate retrospectively because the symptoms manifested in the transference.
Child sexual abuse
Authors: Kolvin Israel , Trowell Judith
Published: November 2023

Over the two last decades sexual abuse of children has now come to be seen as one of the new ‘epidemics’ of childhood and yet previously it must have been present in communities; the question arises, why was it not viewed as pathological behaviour and a serious problem affecting children’s physical and psychological health. It would seem that multiple factors must have contributed to what appears to be a suppression of the facts, or perhaps it was a reluctance to acknowledge the presence of sexual abuse.
Behavioural therapy treatment for sex-off enders
Authors: Abel Gene G , Osborn Candice A
Published: November 2023

Behavioural therapy evolved out of learning theory and is used to evaluate and treat psychiatric and psychological symptoms by directly decreasing the frequency of pathological behaviours and increasing the frequency of appropriate behaviours. Behavioural therapy for sex-offenders initially focused on single treatment interventions, such as aversion therapy, to change the paraphiliac’s deviant behaviour.
The use of guidelines and criteria in peer review
Authors: Grol Richard , Lawrence Martin
Published: November 2023

We have described peer review as a systematic assessment of one’s own and one another’s pattern of care with the aim of achieving a continuous improvement of patient care. In such a peer review process explicit guidelines for what is considered to be desirable general practice care play a central role. However, it is not unusual to find general practitioners objecting to clearly formulated guidelines and criteria and the uniformity they imply. This feeling of threat is increased by poor understanding of ter-minology which is often seen to imply external imposition when it does not.
The health risks women face
Authors: Russell Cristine
Published: November 2023

When it comes to health, women and men are certainly not created equally. From the first breath to the last, women face different health risks than men, not only in how and when they die but in the nagging medical conditions that affect the way they Jive. Women generally have a strong advantage in terms of life span, but unfortunately they often live less healthy lives than their male counterparts.
Sexually transmitted diseases
Authors: Cates Willard
Published: November 2023

Just as syphilis predominated in the beginning of the twentieth century, sexually transmitted diseases (STDs) remain a major international public health priority in its last decade (Holmes et al. 1990). Trends in STDs are important indicators of both high-risk sexual behavior and the adequacy of control programs in both developed and developing countries. Variations in STD prevalence serve to monitor the effectiveness of our public policies, especially strategies aimed at the human immunodeficiency virus (HIV). This chapter will emphasize the epidemiologic patterns of STDs, their historic perspective, their impact on the health of women and children, the role of diagnosis and treatment in prevention, and current ethical problems in controlling STDs.
Infant mortality: confronting disciplinary fragmentation in research and policy
Authors: Wise Paul H
Published: November 2023

It is a curious paradox that infant mortality is as much a public concern today as it was in the mid-nineteenth century, despite the fact that the rate hasfallen by more than 95 per cent since then. In a sense, concern persists because interpretation of infant mortality demands context and in each era a society derives its own context from its perceptions of the causes of infant mortality and what it considers to be its capacity to respond.
Small for gestational age infants
Authors: Goldenberg Robert L
Published: November 2023

While it has long been recognized that the weight of a baby at birth is highly correlated to both survival and freedom from handicap, only in the last two decades have researchers clearly distinguished the concept of born too early from the concept of born at the right time, but too small. The latter infants are frequently labeled as being small for gestational age (SGA) or having intrauterine growth retardation. While some writers attempt to distinguish between SGA and intrauterine growth retardation, with SGA meaning a birth weight less than an arbitrary standard for gestational age and intrauterine growth retardation referring to an infant whose size at birth is ‘less than its potential’, for the purpose of this chapter both terms will be used to dtiscribed infants whose weight at birth is below some arbitrary cut-off point for their gestational age.
Human genome project: implications for practicing obstetricians
Authors: Sachs Benjamin P , Korf Bruce
Published: November 2023

It is safe to say that the knowledge gained will revolutionize medicine, because a better understanding of the ways in which genes control the body will make it possible to develop new methods for diagnosis, treatment, and prevention. Genetics is already an important part of clinical practice for the obstetrician. The introduction, approximately 25 years ago, of amniocentesis and more recently of chorionic villus sampling, has provided the tools to screen for a few genetic disorders, the most common being trisomy 21 (Down’s syndrome).
Facilitating communication
Authors: Myerscough Philip R , Ford Michael J , Currie C T , Doyle D , Hewitt A N M , Laing I A , Speirs A L , Wrate R M
Published: November 2023

After reviewing the broad strategy of the interview, we need to look at the tactics of the dialogue. Of particular importance are the methods by which a doctor can facilitate communication. These help to elicit as accurately as possible, in the limited time available, the information needed to make a diagnosis and plan treatment, while giving the patient adequate opportunity to express his feelings. Whatever the nature of the verbal exchanges, the patient’s body language, which is likely to convey information of its own, must be carefully observed throughout.

The doctor should ask questions in clear, unambiguous language suitable to the patient’s age, education, and cultural background; the information often gained during the introductory phase of the interview about the patient’s general background will be of assistance. Unsuitable language, whether in vocabulary, accent, or overformal style, can regrettably inhibit rather than facilitate dialogue.
Communication by and during touching
Authors: Myerscough Philip R , Ford Michael J , Currie C T , Doyle D , Hewitt A N M , Laing I A , Speirs A L , Wrate R M
Published: November 2023

Discussion of interpersonal communication would not be complete without reference to communication by touching. In all cultures, touching is a basic form of both social and sexual communication. Lovers touch to convey affection, and so do all human beings when they wish to convey, without the use of words, affinity and warmth, sympathy, encouragement, or reassurance. When comforting a patient in pain, a hand instinctively reaches out to touch. In the labour room, for example, one may quietly stroke the patient’s arm or her hair during painful contractions. I have sometimes noticed in dealing with demented old ladies, agitated almost beyond the reach of words, that gentle facial stroking can help to reassure and calm them, allowing some communication to be established.
Caring communication skills
Authors: Myerscough Philip R , Ford Michael J , Currie C T , Doyle D , Hewitt A N M , Laing I A , Speirs A L , Wrate R M
Published: November 2023

The manner in which a doctor communicates with a patient is influenced considerably by the extent to which he feels the need to remain detached from, or is prepared to become involved with, patients’ problems and concerns generally, and with their feelings in particular. The extent of the professional ‘distance’ thus established is readily recognized by the patient. This in turn determines his perception of the doctor’s role—of how much involvement he can expect the doctor to show. Some of the ploys which doctors may adopt to maintain greater distance are described on p. 76.

Because of the contrast between detachment and involvement, it is easy to generate a misleading antithesis between curing and caring. Curing is portrayed in this rather stereotyped view as a detached activity on the doctor’s part, in which the patient is essentially passive. Caring is taken to imply involvement, a holistic concern with all aspects of the patient’s situation.
Talking about choices and making decisions
Authors: Myerscough Philip R , Ford Michael J , Currie C T , Doyle D , Hewitt A N M , Laing I A , Speirs A L , Wrate R M
Published: November 2023

We now turn to the latter part of a medical interview, during which the doctor usually needs to outline the options open to the patient, and steer the dialogue towards decision-making. Often therefore this is the crux of the whole interview and sometimes it provides the greatest test of the doctor’s skill as a communicator.

This part of the interview has been called ‘the exposition’, because traditionally the doctor was expected to pronounce, with all his professional authority, his views and conclusions about the diagnosis and to spell out what should be done. The phrase ‘doctor’s orders’ (implying in general usage unquestioned authority) reflects the passive acceptance which was expected from patients. Similarly, the terms ‘prescription’ and ‘compliance’ carry the same authoritarian overtones.
Written communication
Authors: Myerscough Philip R , Ford Michael J , Currie C T , Doyle D , Hewitt A N M , Laing I A , Speirs A L , Wrate R M
Published: November 2023

While this book is primarily concerned with direct person-toperson communication, particularly in its affective aspects, something needs to be said about the written material relating to patients-the case records, letters, and so on-and the way in which these ought to complement and promote good interpersonal communication. If talking with the patient is to include the patient’s feelings and concerns, this needs to be reflected in the written observations relating to the patient’s care.

Clinical case records, of course, serve many functions: recording the history, clinical findings and investigation results, the details of treatment and the progress notes, as well as bringing together the correspondence between doctors.