bluuebunny/crossref_metadata_2025 huggingface dataset:
What kills Lady Dedlock?
Authors: Rowson Martin
Published: November 2023

A recent disagreement between two Dickensian critics highlights a central puzzle in Bleak House. In a 1983 article, entitled ‘The Fever of Bleak House’, Fred Schwarzbach noted that ‘disease plays a central part’ in the novel’s plot, ‘as both subject and metaphor’. Few readers will disagree. Many characters in Bleak House die, of many ailments, ranging from opium poisoning, through cerebral stroke, to that most controversial of causes of death, ‘spontaneous combustion’. But ‘What is not clear; and has puzzled modern critics’, Schwarzbach notes, ‘is why Dickens has Jo contract smallpox. Should he not have written instead about cholera, the most feared of all fevers in midVictorian England, which recently had ravaged the nation in the epidemic of 1848–9?’
Why doesn’t Laura tell her own story?
Authors: Rowson Martin
Published: November 2023

The Woman in White opens with Walter Hartright’s startlingly original declaration of how the subsequent narrative will be laid out:

As the Judge might once have heard it, so the Reader shall hear it now. No circumstance of importance, from the beginning to the end of the disclosure, shall be related on hearsay evidence. When the writer of these introductory lines (Walter Hartright by name) happens to be more closely connected than others with the incidents to be recorded, he will describe them in his own person. When his experience fails, he will retire from the position of narrator; and his task will be continued, from the point at which he has left it off, by other persons who can speak to the circumstances under notice from their own knowledge, just as clearly and positively as he has spoken before them. (p. 5)

Wilkie Collins’s reportage style of narration was to be central in the evolution of the ‘Sensation Novel’, and its influence can still be felt as far afield as contemporary docufiction. The Woman in White is, in terms of its narrative technique, one of the most innovative novels of the nineteenth century.
Why was Pip not invited to Joe’s wedding?
Authors: Rowson Martin
Published: November 2023

Malcolm Hurwitt writes to ask ‘if you are aware of the puzzle which I feel exists in Great Expectations? It may be described as “Why was not Pip invited to the Wedding?”.’ Mr Hurwitt goes on:

It is, as Mr Hurwitt rightly says, odd; and it gets odder the closer one looks at the episode. After Magwitch’s euthanasia, during a ‘cold and dusty spring’ (p. 453), Pip falls into a ‘fever’–– the dreaded ‘jail-fever’, as we apprehend. (The OED defines the disease as ‘a virulent type of typhus-fever, formerly endemic in closed jails, and frequent in ships and other confined places.’) The illness is the last of Magwitch’s gifts to Pip, and the most fatal.
Does Dickens know his train signals?
Authors: Rowson Martin
Published: November 2023

Departing from his normal practice, Dickens offers at the end of the serialized Our Mutual Friend a ‘Postscript: in lieu of Preface’. This afterword reminds readers of what most of them must have well known –– that there almost was no concluding part of the novel. Everything after Chapter 51 was, in a sense, a ‘postscript’, because thereafter Mr Charles Dickens was living on borrowed time.

Dickens gives here a vivid thumbnail account of the terrible Staplehurst accident, in which ten less fortunate passengers perished and forty were seriously injured. The

train from Folkestone to London (Dickens had been in France) crashed at speed on a viaduct under repair. The system of red-flag warnings (it was daylight) had failed.
Is Franklin Blake a thief and a rapist?
Authors: Rowson Martin
Published: November 2023

The Moonstone has an honoured place in literary history as, to quote no less an authority than T. S. Eliot, ‘the first, longest and best of English detective novels’. Many detective novels have been written since Eliot’s accolade (offered, it is pleasing to note, in the first World’s Classics edition of The Moonstone). But Collins’s novel still retains the power to delight and to surprise.

The story, a version of the ‘locked room mystery’, hinges on a jewel theft. A fabulous Indian gem, the Moonstone, is left to Rachel Verinder. So nervous is she on getting possession of it that she keeps it safely secreted in her bedroom suite at night. None the less, it is stolen. The thief must be someone in the household. Sergeant Cuff of Scotland Yard is called in. There is a likely looking clue. Whoever stole the diamond must have brushed against some wet paint on the door to Rachel’s boudoir. But the incriminatingly stained garment is never found.
How criminal is Melmotte and when is he criminalized?
Authors: Rowson Martin
Published: November 2023

Novelists, from Henry Fielding to Jeffrey Archer, are perennially fascinate by great swindlers –– the most adventurous of criminals. For the Victorians, the most notorious such ‘buccaneer’ was John Sadleir (1814–56). One of the few financier-criminals (along with Robert Maxwell) to earn an entry in the DNB, the Irish-born Sadleir rose to fame, power, and high political office on the immense bubble of speculative wealth created by his fraudulent banking activities. When the Tipperary Bank collapsed in February 1856, Sadleir was found to have embezzled £200,000 of its funds and to have ruined legions of widows and children. A couple of days later his body was found on Hampstead Heath, alongside a phial of prussic acid.
What English novel is Anna reading?
Authors: Rowson Martin
Published: November 2023

If Tolstoy’s novel Anna Karenina had ended a fifth of the way through, at the end of Chapter 29, we would have a bittersweet short story with a happy ending. In this chapter Anna is returning from Moscow to her home, her beloved son Seriozha, and her less-than-beloved husband, Alexei, in Saint Petersburg. She has been in the capital to sort out the marriage problems of her hapless sister-in-law, Dolly

In Moscow, Anna has fallen under the spell of the dashing cavalry officer, Count Vronsky. But she has not surrendered to temptation. She is still a virtuous wife and matron. By no means entirely happy: but virtuous.
Clinical disagreement
Authors: Ebrahim Shah
Published: November 2023

Whenever two or more doctors are asked to assess the same patient it is unlikely that they will agree completely on their clinical findings. This phenomenon is well recognized in several fields of medicine, ranging from taking a history (Cochrane et al. 1951), examination of the pedal pulses (Meade et al. 1968), chest examination (Spiteri et al. 1988), to interpretation of exercise electrocardiograms (Blackburn et al. 1968). It is not surprising, therefore, that in the assessment of stroke patients agreement is not absolute. Information on which doctors disagree can be considered in terms of its importance to diagnosis, management, and prognosis. If the information is crucial, every effort must be made to reduce dis agreements; if the information is of little value, there is no point in wasting time collecting it, much less trying to improve its reliability. For example, if two clinicians disagree on the presence of a carotid bruit the patient may or may not be exposed to the risk of angiograms (or denied the benefits of investigation and treatment) depending on one’s point of view. Disagreements on factors that determine rehabilitation potential (e.g. mental state, severity of stroke, pre-stroke ability) may lead to patients being denied access to therapy and discharged to nursing homes inappropriately or before their full potential has been achieved.
Severity
Authors: Ebrahim Shah
Published: November 2023

Is it a bad stroke? The severity of disease can be described in many different ways, ranging from the patient’s perception, the degree of physiological disturbance, the consequent disability, and handicap caused, to the burden on society (Stein et al. 1987). The severity of a stroke may be assessed in terms of the amount of brain damaged, the size of the lesion(s) demonstrated on CT scanning, or the number and severity of the neurological impairments. At the level of disability, the severity of a stroke may be measured by ability to walk, the ability to climb stairs, or the ability for self-care. At the level of handicap, severity may be measured by impact on work, enjoyment of usual sex life, or social engagement. The aetiological and pathogenetic differences between types of stroke, together with the wide range of possible consequences, make a simple classification of severity difficult.
Minimal access surgery
Authors: Majeed Ali , Carmody Matthew J
Published: November 2023

Minimal access surgery (MAS) is a term introduced relatively recently into the surgical literature to indicate techniques where there is a substantial reduction in the size of the access wounds through which a surgical procedure is performed. Initially, this type of procedure was called ‘minimally invasive’ until it was realized that it was only the trauma of access that was reduced; the procedure and the ‘invasion’ into the patient remained the same. The old adage that ‘big surgeons make big incisions’ has been superseded by the rapid pace of development of sophisticated instruments and techniques. It must be remembered that whatever the route of access, the procedure performed remains the same and that the safety of the patient is paramount. If an attempt at minimal access surgery is found to give inadequate access, then it is prudent to make a standard incision to help achieve a safe resolution. Persisting with inadequate access is indefensible.
Trauma
Authors: Anderson lain D
Published: November 2023

Accidental injury is a major yet neglected health problem. Trauma is the principle cause of hospital admission in males aged less than 35 years and is the most common cause of death in males and females between 1 and 34 years of age. In Britain, 40 deaths a day occur from accidents of all kinds and 100 deaths per week result from road traffic accidents alone. Trauma results in the loss of more economically productive years than cancer and heart disease combined. Trauma patients over 65 years of age are twice as likely to die and cost twice as much as young patients to treat. Deaths, however, are only the tip of the iceberg, with more than half a million patients surviving hospital admission as a result of trauma each year. Unlike other serious illnesses, some 80 per cent of trauma patients can be returned to full productive and unrestricted life if high-quality care can be provided.
Philosophy and Psychology —Worlds and Minds
Authors: Cutting J
Published: November 2023

In the beginning there was multiplicity. There was no concept of any of the modes of human existence which we now take for granted. Primitive man recognises no clear-cut difference between the familiar and the strange, an inner and an outer world, life and death, soul and body. For him soul and body are neither of them well defined and demarcated areas. What he does recognise, in him and all around him, is a world of strange forces with a quality of ‘otherness’ … For the most part one would have to speak of several different souls manifesting themselves in man rather than of a soul … The soul is never simply immaterial, because the world is never simply material … For primitive people the world has become something more than just what happens in the course of nature.
The purpose of medical audit
Authors: Schofield Theo
Published: November 2023

In 1983 the Royal College of General Practitioners launched its Quality Initiative with the following aims: 1. Each general practitioner should describe his or her current work and should be able to say what services his or her practice provides for the patients. 2. Each general practitioner should define specific objectives for the care of his or her patients and should monitor the extent to which these objectives are met. One of the central proposals in the British Government’s 1989 White Paper on the reform of the National Health Service (NHS) was that all doctors should participate in regular and systematic medical audit (Secretaries of State 1989). This was welcomed by leaders of the medical profession as it was in line with their previously stated policies.
Introduction: Preparing the ground
Authors: Havelock Peter
Published: November 2023

The introduction of audit into a practice can be fraught with difficulties. To maximize the chances of success an essential first step is for the practice team to take an inward look to see if it is capable of and ready for the challenge. The mood of the whole practice needs to be right. Successful audit requires members of the team to have confidence in each other, an ability to work together, enthusiasm and energy, the ability to accept criticism, and a wish to improve. It is not always possible to produce entirely the right mood in the practice before starting audit. Sometimes there are seemingly insuperable obstacles. For instance, a difficult partner or practice manager, an overwhelming workload, or terrible premises, can make individuals feel discouraged before starting. But it is quite feasible to start in a very modest way, either alone or with another person of like mind. Looking at the quality of care and trying to improve it can be an introduction to a whole new way of working in the practice. Audit can often be the first truly shared activity in the practice and many others can follow.
Implementing change and planning care
Authors: Havelock Peter
Published: November 2023

The process of bringing about change is based on simple, common sense theory, but the implementation of that theory is complex and riddled with hazards. It involves a move from collecting, collating, and presenting data to an alteration of behaviour in the practice to improve the quality of care (Rogers 1971). In the introduction to Part II the characteristics of a healthy practice were outlined. Those characteristics allow a practice to perform effectively and the time and effort expended in attaining them are well rewarded. Often such ideal circumstances are unobtainable; for instance, due to a long history of resistance to change within the practice, or due to one powerful partner blocking all progress. If these or other similar circumstances apply to you, do not be put off introducing audit. Often the process of examining the quality of the care you provide, including team work, discussion, planning, and effective meetings can help to bring about the metamorphosis to a healthier practice. If you are the person trying to introduce change into your practice do not get too disheartened by initial resistance and failures, but use the ideas and principles in the following chapter to help ‘sell’ your ideas to the other members of your practice.
Preventive care: cardiovascular disease
Authors: Farmer Andrew
Published: November 2023

Cardiovascular diseases are the most common cause of premature death in the UK. Heart disease leads to disability and a restricted life-style for those suffering from angina and heart failure. The economic cost of treating established heart disease is high. Intensive care for those suffering myocardial infarction is expensive, new drugs such as streptokinase offer improved survival but at great cost, and coronary artery bypass grafting is an increasingly common procedure. Developing a coherent strategy for the prevention of cardiovascular disease has been a priority of many groups, including the government, royal colleges, and district and regional health authorities.
Standardized concentrations
Authors: Cruickshank Steven
Published: November 2023

Antagonists are classified as competitive or non-competitive. There are various ways in which the non-competitive antagonists may act but the most familiar exemplified by phenoxy benzamine at the a-receptor—is the irreversible (or only very slowly reversible) reaction with a receptor site. The effect is essentially a depletion of the receptor pool [R] and hence a reduction in [DR] for any given agonist concentration. We concentrate on the more familiar competitive antagonism.
Masses and springs: Hooke’s Law
Authors: Cruickshank Steven
Published: November 2023

Oscillating systems are seen everywhere. Anaesthetists are particularly interested in cyclical physiological processes such as the cardiac and respiratory cycles. As in previous modelling examples, we shall start quite simply and build up only such complexity as we need to describe the systems that concern us. We shall build a model of a typical arterial pressure waveform and see how this model relates to the physical behaviour of the clinical measurement systems that we use to display it. We start with the simplest ideal oscillating system, in which no frictional forces are involved.
Modelling real oscillations: frictional forces and damping
Authors: Cruickshank Steven
Published: November 2023

We have studied the behaviour of a model system without considering frictional forces. The SHM oscillations continue undiminished for ever in such a model; the energy imparted to the system at the outset remains within the system. This is evidently quite unrealistic, since in reality we observe a progressive diminution in the amplitude of the excursion of the mass. If we suspended the mass-spring system in oil rather than air, we would expect the oscillations to be more sluggish (longer period of cycle) and to die away quickly (rapid diminution in amplitude.) We need to incorporate a frictional element into the model to account for this energy dissipation. The dissipation of energy from oscillating systems is damping.
Sinusoidal functions
Authors: Cruickshank Steven
Published: November 2023

The sinusoidal functions are the building blocks for modelling oscillating and repetitive phenomena. We have studied the modelling of physiological pressure waves quite extensively in ( 1.19). This section summarizes some of the properties of the sinusoidal functions in general.
Integrals
Authors: Cruickshank Steven
Published: November 2023

If we have a differentiable function, we can find its derivative and hence the gradient at any point on the graph. Our modelling equations are frequently expressed in terms of the rate of change or gradient of a quantity, and our task is to recover the original function. This process is integration, and is the reverse process of differentiation. The function the derivative of which we know is called a primitive. This is expressed in function notation as: F(x) is a primitive of f(x) which in turn has a derivative f(x). This also means that F’(x) = f(x) and F”(x) = f(x).
Thiamin (vitamin B1>
Authors: Bender David A , Bender Arnold E
Published: November 2023

The peripheral nervous system disease beriberi, due to thiamin deficiency, has been known sporadically for some 1300 years; it became a major problem of public health in the Far East in the nineteenth century with the introduction of the steam-powered rice mill, which resulted in more widespread consumption of highly milled (polished) rice. Thiamin was discovered as the factor in the discarded polishings which protected against the disease, and was initially called aneurine, the anti-neuritic vitamin.
Symposium: neural tube defects
Authors: Bell Jeanne E
Published: November 2023

Defects of the central nervous system (CNS) are among the most common of the severe congenital malformations. Abnormalities such as spina bifida and anencephaly have been recognized since antiquity and have been the subject of historical pathology studies (Cleland 1883; von Recklinghausen 1886). Despite this the causes of these abnormalities, and therefore the means to total prevention, remain poorly understood. From observation of human embryos (Frazer 1921; de Vries 1927; Patten 1952; Erskine 1955; Dekaban 1963; Lemire et al. 1965; Bell and Gosden 1978; Bell 1979; Smith et al. 1993), it is clear that these malformations have their origin very early in development. It is for this reason that the generic term, neural tube defects (NTD), has been given to conditions such as anencephaly, spina bifida, and some other rarer CNS abnormalities.
Litigation and obstetric ultrasound
Authors: Pearce J Malcolm
Published: November 2023

For more than a decade now most pregnant women have had at least one ultrasound examination during the course of their pregnancy. As an imaging modality ultrasound is unique in at least two respects. Firstly, it is mostly carried out by radiographers who are then expected to talk to both the pregnant woman and the managing clinicians, often without the intervention of or reinterpretation by a doctor. Secondly, ultrasound is both a screening and a diagnostic test. The main role of routine ultrasound examination in the first half of pregnancy is to confirm or establish the gestational age. Secondary roles include the diagnosis of multiple pregnancy, the localization of the placenta, early maternofetal bonding, and a survey of fetal anatomy. Unusual appearances or measurements should lead to a detailed examination by an appropriately trained doctor who will attempt to make a diagnosis and give a prognosis.
Charting the course: designing a medical curriculum
Authors: Jolly Brian
Published: November 2023

In this chapter we shall look at why a curriculum needs to be designed, who should be involved, and different methods and approaches to designing it. We will also look at some of the effects that such decisions have in practice. However, a detailed discussion of course planning is not envisaged here. The title of this sub-chapter is ‘charting the course’, not ‘trimming the sails’. We will take a global approach. A few simple models to help curriculum designers will be presented and the implications of ignoring the interactivity of curriculum decisions discussed. Within each section we will try to identify useful principles for curriculum design in medicine. Finally we will make some remarks on the difficulty of curriculum maintenance in the face of rapid and far-reaching developments in health care.
Pain in cancer
Authors: Coniam S W , Diamond A W
Published: November 2023

The relief of the physical, mental, and social symptoms of disease in the dying has become the basis of palliative care. Among the most distressing of these symptoms is pain associated with malignant disease. Relieving it is not curative treatment and does not alter the disease process, and yet it is not necessarily ‘terminal care’. Relief of distressing symptoms should begin whenever they arise and not be reserved for the terminal stages. Although pain is often thought to be the main symptom in cancer, and will be the main consideration in this chapter, palliative care should aim to ameliorate all the distressing symptoms in a patient with malignant disease.
Intercostal nerve block
Authors: Mather S J
Published: November 2023

The intercostal nerves are the ventral branches of the first 11 thoracic segmental nerves (Fig. 8.1). In the paravertebral space the nerve passes very close to thepleura. At the costal angle it enters the subcostal groove. Themajor part of nerve runs with the blood vessels in the intercostalspace, protected by the subcostal groove of the rib (Fig. 8.2).
Nerve blocks for inguinal herniotorny and orchidopexy
Authors: Mather S J
Published: November 2023

The ilioinguinal nerve (Tl2, LI) runs below the ventral branch of the iliohypogastric nerve (Tl 2, Ll). The iliohypogastric nerve lies between the transversus abdominis and internal oblique muscles, dose to the anterior superior iliac spine, and supplies the skin in the area of the inguinal ligament. The ilioinguinal nerve runs through the superficial inguinal ring to supply the skin of the scrotum in the male and the labia majora in the female.
Monitoring progress
Authors: Faulkner Ann , Maguire Peter
Published: November 2023

Assessment is not a ‘one-off’ activity carried out only when the patient is first seen, but is a dynamic ongoing activity, which allows progress to be monitored. Soon after admission, the patient’s problems should have been identified, and their care planned in the light of the presenting problems, whether these are physical, social, or psychological. The patient will still be attempting to come to terms with the illness and its sequelae and treatment, which can be frightening and unpleasant. Fears and worries do not disappear overnight, and nursing and medical staff will need to review both social and psychological problems.
Handling conflict in cancer care
Authors: Faulkner Ann , Maguire Peter
Published: November 2023

The health professional will inevitably encounter situations in daily practice where the potential for interpersonal conflict is high. This chapter seeks to provide guidelines to help deal with these situations constructively. A common requirement is the willingness to confront individuals promptly once conflict arises, in a way that makes resolution reasonably likely. If health professionals are to be able to confront in this way they have to be willing to be assertive and represent their own views firmly, without alienating other people.
Training in communication skills
Authors: Faulkner Ann , Maguire Peter
Published: November 2023

In the past, conventional medical and nursing curricula have contained little, if any, input on communicating with patients. Faulkner (1985) found that a majority of nurse educators believed that such skills were inherent in health professionals, and there is lively debate in medical schools on whether to include communication as a subject in the curricula. However, when the ability of doctors and nurses to elicit cancer patients’ concerns was assessed by asking them to interview simulated patients, recording their interviews, and rating transcripts of audiotapes many were found to be lacking in the behaviours which promote disclosure (Chapter 4). In contrast, behaviours which inhibit disclosure were used more frequently. When the ratio of desired to undesired interviewing behaviours was compared it was found to be one to three. This ratio was not affected by the age of the health professionals, the length of time they had been working with cancer patients, or their professional discipline or training.
The Spectrum, of Paediatric Intensive Care
Authors: Sinclair J
Published: November 2023

A paediatric intensive care unit (PICU) is a facility specially designed, staffed and equipped for the treatment and management of critically ill children from early infancy to adolescence. Because PICUs are tertiary referral centres based at major paediatric teaching hospitals, large numbers of children are cared for, at least initially, outwith the tertiary centre in adult intensive care units (ICUs). The aims of this chapter are to introduce some of the wide spec trum of illnesses seen in the PICU, to highlight the differences between the management of patients in PICUs and adult ICUs, and to explain the reasons behind these differences. The spectrum of disease seen in any given PICU depends on the population from which it receives its patients. The presence of a cardiac surgery programme or organ transplant programme within the hospital will have major implications for the PICU.
Sedation and analgesia for critically ill children
Authors: Hansen T G , Morton N S
Published: November 2023

Critically ill children undergoing mechanical ventilation frequently require sedation and/or analgesia.1-4 The main purpose of this treatment is to improve the efficacy of mechanical ventilation but sedation and analgesia are also required to alleviate unpleasant experiences faced by children in the paediatric intensive care unit (PICU) (Table 10.1). Sedation and analgesia can also be used as therapy in patients with increased intracranial pressure, status asth maticus, status epilepticus and to attenuate pulmonary hypertension. l,z,s-s Sedation should always be performed without compromising the child’s haemodynamic stability.
Stabilization and transport of the critically ill child
Authors: Morton N S
Published: November 2023

Centralization of paediatric intensive care facilities means that more children will need to be moved to specialist units. It has been clearly shown that this results in improved morbidity and mortality rates for the sickest children1 and that properly conducted transportation does not cause a deterioration in the patient’s condition and outcome. By recognizing critically ill children early, by thoroughly assessing and stabilizing their condition prior to transfer and by ensuring that appropriately experienced personnel accompany the child using appropriate equipment, secondary insults during transport can be avoided.
.Growth and its problems
Authors: Modell Michael , Mughal Zulf , Boyd Robert
Published: November 2023

Growth is a very sensitive indicator of a child’s well-being. There is rarely anything serious chronically amiss with a baby or a child who is growing well physically and mentally. Unfortunately, a healthy growth is not always found. Failure to thrive is a time-honoured phrase which merely means failure to gain weight at the expected rate. It is best diagnosed by plotting sequential weights, and, ideally, length and head circumference measurements (often overlooked) on a suitable centile chart. The weight of the child who is failing to thrive will fall across centile lines, or away from the second centile. In essence, the rate of growth is more important than a single weight measurement which lies below the second centile. Edwards et al. (1990) have suggested that the child’s ‘genetic weight centile’ is achieved between four and eight weeks rather than at birth. This is a better predictor of his centile at 12 months than the birth centile, which is partially determined by maternal influences and the fetal well-being during pregnancy.
Fetishism
Authors: Greenacre Phyllis
Published: November 2023

The concept of the fetish rests on a very broad base. The term seems to have originated in the 15th century, when Portuguese explorers in West Africa applied it to carved wooden figures or stones. It was thought that the natives regarded these as having magic value, and that they might have been considered as the habitations of gods or, spirits. This interpretation may have been derived in part from the regard and worship of relics of the saints or other holy persons, already familiar to the explorers.
Exhibitionism, scopophilia, and voyeurism
Authors: Rosen Ismond
Published: November 2023

An exhibitionist may be defined as a person who exposes his genitals to someone of the opposite sex outside the context of the sexual act. Exhibitionism is classified in DSMUIR as a paraphilia, a subdivision of the psychosexual disorders.
Advances in the psychoanalytic theory and therapy of male homosexuality*
Authors: Socarides Charles W
Published: November 2023

In a new era of sexual permissiveness and intensive sociopolitical activism threatening to remove homosexuality as a psychopathological disorder and even proscribe its treatment, it is well to begin this chapter by a definition of homosexual and homosexuality, preceded by definitions of the words ‘sexual’, ‘heterosexual’, and ‘heterosexuality’.
Biological factors in the organization and expression of sexual behaviour
Authors: Michael Richard P , Zumpe Doris
Published: November 2023

No single physical, chemical, educational, cultural, biological, or ethical factor is responsible for the expression of sex. On the contrary, the more complex the organism, the more numerous are the factors influencing the phenomenon. In some simple forms of motile, water-dwelling plants, the addition of a chemical to the medium causes the population to divide into two groups: those which attract and those which repel each other. This simple chemistry no longer holds in more complex forms; and in the human, powerful cultural as well as subtle educational influences may be just as important in determining sex role and orientation as are the genetic and endocrine factors.
Observing practice and evaluating care in peer review
Authors: Grol Richard , Lawrence Martin
Published: November 2023

After setting criteria and target standards for evaluating general practice care the next steps in the peer review process are concerned with observing practice and collecting data on the actual care provided to patients. What kind of care is delivered and to what extent does it meet the quality criteria? Assessing patient care is a crucial activity in quality improvement. Care providers often overestimate what they do. Providing information about what actually happens makes performance clear to doctors themselves, to their peers, and to others.
Improvement and change through peer review
Authors: Grol Richard , Lawrence Martin
Published: November 2023

Improving and changing practice performance is definitely the most complex step in medical audit. It is also an aspect which is often undervalued or neglected (Pringle et al. 1991). Nevertheless, there is a lot of evidence that, even if care providers are well informed about what they should be doing, they often do not perform in accordance with their knowledge or skills (Kosecoff et al. 1987; Sanazaro 1983), so behaviour change is desirable.
Methods for observing and reviewing practice with peers: some principles
Authors: Grol Richard , Lawrence Martin
Published: November 2023

In this part of the book the development of performance review with peers and colleagues in a practice or in a local or regional group is taken a step further. In this chapter the model for peer review, presented in Chapter 1, is made more explicit and general principles of the peer review process are described. In the remaining chapters of this part of the book some methods of peer review process are described.
Developing guidelines and criteria in peer review
Authors: Grol Richard , Lawrence Martin
Published: November 2023

In Chapter 2 of this book we highlighted the importance in peer review of having explicit criteria based on recognized guidelines. In this chapter three methods for developing such criteria and guidelines in a peer group are presented (see box on pp. 63-4) Being involved in developing guidelines for high quality in patient care using consensus discussions can be a very valuable, educational experience (see example, North of England Study of Standards and Performance 1992). When it is carried out on a local or practice level, it may help care providers to develop a sense of ‘ownership’ of the guidelines. Developing guidelines should take place in a rigorous way, through a standardized procedure, in order to prevent obsolete performance being selected as an objective so reinforcing the status quo, or dominant group members with outspoken convictions forcing their ideas on a peer group. This demands specific interpersonal and technical skills and skills with regard to analysing the available literature.
Mutual practice observation
Authors: Grol Richard , Lawrence Martin
Published: November 2023

In this chapter we present methods for observing each other’s practices and reviewing each other’s consultation skills. These have proven to be very valuable additions to peer review group work and can be easily included as one of the peer review activities.
Instruments for evaluating management in general practice
Authors: Grol Richard , Lawrence Martin
Published: November 2023

Following consultation skills and clinical performance the management of the practice is a third central aspect of general practice care. A wide area must be considered, including: practice equipment, organization of services, staff organization, communication and co-operation with colleagues, teamwork, medical recording and finance, and information technology.
Reproductive cycles in women: quality of life impact
Authors: Kessel Bruce
Published: November 2023

Through menarche, the reproductive years, and the menopause, both normal and abnormal gynecologic events influence women’s health and have an impact on quality of life. The events that most significantly alter psychosocial adjustment include premenstrual syndrome, infertility, childbirth, pelvic pain, abnormal uterine bleeding, and the menopause. Undoubtedly the medical aspects of repro ductive health and disease receive far more attention than the psychosocial and cultural aspects. There is only limited knowledge of the impact of reproductive cycles on work, family, and personal sense of well-being. A further limitation to the ability to address health policy issues for women has been the relative disre gard for women in much medical research, which is conducted mainly on men, resulting in conclusions that are of little relevance to women. As gynecologic pro cesses are chiefly age related, the effect of reproductive events on quality of life in women may be considered with respect to age-related reproductive milestones.
AIDS in women
Authors: Cotton Deborah
Published: November 2023

In the USA, the acquired immunedeficiency syndrome (AIDS) was the fifth lead ing cause of death in women of childbearing age in 1990 (Chu et al. 1990a), and almost 80 000 women were estimated to be infected (Gwinn et al. 1991). World wide the specter of AIDS is even more sobering, with estimates that 20–50 million women may be infected by the year 2000 (Mann et al. 1992). Despite the enormity of the problem, until recently little attention has been paid to the unique aspects of HIV infection in women, and there are inadequate data on the natural history of the disease in women. Few AIDS-related programs are gender specific in their approach to disease detection or management, and women as a group have had less access than men to state-of-the-art therapies and experimental drug trials.
Maternity-related health the USA
Authors: Kleeman Lorraine V , Merkatz Irwin R
Published: November 2023

The four components of maternity-related care are preconception care, pre natal care, labor and delivery management, and postpartum follow-up. The postpartum visit should lead to continuing gynecological care, whether or not further pregnancies are planned. Although in the USA there is general consensus on the value of each component of this sequence, in reality the delivery of these services is often greatly influenced by financial and political considerations. Consequently, the quality and quantity of care that women receive varies according to their economic status, geographic location, and other factors. These inequities contribute to low birth weight and infant mortality, pregnancy outcomes whose rates are higher in the USA than in many countries with similar degrees of industrialization (Liu et al. 1992).
An evaluation of maternity services
Authors: Beard R W , Chapple Jean
Published: November 2023

Pregnancy has become a relatively safe event for the mother and her baby, so why is it that Western societies continue to make a substantial investment in providing health care? This question highlights an ambivalence of approach that spreads from government to all professions involved in maternity care and to the public. Pregnancy is a natural and important event and most women remain well through out their pregnancy.
Introduction
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

Most medical students approach their training with a desire to help people. Thus, from the very beginning of their studies, students look forward to clinical involvement—to meeting ‘real’ patients and learning to interact with them. After qualifying, most doctors spend a great deal of their working time communicating with patients—speaking, listening, responding. This face-to-face interaction, with exchange of information, is essential if the doctor is to be effective in his or her work.

Accordingly, skilful communication has become widely recognized as a primary component of medical education, something that the student should learn about as a basic part of professional training. However, this is the very aspect of doctors’ professional skills that is still the most common cause of complaint from patients or their relatives, an apparent weak point in doctors’ professional competence [1,9,10,11,12,l3].
Other aspects of doctor–patient 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

Up to this point is has been tacitly assumed that communication between doctor and patient takes place ‘on the level’, that the exchanges are always characterized by honesty and openness. This is certainly not invariably the case, and sometimes lies or half-lies, deceptions, and denials are at the heart of the dialogue.

Deceit by the patient may take many forms, ranging from flagrant to subtle. Even the patient’s initial complaints may be falsified. An unusual skin lesion (for example) may be factitious. Sometimes the motivation is obscure or psychopathic, as in Munchausen’s syndrome (p. 8).
Talking to the dying patient
Authors: Doyle D
Published: November 2023

Those who are dying, contrary to what one might expect, seldom want their diagnosis discussed or repeatedly explained. But they do ask, in one way or another, for confirmation that they are dying; they are then ready to tackle the business in hand, that of living out what is left of life with minimal suffering, with a dignity that is defined by them and respected by their attendants, and with an unclouded mind. As death approaches, whether they are young or old, they seem to invite the doctors and nurses caring for them to change their roles from ‘professional advisers and attendants’ to intimate companions on the loneliest journey a human being ever takes.

Some years ago, I and a nursing colleague visited a woman at her doctor’s request. She had advanced oesophageal carcinoma with considerable pain and almost total dysphagia. As is my custom, I did not immediately take a history, but rather asked the patient in what way she felt I could help her: ‘Ease my pain, show me what I can eat, and reassure me that you will always answer my questions honestly. I must be fit enough to finish some unfinished business.’
Aspects of transcultural munication
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

With travellers, visitors, and immigrants from many countries of the world very much part of the everyday scene, doctors need to broaden their understanding of how best to communicate with patients from other cultures, avoiding the difficulties that can arise through ignorance of their customs and beliefs.

In a short chapter, there is a risk of seeming to sketch stereotypes. This I have tried to avoid, but it is only possible to attempt very incomplete outlines of certain general cultural patterns.
lmmunopathogenesis of cresccntic glomerulonephritis
Authors: Holdsworth Stephen R , Erhch Jonathan H , Tipping Peter G
Published: November 2023

The characteristic and unifying feature of crescentic glomerulonephritis is the extracapillary accumulation of cells within Bowman’s space. The consequent shape of the accumulating cells within this space surrounding and compressing the residual capillary loop resembles that of a crescent when cut in section and viewed under the microscope.
Clinical aspects of systemic vasculitis
Authors: Gaskin Gillian , Pusey Charles D
Published: November 2023

Necrotizing inflammation of small blood vessels is the hallmark of the primary systemic vasculitides associated with rapidly progressive glomerulonephritis. Other primary vasculitic syndromes affect larger vessels, and vasculitis may also occur as a variable accompaniment to other systemic diseases, including rheumatoid arthritis, systemic lupus erythematosus, and infective endocarditis. This chapter will deal principally with the small vessel vasculitides, Wegener’s granulomatosis and microscopic polyangiitis.
Rapidly progressive glomerulonephritis 1n children
Authors: Dillon Michael J
Published: November 2023

As discussed in previous chapters, crescentic glomerulonephritis can accompany most forms of primary glomerulonephritis in childhood. However, in this age group it is associated also with various systemic diseases, such as systemic lupus erythematosus and several forms of systemic vasculitis (SPNSG 1985; Niaudet and Lèvy 1983). The severity of the condition, the multiple aetiologies, and the associated poor prognosis have led to the use of multiple treatment regimens, the efficacy of which has been difficult to assess (Haycock 1988), and there has been lack of clarity in identifying variables with possible therapeutic and prognostic implications.
The Community Module:adopting a community-oriented approach ,n partnership with the community
Authors: Wykurz Geoff
Published: November 2023

In these words Janet Richardson of the City and Hackney Community Health Council (CHC) sums up the impetus for the introduction of the Community Module and alludes to the way the innovation was introduced (Wykurz 1992). The CHC’s ambitions coincided with the emerging alliance between the local medical colleges of the St Bartholomew’s and Royal London School of Medicine. Although students entered medical school motivated to meet people, no programmed involvement in the community existed to tap and channel this enthusiasm. Restructuring of the curriculum created the opportunity to introduce a community-based clement for first-year students. Consulting community organizations and public health departments at the outset ensured that the module reflected local health issues. This approach reflects the principles adopted by the World Health Organization for community-based educational programmes that have been valuable reference points during the module’s development (WHO 1987).
An integrated course in public health and primary care
Authors: Graham-Jones Susanna , Lawrence Martin
Published: November 2023

Until recent years, medical students at Oxford University had very little structured teaching in primary care. Each student had two practice attachments of a fortnight each, at the beginning and the end of the three-years clinical course. These were popular, but there was no curriculum as such, and little in the way of staff development for the general practitioners involved. Apart from a single seminar at the end of each attachment, there were no timetabled opportunities for students to reflect with teachers on their very diverse experiences. Similarly, the public heailh course was run in the traditional manner as a teaching block for 14 to 16 students at a time, covering the fundamentals of epidemiological methods and community medicine. As in most other medical schools, it was difficult to interest medical students, preoccupied with the acquisition of clinical skills, in public health.
Teaching cultural aspects of health
Authors: Gill Paramjit S , Adshead David
Published: November 2023

The United Kingdom is a multiracial, multicultural society, with a large black and ethnic minority population (Balarajan and Soni Raleigh 1992), with variations between different ethnic groups both in health care needs, and in the delivery of services (Hopkins and Bahl 1993; Department of Health 1992). Both doctors and patients experience difficulties when dealing with someone from a different ethnic group (Chugh et al. 1993; Eisenbruch 1989). These difficulties arc widely recognized, and have been expressed by junior hospital doctors who felt inadequately trained to assess patients from the different ethnic groups they encountered (Poulton et al. 1986).
Shadowing other professionals: a short course introducing preclinical students to other health care professions
Authors: Biran Len
Published: November 2023

Among the objectives proposed by the General Medical Council (1993) (p. 37-39) are an understanding of the importance of communication . . with other professionals (1 (j)), respect for colleagucs (J(a)), and the ability to work effectively as a member of a team (3(h)). At Leeds Medical School a short course was designed to address these objectives. It ran within a communication skills course in the second (preclinical) year of the medical course. As with the course on ‘teaching cultural aspects of health’ (sec Chapter 22), it ran over only four afternoons but evaluation suggested that it had a significant impact on the students.