beta Blockade after myocardial infarction: systematic review and meta regression analysis

OBJECTIVES

To assess the effectiveness of beta blockers in short term treatment for acute myocardial infarction and in longer term secondary prevention; to examine predictive factors that may influence outcome and therefore choice of drug; and to examine the clinical importance of the results in the light of current treatment.

DESIGN

Systematic review of randomised controlled trials.

SETTING

Randomised controlled trials.

SUBJECTS

Patients with acute or past myocardial infarction.

INTERVENTION

beta Blockers compared with control.

MAIN OUTCOME MEASURES

All cause mortality and non-fatal reinfarction.

RESULTS

Overall, 5477 of 54 234 patients (10.1%) randomised to beta blockers or control died. We identified a 23% reduction in the odds of death in long term trials (95% confidence interval 15% to 31%), but only a 4% reduction in the odds of death in short term trials (-8% to 15%). Meta regression in long term trials did not identify a significant reduction in effectiveness in drugs with cardioselectivity but did identify a near significant trend towards decreased benefit in drugs with intrinsic sympathomimetic activity. Most evidence is available for propranolol, timolol, and metoprolol. In long term trials, the number needed to treat for 2 years to avoid a death is 42, which compares favourably with other treatments for patients with acute or past myocardial infarction.

CONCLUSIONS

beta Blockers are effective in long term secondary prevention after myocardial infarction, but they are underused in such cases and lead to avoidable mortality and morbidity.

The EuroHeart Failure Survey programme--a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment

BACKGROUND

National surveys suggest that treatment of heart failure in daily practice differs from guidelines and is characterized by underuse of recommended medications. Accordingly, the Euro Heart Failure Survey was conducted to ascertain how patients hospitalized for heart failure are managed in Europe and if national variations occur in the treatment of this condition.

METHODS

The survey screened discharge summaries of 11304 patients over a 6-week period in 115 hospitals from 24 countries belonging to the ESC to study their medical treatment.

RESULTS

Diuretics (mainly loop diuretics) were prescribed in 86.9% followed by ACE inhibitors (61.8%), beta-blockers (36.9%), cardiac glycosides (35.7%), nitrates (32.1%), calcium channel blockers (21.2%) and spironolactone (20.5%). 44.6% of the population used four or more different drugs. Only 17.2% were under the combination of diuretic, ACE inhibitors and beta-blockers. Important local variations were found in the rate of prescription of ACE inhibitors and particularly beta-blockers. Daily dosage of ACE inhibitors and particularly of beta-blockers was on average below the recommended target dose. Modelling-analysis of the prescription of treatments indicated that the aetiology of heart failure, age, co-morbid factors and type of hospital ward influenced the rate of prescription. Age <70 years, male gender and ischaemic aetiology were associated with an increased odds ratio for receiving an ACE inhibitor. Prescription of ACE inhibitors was also greater in diabetic patients and in patients with low ejection fraction (<40%) and lower in patients with renal dysfunction. The odds ratio for receiving a beta-blocker was reduced in patients >70 years, in patients with respiratory disease and increased in cardiology wards, in ischaemic heart failure and in male subjects. Prescription of cardiac glycosides was significantly increased in patients with supraventricular tachycardia/atrial fibrillation. Finally, the rate of prescription of antithrombotic agents was increased in the presence of supraventricular arrhythmia, ischaemic heart disease, male subjects but was decreased in patients over 70.

CONCLUSION

Our results suggest that the prescription of recommended medications including ACE inhibitors and beta-blockers remains limited and that the daily dosage remains low, particularly for beta-blockers. The survey also identifies several important factors including age, gender, type of hospital ward, co morbid factors which influence the prescription of heart failure medication at discharge.

How effective are selection methods in medical education? A systematic review

CONTEXT

Selection methods used by medical schools should reliably identify whether candidates are likely to be successful in medical training and ultimately become competent clinicians. However, there is little consensus regarding methods that reliably evaluate non-academic attributes, and longitudinal studies examining predictors of success after qualification are insufficient. This systematic review synthesises the extant research evidence on the relative strengths of various selection methods. We offer a research agenda and identify key considerations to inform policy and practice in the next 50 years.

METHODS

A formalised literature search was conducted for studies published between 1997 and 2015. A total of 194 articles met the inclusion criteria and were appraised in relation to: (i) selection method used; (ii) research question(s) addressed, and (iii) type of study design.

RESULTS

Eight selection methods were identified: (i) aptitude tests; (ii) academic records; (iii) personal statements; (iv) references; (v) situational judgement tests (SJTs); (vi) personality and emotional intelligence assessments; (vii) interviews and multiple mini-interviews (MMIs), and (viii) selection centres (SCs). The evidence relating to each method was reviewed against four evaluation criteria: effectiveness (reliability and validity); procedural issues; acceptability, and cost-effectiveness.

CONCLUSIONS

Evidence shows clearly that academic records, MMIs, aptitude tests, SJTs and SCs are more effective selection methods and are generally fairer than traditional interviews, references and personal statements. However, achievement in different selection methods may differentially predict performance at the various stages of medical education and clinical practice. Research into selection has been over-reliant on cross-sectional study designs and has tended to focus on reliability estimates rather than validity as an indicator of quality. A comprehensive framework of outcome criteria should be developed to allow researchers to interpret empirical evidence and compare selection methods fairly. This review highlights gaps in evidence for the combination of selection tools that is most effective and the weighting to be given to each tool.

Differences between patients with a preserved and a depressed left ventricular function: a report from the EuroHeart Failure Survey

AIMS

Due to a lack of clinical trials, scientific evidence regarding the management of patients with chronic heart failure and preserved left ventricular function (PLVF) is scarce. The EuroHeart Failure Survey provided information on the characteristics, treatment and outcomes of patients with PLVF as compared to patients with a left ventricular systolic dysfunction (LVSD).

METHODS AND RESULTS

We performed a secondary analysis using data from the EuroHeart Failure Survey, only including patients with a measurement of LV function (n = 6806). We selected two groups: patients with LVSD (54%) and patients with a PLVF (46%). Patients with a PLVF were, on average, 4 years older and more often women (55% vs. 29%, respectively, p < 0.001) as compared to LVSD patients, and were more likely to have hypertension (59% vs. 50%, p < 0.001) and atrial fibrillation (25% vs. 23%, p = 0.01). PLVF patients received less cardiovascular medication compared to PLVF patients, with the exception of calcium antagonists. Multivariate analysis revealed that LVSD was an independent predictor for mortality, while no differences in treatment effect on mortality between the two groups was observed. A sensitivity analysis, using different thresholds to separate patients with and without LVSD revealed comparable findings.

CONCLUSIONS

In the EuroHeart Failure Survey, a high percentage of heart failure patients had PLVF. Although major clinical differences were seen between the groups, morbidity and mortality was high in both groups.

Losartan in heart failure. Hemodynamic effects and tolerability. Losartan Hemodynamic Study Group

BACKGROUND

The aim of the present study was to assess the short- and long-term effects of multiple doses of the angiotensin II receptor antagonist losartan in heart failure.

METHODS AND RESULTS

A multicenter, placebo-controlled, oral, multidose (2.5, 10, 25, and 50 mg losartan once daily) double-blind comparison in patients with symptomatic heart failure and impaired left ventricular function (ejection fraction < 40%). Invasive 24-hour hemodynamic assessment was performed after the first dose and after 12 weeks of treatment. Clinical status and tolerability of treatment with losartan over the 12-week period were also evaluated. One hundred fifty-four patients were enrolled, of which 134 met the protocol criterion of baseline pulmonary capillary wedge pressure > or = 13 mm Hg. During short-term administration, systemic vascular resistance (SVR) (largest reduction against placebo of 197 dyne.s-1.cm-5 at 4 hours) and blood pressure fell significantly with 50 mg, lesser decreases were seen with 25 mg, and no discernible effects were seen with 2.5 and 10 mg. After 12 weeks of treatment, similar effects were seen on SVR and blood pressure (maximal fall in SVR against placebo, 318 dyne.s-1.cm-5 at 5 hours with 50 mg). In addition, pulmonary capillary wedge pressure fell with 2.5, 25, and 50 mg (largest reduction against placebo of 6.3 mm Hg at 6 hours with 50 mg), cardiac index rose with 25 and 50 mg, and heart rate was lower with all active treatment groups. Active treatment was well tolerated, and excess cough was not reported.

CONCLUSIONS

This study showed that oral losartan administered to patients with symptomatic heart failure resulted in beneficial hemodynamic effects with short-term administration, with additional beneficial hemodynamic effects seen after 12 weeks of therapy. Clear effects were seen with both 25 and 50 mg, with the greatest effect seen with 50 mg.

Repeat heart valve surgery: risk factors for operative mortality

BACKGROUND

Patients undergoing repeat heart valve operations are a diverse population. We assessed risk factors for operative mortality in patients undergoing a first heart valve reoperation.

METHODS

A retrospective review of hospital records was performed for 671 patients who underwent first repeat heart valve operations between 1969 and 1998. Univariable and multivariable analyses were performed.

RESULTS

Operative mortality was 8.6%. Mortality fell each decade to 4.8% in the most recent period (adjusted chi(2) for linear trend P <.0005). Mortality increased from 3.0% for reoperation for a failed repair or reoperation at a new valve site to 10.6% for prosthetic valve dysfunction or periprosthetic leak and to 29.4% for endocarditis or valve thrombosis. Concomitant coronary artery bypass grafting was associated with a mortality of 15.4% compared with 8.2% when it was not required. Mortality for aortic valve replacement was 6.4%, mitral valve replacement 7.4%, aortic and mitral valve replacement 11.5%, tricuspid valve replacement 25.6%, periprosthetic leak repair 9.1%, and isolated valve repair 2.2%. Among 336 patients requiring replacement of prosthetic valves, mortality was 26.1% for replacement of a mechanical valve compared with 8.6% for replacement of a tissue valve (P <.0005). Multivariable analyses identified year of reoperation, age, coronary artery bypass grafting, indication, and replacement of a mechanical valve rather than a tissue valve as significant explanatory variables for operative mortality.

CONCLUSIONS

Heart valve reoperations can be performed with an acceptable operative mortality. However, we have identified several categories of patients in whom reoperation carries an increased risk.

Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial

OBJECTIVE

To determine whether supported self management in chronic obstructive pulmonary disease (COPD) can reduce hospital readmissions in the United Kingdom.

DESIGN

Randomised controlled trial.

SETTING

Community based intervention in the west of Scotland.

PARTICIPANTS

Patients admitted to hospital with acute exacerbation of COPD.

INTERVENTION

Participants in the intervention group were trained to detect and treat exacerbations promptly, with ongoing support for 12 months.

MAIN OUTCOME MEASURES

The primary outcome was hospital readmissions and deaths due to COPD assessed by record linkage of Scottish Morbidity Records; health related quality of life measures were secondary outcomes.

RESULTS

464 patients were randomised, stratified by age, sex, per cent predicted forced expiratory volume in 1 second, recent pulmonary rehabilitation attendance, smoking status, deprivation category of area of residence, and previous COPD admissions. No difference was found in COPD admissions or death (111/232 (48%) v 108/232 (47%); hazard ratio 1.05, 95% confidence interval 0.80 to 1.38). Return of health related quality of life questionnaires was poor (n=265; 57%), so that no useful conclusions could be made from these data. Pre-planned subgroup analysis showed no differential benefit in the primary outcome relating to disease severity or demographic variables. In an exploratory analysis, 42% (75/150) of patients in the intervention group were classified as successful self managers at study exit, from review of appropriateness of use of self management therapy. Predictors of successful self management on stepwise regression were younger age (P=0.012) and living with others (P=0.010). COPD readmissions/deaths were reduced in successful self managers compared with unsuccessful self managers (20/75 (27%) v 51/105 (49%); hazard ratio 0.44, 0.25 to 0.76; P=0.003).

CONCLUSION

Supported self management had no effect on time to first readmission or death with COPD. Exploratory subgroup analysis identified a minority of participants who learnt to self manage; this group had a significantly reduced risk of COPD readmission, were younger, and were more likely to be living with others.

TRIAL REGISTRATION

Clinical trials NCT 00706303.

The remediation challenge: theoretical and methodological insights from a systematic review

OBJECTIVES

Remediation is usually offered to medical students and doctors in training who underperform on written or clinical examinations. However, there is uncertainty and conflicting evidence about the effectiveness of remediation. The aim of this systematic review was to synthesise the available evidence to clarify how and why remediation interventions may have worked in order to progress knowledge on this topic.

METHODS

The MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Educational Resources Information Centre), Web of Science and Scopus databases were searched for papers published from 1984 to April 2012, using the search terms 'remedial teaching', 'education', 'medical', 'undergraduate'/or 'clinical clerkship'/or 'internship and residency', 'at risk' and 'struggling'. Only studies that included an intervention, then provided retest data, and reported at least one outcome measure of satisfaction, knowledge, skills or effects on patients were eligible for inclusion. Studies of practising doctors were excluded. Data were abstracted independently in duplicate for all items. Coding differences were resolved through discussion.

RESULTS

Thirty-one of 2113 studies met the review criteria. Most studies were published after 2000 (n=24, of which 12 were published from 2009 onwards), targeted medical students (n=22) and were designed to improve performance on an immediately subsequent examination (n=22). Control or comparison groups, conceptual frameworks, adequate sample sizes and long-term follow-up measures were rare. In studies that included long-term follow-up, improvements were not sustained. Intervention designs tended to be highly complex, but their design or reporting did not enable the identification of the active components of the remedial process.

CONCLUSIONS

Most remediation interventions in medical education focus on improving performance to pass a re-sit of an examination or assessment and provide no insight into what types of extra support work, or how much extra teaching is critical, in terms of developing learning. More recent studies are generally of better quality. Rigorous approaches to developing and evaluating remediation interventions are required.

The Living & Breathing Study: a study of patients' views of asthma and its treatment

AIM

To evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment.

METHODS

Adults with asthma receiving treatment for mild to moderate asthma were recruited to a two-part study: a qualitative phase using a semi-structured interview schedule followed by a quantitative phase based on a structured interview schedule. All interviews were undertaken face-to-face.

SETTING AND SUBJECTS

A random sample of 40 patients with mild to moderate asthma from seven areas of the UK took part in the qualitative phase of the study. In the quantitative phase, 517 patients on treatment for mild to moderate asthma were interviewed in person by market researchers. This population was achieved using a quota sampling approach that also achieved a representative demographic profile. Initial contact was made in door-to-door calls. Interviews took place in 64 locations across the UK.

RESULTS

Ninety-one percent (n=468) of respondents felt their asthma was under control, yet two-thirds (n=339) experienced symptoms at least 2-3 times a week. Only 24% (n=123) felt their asthma could improve over time, and 71% (n=366) received no advice from healthcare professionals on how their asthma might change in the future. Fourteen percent (n=74) of respondents had no ongoing contact with any healthcare professional regarding their asthma. Fifty-eight percent (n=301) were very satisfied with their asthma care, but this dropped to 33% (n=173) when respondents were shown asthma guidelines regarding what to expect from treatment. Sixty-two percent (n=318) of respondents said their asthma varied at different times of the day, and 86% (n=444) stated that their asthma varied at different times of the year. Eighty percent (n=414) of respondents had never been provided with a written, personal asthma action plan recommending changes patients could make themselves to prescribed treatment according to symptom severity, though 68% (n=353) said they would feel comfortable following such a plan.

CONCLUSIONS

Most patients have low expectations of what can be achieved by asthma management and do not realise their condition can be improved. Many are resigned to the effects of poor asthma control until made aware that guidelines indicate this can be better. Given that many are receptive to the notion of written, personal asthma action plans, the implementation of these, supported by appropriate education, could help patients achieve improved asthma control.

Maternal and child health services in rural Nepal: does access or quality matter more?

This study seeks to establish the relative importance of service access and quality on utilization of preventive health services in the western and middle-western Hill region of Nepal. Access was measured in terms of travel time to the nearest health post and coverage by outreach workers. The quality of static services was defined in structural terms: physical infrastructure, number of staff, availability of drugs and holding of special maternal and child health clinics. The initial analysis showed that no single indicator of quality was of overriding importance and therefore an overall quality index was constructed. After adjustment for access and for socioeconomic characteristics of families and communities, a very pronounced relationship between overall structural quality of the nearest health post and service uptake persisted. The adjusted odds of using some form of antenatal service were 6.6 times higher in the catchment areas of high quality posts than in areas served by low quality posts. The corresponding figure for receipt of BCG vaccination is 8.1. By comparison, the effects of travel time to the nearest health post are modest. Uptake of services is about twice as high when there is a health post in the community. Regular monthly visits by outreach workers also had a marked effect on service utilization. These results suggest that investment in the quality of health posts is more important than further increases in their number and that a further expansion of outreach services is a priority.

Patient safety: helping medical students understand error in healthcare

OBJECTIVE

To change the culture of healthcare organisations and improve patient safety, new professionals need to be taught about adverse events and how to trap and mitigate against errors. A literature review did not reveal any patient safety courses in the core undergraduate medical curriculum. Therefore a new module was designed and piloted.

DESIGN

A 5-h evidence-based module on understanding error in healthcare was designed with a preliminary evaluation using self-report questionnaires.

SETTING

A UK medical school.

PARTICIPANTS

110 final year students.

MEASUREMENTS AND MAIN RESULTS

Participants completed two questionnaires: the first questionnaire was designed to measure students' self-ratings of knowledge, attitudes and behaviour in relation to patient safety and medical error, and was administered before and approximately 1 year after the module; the second formative questionnaire on the teaching process and how it could be improved was administered after completion of the module.

CONCLUSIONS

Before attending the module, the students reported they had little understanding of patient safety matters. One year later, only knowledge and the perceived personal control over safety had improved. The students rated the teaching process highly and found the module valuable. Longitudinal follow-up is required to provide more information on the lasting impact of the module.

Monitoring sexual behaviour in general populations: a synthesis of lessons of the past decade

This supplement contains selected papers from a workshop on the measurement of sexual behaviour in the era of HIV/AIDS held at the London School of Hygiene and Tropical Medicine in September 2003. The focus was on low and middle income countries, where the majority of HIV infections occur. The motive for holding such a meeting is easy to discern. As the AIDS pandemic continues to spread and as prevention programmes are scaling up, the need to monitor trends in sexual risk behaviours becomes ever more pressing. Behavioural data are an essential complement to biological evidence of changes in HIV prevalence or incidence. Biological evidence, though indispensable, is by itself insufficient for policy and programme guidance. AIDS control programmes need to be based on monitoring of not only trends in infections but also of trends in those behaviours that underlie epidemic curtailment or further spread.

Are pharmacy-based minor ailment schemes a substitute for other service providers? A systematic review

BACKGROUND

Pharmacy-based minor ailment schemes (PMASs) have been introduced throughout the UK to reduce the burden of minor ailments on high-cost settings, including general practice and emergency departments.

AIM

This study aimed to explore the effect of PMASs on patient health- and cost-related outcomes; and their impact on general practices.

DESIGN AND SETTING

Community pharmacy-based systematic review.

METHOD

Standard systematic review methods were used, including searches of electronic databases, and grey literature from 2001 to 2011, imposing no restrictions on language or study design. Reporting was conducted in the form recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist.

RESULTS

Thirty-one evaluations were included from 3308 titles identified. Reconsultation rates in general practice, following an index consultation with a PMAS, ranged from 2.4% to 23.4%. The proportion of patients reporting complete resolution of symptoms after an index PMAS consultation ranged from 68% to 94%. No study included a full economic evaluation. The mean cost per PMAS consultation ranged from £1.44 to £15.90. The total number of consultations and prescribing for minor ailments at general practices often declined following the introduction of PMAS.

CONCLUSION

Low reconsultation and high symptom-resolution rates suggest that minor ailments are being dealt with appropriately by PMASs. PMAS consultations are less expensive than consultations with GPs. The extent to which these schemes shift demand for management of minor ailments away from high-cost settings has not been fully determined. This evidence suggests that PMASs provide a suitable alternative to general practice consultations. Evidence from economic evaluations is needed to inform the future delivery of PMASs.

Early sexual debut among young men in rural South Africa: heightened vulnerability to sexual risk?

OBJECTIVE

This report examines early sexual debut (<age 15) among young men in rural South Africa including (1) risk behaviours at first sexual experience, and (2) age at first sex as a predictor of later sexual risk.

METHODS

Analysis of sexual behaviour data for men 15-24 years (n = 314) from representative cross sectional household survey.

RESULTS

13.1% of 15-24 year old men experienced sexual debut before age 15. Men with sexual debut at less than age 15 were more likely to report risk behaviours at first sexual experience: no condom use (19%), a casual partner (26.8%), and not feeling they had been "ready and wanted to have sex" (19.5%). In multivariate analysis, early sexual debut was strongly associated with > or = 3 partners in the past 3 years (OR = 10.26, p<0.01).

CONCLUSIONS

Men who initiate sex before age 15 form a distinct risk group in this setting. Specific interventions are needed for young men in the pre-teen years, before sexual debut.

Asthma and psychological dysfunction

Despite effective treatment, asthma outcomes remain suboptimal. Anxiety and depression occur more commonly in people with asthma than expected, and are associated with poor asthma outcomes. The direction of the relationship and the mechanisms underlying it are uncertain. Whether screening for and treating co-morbid anxiety and depression can improve asthma outcomes is unclear from the current evidence. Primary care clinicians treating asthma should be aware of the possibility of psychological dysfunction in asthmatics, particularly those with poor control. Further research is required to assess the importance of detecting and treating these conditions in community asthma care.

Stress, debt and undergraduate medical student performance

INTRODUCTION

Against the background of current debate over university funding and widening access, we aimed to examine the relationships between student debt, mental health and academic performance.

METHODS

We carried out an electronic survey of all medical undergraduate students at the University of Aberdeen during May-June 2004. The questionnaire contained items about demographics, debt, income and stress. Students were also asked for consent to access their examination results, which were correlated with their answers. Statistical analyses of the relationships between debt, performance and stress were performed.

RESULTS

The median total outstanding debt was pound 7300 (interquartile range 2000-14 762.50). Students from lower socioeconomic backgrounds and postgraduate students had higher debts. There was no direct correlation between debt, class ranking or General Health Questionnaire (GHQ) score; however, a subgroup of 125 students (37.7%), who said that worrying about money affected their studies, did have higher debt and were ranked lower in their classes. Some of these students were also cases on the GHQ-12. Overall, however, cases on the GHQ had lower levels of debt and lower class ranking, suggesting that financial worries are only 1 cause of mental health difficulties.

DISCUSSION

Students' perceptions of their own levels of debt rather than level of debt per se relates to performance. Students who worry about money have higher debts and perform less well than their peers in degree examinations. Some students in this subgroup were also identified by the GHQ and may have mental health problems. The relationships between debt, mental health and performance in undergraduate medical students are complex but need to be appreciated by medical education policy makers.

Guidelines: The dos, don'ts and don't knows of remediation in medical education

INTRODUCTION

Two developing forces have achieved prominence in medical education: the advent of competency-based assessments and a growing commitment to expand access to medicine for a broader range of learners with a wider array of preparation. Remediation is intended to support all learners to achieve sufficient competence. Therefore, it is timely to provide practical guidelines for remediation in medical education that clarify best practices, practices to avoid, and areas requiring further research, in order to guide work with both individual struggling learners and development of training program policies.

METHODS

Collectively, we generated an initial list of Do's, Don'ts, and Don't Knows for remediation in medical education, which was then iteratively refined through discussions and additional evidence-gathering. The final guidelines were then graded for the strength of the evidence by consensus.

RESULTS

We present 26 guidelines: two groupings of Do's (systems-level interventions and recommendations for individual learners), along with short lists of Don'ts and Don't Knows, and our interpretation of the strength of current evidence for each guideline.

CONCLUSIONS

Remediation is a high-stakes, highly complex process involving learners, faculty, systems, and societal factors. Our synthesis resulted in a list of guidelines that summarize the current state of educational theory and empirical evidence that can improve remediation processes at individual and institutional levels. Important unanswered questions remain; ongoing research can further improve remediation practices to ensure the appropriate support for learners, institutions, and society.

Adapting to the impact of COVID-19: Sharing stories, sharing practice

Health Professions' Educators (HPEs) and their learners have to adapt their educational provision to rapidly changing and uncertain circumstances linked to the COVID-19 pandemic. This paper reports on an AMEE-hosted webinar: Adapting to the impact of COVID-19: Sharing stories, sharing practice. Attended by over 500 colleagues from five continents, this webinar focused on the impact of the virus across the continuum of education and training. Short formal presentations on teaching and learning, assessment, selection and postgraduate training generated wide-ranging questions via the Chatbox. A thematic analysis of the Chatbox thread indicated the most pressing concerns and challenges educators were experiencing in having to adapt programmes and learning across the continuum of medical education and training. The main areas of concern were: campus-based teaching and learning; clinical teaching; selection and assessment, and educator needs. While there is clearly no one simple solution to the unprecedented issues medical education and training face currently, there were two over-arching messages. First, this is a time for colleagues across the globe to help and support each other. Second, many local responses and innovations could have the potential to change the shape of medical education and training in the future.

Demographic data collection in less developed countries 1946-1996

This evolution over the last 50 years of data collection systems in less developed countries is assessed. The progress made by civil registration systems has been extremely disappointing. Except in Central and South America, their role in providing vital rate estimates is still very limited. In contrast, the promulgation of regular population censuses has been a success, particularly in Africa. The relative merits and demerits of different types of demographic surveys are described. To some extent multi-round designs have given way to single-round surveys, such as the Demographic and Health Surveys (DHS). DHS-style enquiries are particularly suitable for evaluation of interventions but are less appropriate if the main aim is to measure vital rates.

Associations between medical school and career preferences in Year 1 medical students in Scotland

OBJECTIVES

Little is known about the relationship between the career preferences of medical students and the medical schools at which they are enrolled. Our aim was to explore this relationship early in students' medical training.

METHODS

Year 1 (2009-2010) medical students at the five Scottish medical schools were invited to take part in a career preference questionnaire survey. Questions were asked about demographic factors, career preferences and influencing factors.

RESULTS

The response rate was 87.9% (883/1005). No significant differences were found among medical schools with regard to first-choice specialty. Surgery (22.5%), medicine (19.0%), general practice (17.6%) and paediatrics (16.1%) were the top career choices. Work-life balance, perceived aptitude and skills, intellectual satisfaction, and amount of patient contact were rated as the most important job-related factors by most respondents. Few differences were found among schools in terms of the impact of job-related factors on future career preferences. Students for whom the work-life balance was extremely important (odds ratio [OR]=0.6) were less likely to prefer surgery. Students for whom the work-life balance (OR=2.2) and continuity of care (OR=2.1) were extremely important were more likely to prefer general practice.

CONCLUSIONS

Students' early career preferences were similar across the five medical schools. These preferences result from the interplay among demographic factors and the perceived characteristics of the various specialties. Maintaining a satisfactory work-life balance is very important to tomorrow's doctors, and the data hint that this may be breaking down some of the traditional gender differences in specialty choice. Longitudinal work is required to explore whether students' career preferences change as they progress through medical school and training.

Intraocular pharmacokinetics and safety of a humanized monoclonal antibody in rabbits after intravitreal administration of a solution or a PLGA microsphere formulation

Poly(lactic-co-glycolic) acid (PLGA) bioresorbable microspheres are used for controlled-release drug delivery and are particularly promising for ocular indications. The objective of the current study was to evaluate the pharmacokinetics and safety of a recombinant human monoclonal antibody (rhuMAb HER2) in rabbits after bolus intravitreal administration of a solution or a PLGA-microsphere formulation. On Day 0, forty-eight male New Zealand white rabbits (2.3-2.6 kg) were immobilized with intramuscular ketamine/xylazine, and the test materials were injected directly into the vitreous compartment. Group 1 animals received rhuMAb HER2 in 50:50 lactide: glycolide PLGA microspheres; Group 2 animals received rhuMAb HER2 in solution (n = 24/group). The dose for each eye was 25 microg (50 microl). After dosing, animals were sacrificed at 2 min, and on 1, 2, 4, 7, 14, 23, 29, 37, 44, 50, and 56 days (n = 2/timepoint/group). Safety assessment included direct ophthalmoscopy, clinical observations, body weight, and hematology and clinical chemistry panels. At necropsy, vitreous and plasma were collected for pharmacokinetics and analysis for antibodies to rhuMAb HER2, and the vitreal pellet (Group 1) was prepared for histologic evaluation. All animals completed the study per protocol-both treatments were well tolerated, and no suppurative or mixed inflammatory cell reaction was observed in the vitreal samples (Group 1) at any of the time points examined. Antibodies to rhuMAb HER2 were detected in plasma samples by Day 7 in both treatment groups, but infrequently in vitreous samples. There were no safety implications associated with this immune response. The in vitro characterization of the PLGA microspheres provided reasonable projections of the in vivo rhuMAb HER2 release kinetics (Group 1). The total amount of antibody that was released was similar in vitro (25.9%) and in vivo (32.4%). RhuMAb HER2 (Group 2) was cleared slowly from the vitreous compartment, with initial and terminal half-lives of 0.9 and 5.6 days, respectively. The volume of distribution approximated the vitreous volume in a rabbit eye.

Implementing the integration of component services for reproductive health

In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda--integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health-family planning services--has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.

Health-care seeking and expenditure by young Indian mothers in the public and private sectors

A total of 421 young married mothers in Karnataka State, India, were followed up at monthly intervals for 1 year. Results are presented on self-reported morbidity, treatment-seeking behaviour and health expenditures. A total of 911 completed illness episodes were reported, of which 58% resulted in consultations with practitioners, mostly working in the private sector. Amongst those who did consult physicians, an average of 1.76 visits was made per episode. The average cost per visit was 46 Rupees and 38 Rupees, for private and public-sector consultations respectively. The overall mean annual expenditure on treatment and associated costs for the entire sample was 172 Rupees, of which 104 Rupees was spent on private-sector treatment. Poorer women reported significantly more days of morbidity than richer women but spent significantly less per 100 days of illness.