Clin Med
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Diabetes mellitus is an emerging problem in the developing world. In sub-Saharan Africa, for example, the incidence and prevalence of the disease is unknown, diagnosis is often made on the basis of poor information and a loosely defined set of criteria, and access to oral hypoglycaemic agents and insulin is patchy and expensive. The best system of management is currently unclear and this article explores lessons learnt, good practice and the applicability of the structured 'directly observed treatment, short course' (DOTS) approach (the current best care system for tuberculosis disease management in resource-poor settings) to the management of chronic diseases such as diabetes.
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Chronic stable angina is the most common manifestation of ischaemic heart disease in the developed world and is associated with impaired quality of life and increased mortality. The pathogenesis of stable angina is complex and often, albeit not always, involves flow-limiting epicardial coronary artery stenoses (atheromatous plaques) that reduce the ability of the coronary circulation to deliver appropriate blood supply to the myocardium. The coronary microcirculation can also play an important role. ⋯ These novel agents have specific mechanisms of action and fewer side effects compared to conventional drugs. The combined use of traditional and novel treatments is likely to increase the proportion of patients who are managed successfully with medical therapy alone. This article briefly reviews recent advances in the pharmacological management of chronic stable angina pectoris, highlighting how an understanding of the prevailing pathogenic mechanisms in the individual patient can aid appropriate selection of therapeutic strategies and improve clinical outcome.
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Modern medicine is complex and delivered by interdependent teams. Conscious redesign of the way in which these teams interact can contribute to improving the quality of care by reducing practice variation. This requires techniques that are different to those used for individual patient care. ⋯ Reporting the collected indicator data in longitudinal run charts supports teams in monitoring the effect of their QI effort. After identifying the opportunities for improvement, the second section discusses how to reduce practice variation. This includes selecting the 'package' of clinical actions to implement, identifying subsidiary actions to achieve the improvement aim, designing the implementation strategy and ways to incentivise QI.
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Comparative Study
Investigating the frail elderly patient with lower bowel symptoms: what do we do now and can we improve?
To assess the utility of flexible sigmoidoscopy (FS) and minimal preparation CT (MPCT) in investigating lower gastrointestinal (LGI) symptoms in elderly patients who are too frail to undergo colonoscopy or spiral CT. ⋯ LGI investigation in frail elderly patients can be rationalised according to indication. Performing FS and MPCT together is not always necessary.
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Comparative Study
Discordance between cancer prevalence and training: a need for an increase in oncology education.
The impact of cancer on healthcare is increasing. Therefore, it is key that all doctors receive oncology training. This study surveyed UK undergraduate medical schools to determine the extent of oncology training provided by their curricula. ⋯ Oncology was included in 11% posts and 48% programmes offered by the London Deanery specialty schools. Our results show that < 50% of junior doctors receive dedicated undergraduate or postgraduate oncology training. An increase in oncology training is therefore urgently required.