General practitioner training in palliative care: an experiential approach.

With the rising incidence of cancer and with more terminally ill patients wishing to be cared for at home, it is clear that there is a growing need for general practitioners (GPs) who are skilled in providing palliative care. In an attempt to improve the palliative care knowledge and skills of GPs in Western Australia and the quality of care they provide, a 14-week training program was developed by the Silver Chain Nursing Association and the Perth South Eastern Division of General Practice. The program used experiential learning techniques, such as a clinical attachment and mentoring. Research has shown that performance-based rather than cognitive education methods have a greater impact on practice outcomes. The program was evaluated by an external body and found to have achieved its objectives. The results of the evaluation are discussed, together with their implications for postgraduate education.

False complaints of sexual assault: recovered memories of childhood sexual abuse.

False complaints are easily made and carry serious consequences for the accused. Many of those who make false claims sincerely believe the truth of what they report. Some are opportunistic and are consciously lying for personal gain. A special type of false allegation, the false memory syndrome, arises typically within therapy. People report the 'recovery' of memories of previously unknown childhood sexual abuse. The influence of practitioners' beliefs and practices in the eliciting of false 'memories' and of false complaints cannot be overlooked. The problems of diagnosis, issues of confidentiality and the role of the expert witness as court educator are discussed.

Does methocarbamol affect fatigue markers in the low-back electromyogram?

Many low-back patients undergo electromyography (EMG)-based evaluations of muscle performance but present to the clinic after being prescribed muscle relaxants. The question that needed to be addressed was, do centrally acting muscle relaxants (methocarbamol; Robaxin) affect the EMG spectral indices of muscle fatigue that are often used to assess muscle performance. Participants performed an isometric spine extension protocol involving a 30 s fatigue exertion trial, then 1 min rest, and finally a 10 s long repeat exertion trial, at a 60% maximum voluntary contraction (MVC) level of exertion. Seven men were tested on two separate days (approximately 3-7 days apart), one day while medicated (six doses) with Robaxin and on another while not medicated. Specifically, the following parameters were studied in the bilateral multifidus (L5), lower erector spinae (L3) and upper erector spinae (T9): the slope of median power frequencies (MPFs) over the duration of the trial and the initial y-intercept of the MPF. The results generally suggest that methocarbamol (Robaxin) does not have any significant affect on the EMG median power frequency of the extensors during a fatiguing contraction followed by a repeat exertion, at least in normal people (one exception was observed--one side of multifidus at L5). However, given that this appears to be the first study of its kind, and that a relatively small number of subjects were used in this study, further investigation is needed to make a definitive conclusion about the effects of this drug on the several features of the electromyogram, over a broad spectrum of the clinical population performing a wider variety of tasks.

Recovered memories of childhood sexual abuse. Implications for clinical practice.

BACKGROUND: The growth in the USA of 'recovered memory therapy' for past sexual abuse has caused great public and professional concern. It became apparent that the polarisation of views and fierce controversy within the American psychiatric community was in danger of bringing psychotherapy into disrepute and it seemed important to examine objectively the scientific evidence before such polarisation developed in the UK. METHOD: A small working group reviewed their own experience, visited meetings and centres with expertise in this field, interviewed 'retractors' and accused parents, and then began a comprehensive review of the literature. RESULTS: There is a vast literature but little acceptable research. Opinions are expressed with great conviction but often unsupported by evidence. CONCLUSIONS: The issue of false or recovered memories should not be allowed to confuse the recognition and treatment of sexually abused children. We concluded that when memories are 'recovered' after long periods of amnesia, particularly when extraordinary means were used to secure the recovery of memory, there is a high probability that the memories are false, i.e. of incidents that had not occurred. Some guidelines which should enable practitioners to avoid the pitfalls of memory recovery are offered.

The use of caudal epidural anesthesia in clubfoot surgery.

We reviewed records of 31 children who had surgical release of 41 clubfeet under general anesthesia with supplemental caudal epidural anesthesia. Compared to an equivalent group of 27 children (39 feet), the caudal epidural group exhibited a statistically significant decrease in intraoperative narcotic requirement. One child had a bloody tap, and caudal epidural anesthesia was abandoned, but there were no other complications. Excellent postoperative pain relief persisted for > or = 8 h. Twenty-five of 31 caudal epidural patients were discharged safely on the same day as surgery without any surgical complications. Use of caudal epidural supplementation and outpatient surgery (where indicated) met with a high degree of parent satisfaction. Cost savings of outpatient clubfoot surgery, when compared to overnight stay, were disappointingly low.

Treatment of genu valgus deformity in congenital absence of the fibula.

Twenty patients with Syme amputation for congenital absence of the fibula and genu valgus deformity were followed until skeletal maturity. Radiographs were analyzed for genu valgus, mechanical axis, tibial angulation, and the condylar height ratio. This ratio was determined by measuring the greatest perpendicular height from the physis to the joint line and dividing the lateral height by the medial height. A smaller value represented more marked lateral condylar hypoplasia. The presence of medial tibial angulation and the degree of lateral femoral condylar hypoplasia correlated with the degree of genu valgus. Two of three patients who had proximal tibial osteotomies required multiple procedures for recurrent deformity. Medial distal femoral physeal stapling corrected the deformity in five of six limbs. The procedure is simple, allows immediate weightbearing in the prosthesis postoperatively, and has low morbidity. Patients should be followed closely until skeletal maturity. Osteotomy performed before skeletal maturity can result in recurrence of genu valgus deformity.

Muscle force and moment arm contributions to torque production in frog hindlimb.

The relative contribution of maximum muscle tetanic tension (Po) and muscle moment arm to maximum knee flexion torque was investigated in the frog hindlimb. Isometric torque was measured in frog semitendinosus muscle-bone complexes throughout the range of 0-160 degrees of flexion. Optimal joint angle (the angle at which isometric torque was maximum) was observed at 140 degrees of flexion. After torque measurements, the muscle was excised and the muscle length-tension relationship measured for determination of Po and optimal muscle length. In addition, the kinematics of the knee joint and therefore, the muscle moment arm was measured as a function of joint angle using principles of rigid body kinematics. Stepwise linear regression indicated that maximum torque was most highly correlated with Po (r = +0.77, P less than 0.01) and accounted for approximately 75% of the measured torque. In addition, there was no significant correlation between maximum torque and maximum muscle moment arm (r = +0.11, P greater than 0.7) suggesting that muscle force, not musculoskeletal anatomy, represents the major determinant of maximum torque production in the frog hindlimb.

Sarcomere length and joint kinematics during torque production in frog hindlimb.

The relationship between semitendinosus muscle force and knee joint kinematics during isometric torque production was examined in the frog (Rana pipiens) hindlimb. Passive muscle sarcomere length was monitored by laser diffraction during knee rotation, and joint center of rotation was determined later using principles of rigid body kinematics. Contractile force at the distal tibia, resulting from semitendinosus contraction, was also measured, and, using the kinematic data, a torque vs. joint angle curve constructed. Muscle sarcomere length varied from 3.6 micron at full knee extension to 2.0 micron at full knee flexion. Effective lever arm varied almost as a sine function, with optimal lever arm at 90 degrees of flexion. Joint torque increased linearly from 0 to 140 degrees of flexion and then sharply decreased to 160 degrees of flexion. Thus the optimal joint angle occurred at an angle (140 degrees) that was neither the angle at which muscle force was maximum (160 degrees) nor the angle at which the effective lever arm was maximum (90 degrees). These data indicate that knee torque production in the frog results from the interaction between muscular and joint properties and not either property alone.

Hostility and the medical student: how a trait measure influences perception of medical specialties.

This paper describes the influence of hostility as a trait on medical students' perception of medicine and its specialties. By means of Repertory Grid analysis, the authors compare the preferences of students having internally and externally directed hostility. The findings suggest that students with low levels of internal hostility are attracted to the popular image of the surgeon as a highly achieving and successful individual who is oriented towards cure. In contrast, those with high levels of internally directed hostility show an interest in specialties which allow for close human contact, particularly within general medicine. A psychological interpretation of these findings is offered.

What motivates medical students: how they see themselves and their profession.

This paper describes a repertory grid study of medical students' perceptions of medicine and its specialties. By sampling student attitudes at different stages of training, the authors show that in this sample, final-year medical students have a more vocational out-look than first-year students, in whom concern with relief of suffering is more important than aiming at cure and in whom materialistic success matters less than doing something 'important for mankind.' This is reflected in a shift of interest away from the surgical specialties.