Subspecialisation in Emergency Radiology: Proposal for a harmonised European curriculum.

Introduction: Radiology plays a crucial role in the emergency care setting by delivering early and precise diagnoses under pressure of time, right at the beginning of patient treatment. Although there is a need for postgraduate education in emergency radiology, most of the national bodies responsible do not offer it in a uniform fashion and a general proof of qualification is missing in Europe. Therefore, the European Society of Radiology (ESR) has founded the (Sub-)Society of Emergency Radiology (ESER), prompting them to develop a European curriculum. This trend, which is currently also encouraged in many other non-radiological specialties which demand the highest professional qualifications, often lacks expertise in medical education. Goals: The goal of this article is the general description of the curricular planning process for a European postgraduate subspecialisation programme, using the example of Emergency Radiology (European Diploma in Emergency Radiology, EDER), including the utilisation of TOOLS and recommendations derived from comparable projects. Project description: The project was divided into partial steps: the timeline displayed in a GANTT chart, and tasks and responsibilities assigned in a RASCI matrix. The curriculum was iteratively developed using the KERN approach and steps were prioritised using the PARETO principle. Furthermore, the following TOOLS were used: limitations and needs assessment, SWOT analysis, formulating learning objectives and categorising them after MILLER and SCLO, and using BLOOM's taxonomy for cognitive learning objectives and operationalising them according to MAGER. Psychomotoric and affective learning objectives were assigned to CANMEDS roles, grouped by topic using CLUSTERING, and then mapped by MATRIX analysis to appropriate learning and evaluation methods. Striving for continuous improvement, the curriculum was finally embedded in curricular quality management. Results: The standardisation of the EDER access, considering the different national conditions, the minimisation of European learners' attendance phases, restricting expenses by best possible use of existing structures, respecting the requirements and retaining the support of the European umbrella society ESR, finishing the project by a specific deadline and the demands of continuous improvement were particular challenges. A curriculum with the eligibility of five years' speciality training in general radiology has evolved on schedule. The subspeciality training lasts at least one year and is divided into webinars, workshops during congresses (e.g. the annual ESR and ESER congresses) and one year practical training at the individual learner's corresponding local hospitals, which adhere to a catalogue of requirements, comparable to national educational policies. The curriculum is completed by passing a written and oral exam (diploma) and re-accreditation every five years. Conclusions: Despite complex requirements, the TOOLS utilised allowed an almost seamless, resource-minimised, professional, location-independent distributed development of a European subspeciality curriculum within one year. The definitive implementation is still due. If any deviations from the draft presented should become necessary in the future, the embedment in the curricular quality management will lead to a redirection in the right way and, furthermore, secure a continuous improvement in the best way possible.

The Sustained-Release Dexamethasone Implant: Expanding Indications in Vitreoretinal Disease.

Corticosteroids play an important role in the therapeutic approach to vitreoretinal disease. The Ozurdex implant (DEX Implant 0.7 mg, Ozurdex, Allergan Inc., Irvine, CA, USA) offers sustained release of dexamethasone in the vitreous cavity, and this novel drug delivery system has proven useful both in improving clinical outcomes and in reducing injection burden. While the Food and Drug Administration approves the use of the DEX implant in retinal vein occlusions and non-infectious posterior uveitis, its utilization continues to expand in its breadth of diversity across myriad vitreoretinal conditions. Additionally, modified injection techniques are evolving to improve the safety profile of the DEX implant in eyes that are often considered to have relative contraindications to its use, further extending its application. This review aims to evaluate the evidence supporting the expanding indications and injection techniques of the DEX sustained-release implant in vitreoretinal disease, and explores potential future indications for its use. Arenas for future research are also identified to further elucidate the precise role of the DEX implant in our current treatment model. Increased awareness of effective and safe uses of the DEX implant can refine our therapeutic approach to vitreoretinal disease and ultimately improve patient outcomes.

Reproductive rights and the medical care system: a plea for rational health policy.

Recently, there have been many challenges to women's reproductive rights and freedoms: court-ordered cesarean sections; criminal cases against women for prenatal child abuse; and attempts to limit the practice of mid-wifery, home birth, and the operation of alternative birth centers. In these cases, medicine has been complicit or proactive in attempts to control the behavior or health care options of pregnant women. We discuss medicine's role as an agent of social control, the medical reconstruction of problems that are social in nature, and the need for a more coherent policy framework to guide physician practices.

PIP: Reproduction issues are highly controversial. Women's legal right to abortion continues to be challenged, women's rights are being pitted against fetal rights, and there is concern about teen pregnancy, the appropriate use of reproductive technology, and drug and alcohol use during pregnancy. There has been, however, little attention to medicine's role as an agent of social control and arbiter of reproductive behavior, the medical reconstruction of and intervention in problems which are essentially social in nature, or of equity and social justice in reproductive health care. The authors discuss these latter issues in light of historical and more recent attempts to control the behavior of pregnant women. In the absence of current reproductive health policy, the medical profession makes arbitrary decisions in individual cases which may or may not reflect patient or community wishes. A more coherent policy framework and regulatory mechanisms to guide physician practice are needed. The authors discuss the problem in context, key questions, social discrimination in reproductive health care, choosing which services to provide, coercion and choice, and reproductive health policy as a solution.

Infertility in industrialized countries: prevalence and prevention.

We discuss the prevalence and aetiology of infertility and the relevance of this information for national infertility services and prevention programmes. The prevalence of infertility in industrialized countries has been said to be as high as 10-20%. This estimate, and the argument that little can be done to prevent infertility, have been used as justification for increased government investment in, or expansion of, services for medically assisted conception. However, population prevalence surveys indicate that far fewer couples of reproductive age are actually infertile. For example, a recent survey in the United States reported that 8.5% of married couples with a wife age 15-44 were infertile. 4% of the sample were childless and reported having a condition which impaired fecundity, while less than 2% were childless, had impaired fecundity and were over 35 years of age. Other studies show that nearly a third of couples have difficulty conceiving at some point during their reproductive lives but few actually remain childless. A significant proportion of infertility could be prevented through more aggressive application of standard public health measures.

Perinatal care in the Soviet Union: a time of transition.

Recent Soviet reforms in health care policy and financing are expected to have a significant impact on perinatal services. Efforts are under way to upgrade the care of pregnant and birthing women. This paper describes some aspects of the current system of perinatal care and prospects for future change.

Turkey-baster babies: a view from Europe.

Classification of artificial insemination as a medical procedure has largely endured because the practice met the perceived needs of clients, physicians, and society. For nearly two decades, however, the success of self-insemination has challenged both the necessity of involving physicians in the process and the traditional understanding of the procedure as therapy for infertile couples. Demedicalization of artificial insemination as a matter of policy would entail changes in law, custom, and attitudes. The advent of safe and effective self-insemination makes critical a public debate on the issues of reproductive freedom, the meaning of parenthood, and the interests of children.

Are in-vitro fertilisation and embryo transfer of benefit to all?

The efficacy, safety, costs, and benefits of in-vitro fertilisation and embryo transfer (IVF/ET) have been reviewed. IVF/ET benefits only a small proportion of infertile women, it is expensive, and has serious health risks. Therefore policies for the management of infertility in which most financial and manpower resources are applied to prevention of infertility must be developed. Health authorities should also require accreditation of IVF/ET programmes, certification of providers, and ongoing monitoring of clinics. Full and accurate information on IVF/ET must also be disseminated, so that individuals seeking treatment for infertility can make the best informed choice about their care and health authorities can decide the place of IVF/ET in their infertility services.

An epidemiologic investigation of alcohol-dependent schizophrenics.

Most clinicians agree that alcoholism is frequent in schizophrenic patients. However, little is known about the clinical or familial characteristics of this group. We compared alcoholic schizophrenics and nonalcoholic schizophrenics with respect to sociodemographic and clinical characteristics and the rate of various psychiatric illnesses among their first-degree relatives. The only difference in the sociodemographic characteristics was a higher proportion of males among the alcoholic schizophrenics. Clinically, the alcoholic schizophrenics were more likely to report experiencing hallucinations, depressive episodes, manic episodes (females only) and multiple substance abuse (males only). In addition, the male alcoholic schizophrenics were younger at first hospitalization than the male nonalcoholic schizophrenics. This effect was reversed for females. The relatives of alcoholic schizophrenics were 2.6 times more likely to be alcoholic than the relatives of the nonalcoholic schizophrenics. The morbidity for other psychiatric disorders was similar in the two groups.

Infant mortality in Europe: implications for the United States. Statement to the National Commission to Prevent Infant Mortality.

PIP: The solution to the problem of infant mortality in the U.S. is not medical but social, economic and environmental. In the U.S., 70% of infant mortality is neonatal, death in the 1st month of life, due to factors in pregnancy and delivery. The remainder of mortality is primarily related to socio-economic factors such as poverty, poor housing, lack of supervision. The 1st aspect of pregnancy is prenatal care. All European countries mandate from 4 to 30 visits of prenatal care. Women not attending are followed up by home visits. There is no evidence that the quantity of care affects mortality: WHO suggests the minimal number of medical appointments combined with other forms of social support. The 2nd aspect is maternity protection, meaning child allotments, transfer to a less strenuous job during pregnancy, parental leave, assured re-employment, time off for breastfeeding, day care, and even more liberal benefits for single parents. It might be cost-effective for the U.S. to give maternity protection a higher priority than costly prenatal care. The 3rd aspect of pregnancy and birth is operative intervention in delivery. The U.S. has several times the cesarean section rate of European countries with low infant mortality: 2 times that of Sweden and 3 times that of Holland. Surgical intervention does not contribute any demonstrable benefit to infant survival. The excess cesarean sections in the U.S., compared to Sweden and Holland, amount to $2-3 billion yearly. Furthermore, in Europe 70% of all births are attended by professional midwives, who assist the woman with a social, non-interventionist clinical approach. Without a strong, independent midwifery profession, the U.S. suffers from excess intervention, its attendant risks, and serious malpractice suits. Clearly what is needed is not more dollars spent on medically-oriented prenatal and obstetric care, but a shift in priorities toward social and financial support for pregnant women. The U.S. needs far less money spent on surgical obstetrics, and more resources invested in a large, strong, independent midwifery profession.^ieng

Diarrheal disease control and family planning: the status of women and community participation.

PIP: This article discusses current campaigns for diarrheal disease control and family planning from the perspective of the social and educational status of women in Turkey. Survey data indicate that infant mortality is highest in regions with highest illiteracy rates; similarly, acceptance of family planning in 1 region was 79% among literate women but only 24% among illiterate women. These findings suggest that the way women cope with their infants and with fertility control is directly related to their status. Mothers require education in these areas and support. Particularly effective is a self-help approach that relies on the unofficial or traditional sector of society, including the indigenous female lay care network. The traditional birth attendant is often a key person in this network. In a pilot project in Turkey, trained midwives taught birth attendants the basic principles of diarrheal disease control and family planning. The selected women then educated the other women of the village through the usual means of communication of the female network. The project found marked improvement in knowledge and practice in diarrheal disease control and family planning and a sense of empowerment among village women. Thus, it is recommended that both social marketing and self-help methods be used in Turkey's primary health care campaigns.^ieng

Whither goest nutrition?

Three aspects of nutrition are identified. They are food, its production and availability, eating, human metabolism. Nutrition is multifactorial. Medical men are not taught about nutrition. They are concerned with illness, not health. Science, caught up in a Cartesian dichotomy, is hampered by a reductionist approach. The World Health Organisation recommends that nutrition should be approached from the standpoint of health promotion. The implications of such an approach are expounded.