Relationship of suicide rates with climate and economic variables in Europe during 2000-2012.

BACKGROUND: It is well known that suicidal rates vary considerably among European countries and the reasons for this are unknown, although several theories have been proposed. The effect of economic variables has been extensively studied but not that of climate. METHODS: Data from 29 European countries covering the years 2000-2012 and concerning male and female standardized suicidal rates (according to WHO), economic variables (according World Bank) and climate variables were gathered. The statistical analysis included cluster and principal component analysis and categorical regression. RESULTS: The derived models explained 62.4 % of the variability of male suicidal rates. Economic variables alone explained 26.9 % and climate variables 37.6 %. For females, the respective figures were 41.7, 11.5 and 28.1 %. Male suicides correlated with high unemployment rate in the frame of high growth rate and high inflation and low GDP per capita, while female suicides correlated negatively with inflation. Both male and female suicides correlated with low temperature. DISCUSSION: The current study reports that the climatic effect (cold climate) is stronger than the economic one, but both are present. It seems that in Europe suicidality follows the climate/temperature cline which interestingly is not from south to north but from south to north-east. This raises concerns that climate change could lead to an increase in suicide rates. The current study is essentially the first successful attempt to explain the differences across countries in Europe; however, it is an observational analysis based on aggregate data and thus there is a lack of control for confounders.

Relationship of suicide rates to economic variables in Europe: 2000-2011.

BACKGROUND: It is unclear whether there is a direct link between economic crises and changes in suicide rates. AIMS: The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates. METHOD: Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation. RESULTS: There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged. CONCLUSIONS: Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

Twelve tips on setting up a new medical school.

BACKGROUND: Not many set up a new medical school, so those that do usually do it only once. Thus most have no personal previous experience to guide them. AIM: To give those setting up a new school some broad issues to think about as they set about their task. METHODS: The tips were derived from personal experience in the UK and in Africa. RESULTS: The 12 tips identified are engage closely with the parent university from the outset; decide what the medical school is going to concentrate on first; agree on the overall aim of the school; decide who 'owns' the course; agree on the type of pedagogy to be employed; ensure good alignment between the aims, outcomes, learning framework and assessment; plan the assessment along with the rest of the course; make sure the school facilities are sufficient and appropriate to support the aims of the course; appoint the right staff; plan the research programme early; plan the co-ordination between the university and the health services at all levels; communicate, communicate, communicate. CONCLUSION: It is hoped that these suggestions will be widely applicable to different contexts and assist those in the exciting task of setting up a new school.

United Kingdom medical student expansion - Can new medical schools seize the initiative?

In June 2023, National Health Service (NHS) England published a Long-Term Workforce Plan 'to put staffing on a sustainable footing and improve patient care.' The plan falls in to three main areas: train, retain and reform. Currently there are around 7,500 medical school places available annually in England, but it is proposed to increase this to 10,000 by 2028 and to 15,000 by 2031. Five new medical schools were approved in the 2018 expansion and others are preparing applications in anticipation of future expansion. In this article, we discuss what factors might shape a new medical school, ensuring it meets the standards required by the UK regulator (General Medical Council) set out in Promoting Excellence and in Outcomes for Graduates.

A final clinical examination using a sequential design to improve cost-effectiveness.

CONTEXT: Good examinations have a number of characteristics, including validity, reliable scores, educational impact, practicability and acceptability. Scores from the objective structured clinical examination (OSCE) are more reliable than the single long case examination, but concerns about its validity have led to modifications and the development of other models, such as the mini-clinical evaluation exercise (mini-CEX) and the objective structured long examination record (OSLER). These retain some of the characteristics of the long case, but feature repeated encounters and more structure. Nevertheless, the practical considerations and costs associated with mounting large-scale examinations remain significant. The lack of metrics handicaps progress. This paper reports a system whereby a sequential design concentrates limited resources where they are most needed in order to maintain the reliability of scores and practicability at the pass/fail interface. METHODS: We analysed data pertaining to the final examination administered in 2009. In the complete final examination, candidates see eight real patients (the OSLER) and encounter 12 OSCE stations. Candidates whose performance is judged as entirely satisfactory after the first four patients and six OSCE stations are not examined further. The others - about a third of candidates - see the remaining patients and stations and are judged on the complete examination. Reliability was calculated from the scores of all candidates on the first part of the examination using generalisability theory and practicability in terms of financial resources. The functioning of the sequential system was assessed by the ability of the first part of the examination to predict the final result for the cohort. RESULTS: Generalisability for the OSLER was 0.63 after four patients and 0.77 after eight patients. The OSCE was less reliable (0.38 after six stations and 0.55 after 12). There was only a weak correlation between the OSLER and the OSCE. The first stage was highly predictive of the results of the second stage. Savings facilitated by the sequential design amounted to approximately GBP 30,000. CONCLUSIONS: The overall utility of examinations involves compromise. The system described provides good perceived validity with reasonably reliable scores; a sequential design can concentrate resources where they are most needed and still allow wide sampling of tasks.

A critique of the specialty certificate examinations of the Federation of Royal Colleges of Physicians of the U.K.

The Federation of Royal Colleges of Physicians of the U.K. has developed a programme to deliver specialty certificate examinations. These are knowledge-based examinations to be passed by all senior trainees in most medical specialties seeking a Certificate of Completion of Training (CCT). These examinations have been evaluated on their validity, reliability, educational impact, cost effectiveness, acceptability and standard setting methodology on the basis of internal evidence and the results of a published pilot. The evidence so far suggests that though reasonable reliability (reproducibility) can be achieved, validity (testing what is intended) may be lacking. Educational impact, cost effectiveness, and acceptability require more evidence. Consistency in standard setting is difficult.

LOS management: the path to efficiency.

Optimizing efficiency to reduce patient lengths of stay can enable a hospital to improve not only the quality of patient care, but also the financial bottom line. To evaluate opportunities for achieving greater efficiencies in this area, hospitals should: Gather and analyze data to identify pockets of variance. Determine the nature of discharge delays and why they occur. Identify opportunities for improvement, define possible solutions, and conduct cost-benefit analyses of the alternatives.

A UK clinical audit addressing the quality of prescribing of sodium valproate for bipolar disorder in women of childbearing age.

OBJECTIVES: To review prescribing practice concerning valproate, an established human teratogen, for the management of bipolar disorder in women of childbearing age. DESIGN: The Prescribing Observatory for Mental Health conducted a baseline clinical audit in the UK, as part of a quality improvement programme. PARTICIPANTS: Six hundred and forty-eight clinical teams from 55 mental health Trusts submitted retrospective treatment data relating to patients with a diagnosis of bipolar disorder. RESULTS: Of the audit sample of 6705 patients, 3854 were 50 years of age or younger. Valproate was prescribed for 24% of women and 43% men in this age group, and the mean dose of valproate was lower in women (1196 mg) than in men (1391 mg). For only half of such women was there documented evidence that information had been provided on the risks for the unborn child and the need for adequate contraception. Valproate was more often used in men to treat mania and aggression, while the most common treatment targets in women were hypomania and relapse prevention. CONCLUSIONS: Despite explicit recommendations in national treatment guidelines and published safety alerts and warnings regarding the use of valproate in women of childbearing age, current prescribing of this medication to such women in the context of the treatment of bipolar disorder falls short of best practice, particularly with regard to provision of information regarding the risks associated with exposure to valproate during pregnancy. While women younger than 50 years of age were less likely to be prescribed valproate than men in the same age group, and at a lower dosage, it is unclear to what extent this reflects clinicians' concerns about teratogenicity or is driven by perceptions of the indication for valproate, and the dosage required, for the treatment of different phases of the disorder in men and women.

Number needed to treat and time to response/remission for quetiapine monotherapy efficacy in acute bipolar depression: evidence from a large, randomized, placebo-controlled study.

The objectives of this analysis are to elucidate the clinical significance of antidepressant effects with quetiapine by evaluating number needed to treat as well as time to response and remission with quetiapine monotherapy in patients with acute bipolar depression. A post-hoc analysis was conducted of 542 patients with bipolar I or II disorder, (moderate to severe depression), randomized to 8 weeks of double-blind treatment with quetiapine 600 mg/day (n=180), quetiapine 300 mg/day (n=181), or placebo (n=181). Number needed to treat, time to response (> or =50% reduction from baseline in Montgomery-Asberg Depression Rating Scale total score) and time to remission (Montgomery-Asberg Depression Rating Scale total score < or =12) were evaluated. Response rates at week 8 were 58.2 and 57.6% for quetiapine 600 and 300 mg/day, respectively, and 36.1% for placebo (P<0.001). Remission rates were 52.9% for both quetiapine groups and 28.4% for placebo (P<0.001). The number needed to treat was five for both response and remission for quetiapine (600 and 300 mg/day) compared with placebo. Median time to response and remission were significantly shorter with quetiapine 600 and 300 mg/day than placebo. No between-group difference was found in the incidence of treatment-emergent mania or hypomania (quetiapine 600 mg/day: 2.2%, quetiapine 300 mg/day: 3.9, and placebo: 3.9%). In conclusion, quetiapine compared with placebo significantly reduces time to response and remission compared with placebo, and has a favorable number needed to treat.

Patient-centred learning--back to the future.

BACKGROUND: Historically, medical students learned the art and science of medicine from the patients they encountered. While students were highly motivated to learn through this approach, the serendipitous nature of real practice and the variability in the skills of their teachers proved to be liabilities for learning. This apprenticeship-style education was replaced by a more formal didactic curriculum during the twentieth century. DESCRIPTION: The power of computer technology enables medical educators to recapture the authenticity of patient-centred learning (PCL) through the creation of a virtual practice populated by a panel of virtual patients. In contrast to traditional problem-based learning cases, PCL virtual patients return for multiple visits with their student-doctors, demonstrating how diseases change over time, interact with other diseases and risk factors, and are influenced by psychosocial factors. CONCLUSIONS: New approaches to pedagogy embodied in patient-centred learning allow the curriculum to be organized around the patients, both real and simulated.

Angoff anchor statements: setting a flawed gold standard?

This article was migrated. The article was marked as recommended. The Angoff standard setting method depends fundamentally on the conceptualisation of an anchor statement. The precise wording and consequent interpretation of anchor statements varies in practice. Emphasis is often placed on standard setting judges' perceptions of difficulty for a candidate subgroup. The current review focusses on the meaning of anchor statements and argues that when determining the required standard of performance it is more appropriate to consider: (1) what it is important to achieve, and not how difficult it is to achieve it; (2) what all candidates should achieve, and not what a subgroup of candidates would achieve. In summary, current practice should be refined by using an anchor statement which refers to estimating the 'minimum acceptable performance by every candidate' for each item being tested, and then requiring each judge to score the relevant aspects of importance which could then be combined to derive a cut-score.

The use of anticonvulsants in the aftermath of mania.

This paper reviews the evidence for the efficacy of anticonvulsants in the continuation and maintenance phases of treatment of bipolar disorder, when there has been an episode of mania (Bipolar-I disorder). The evidence to be considered is primarily that arising from randomized controlled trials. A literature search was performed to identify all randomized controlled trials of anticonvulsants used as maintenance treatment for bipolar-I disorder. Placebo-controlled studies were preferred, however there have been relatively few of these and clinical practice must therefore be guided by evidence carrying a lower level of conviction. Valproate monotherapy lacks a convincing evidence base. The view that valproate is more effective than lithium in rapid cycling has not been borne out. Lamotrigine is effective in preventing depression after an episode of mania. As monotherapy, lithium appears superior to carbamazepine in bipolar patients not previously treated with either drug. The combination of lithium and carbamazepine may be superior to either drug alone, in certain treatment-resistant patients, but is associated with increased side effects. Other anticonvulsants lack evidence supporting their use in bipolar disorder except in treating co-morbid alcohol dependence, anxiety and bulimic symptoms. Valproate continues to be recommended by most current guidelines despite the lack of evidence.

Treatment benefits of duloxetine in major depressive disorder as assessed by number needed to treat.

The efficacy of an antidepressant typically is assessed by comparing it with placebo using a validated rating scale. This type of analysis, however, does not translate well to the clinical settings. For clinicians, a more meaningful measure is the number needed to treat (NNT). The objective of this analysis is to assess the efficacy of duloxetine in terms of NNT. Data were obtained from nine clinical trials designed to assess the efficacy and safety of duloxetine as a treatment for major depressive disorder. These studies examined 8-9 weeks of acute treatment with duloxetine. NNT estimates were determined for duloxetine, selective serotonin reuptake inhibitor comparators from six multi-dose studies, and for duloxetine in patients > or =65 years of age. The NNT was based on the Hamilton Depression Rating Scale (HAMD17) for response and remission, and improvements defined by the Clinical Global Impression (CGI) were estimated and compared. The NNT was favorable for both duloxetine and selective serotonin reuptake inhibitor compared with placebo. The patients receiving duloxetine had NNT for HAMD17 response of 6.0, remission 7-9, and CGI-defined improvement 6-7 by 8 weeks. The NNTs for selective serotonin reuptake inhibitors (fluoxetine or paroxetine, 20 mg/day) were around 7 for response, 11 for remission, and 8 for CGI-defined improvement. The NNTs in the elderly were similar. The NNT for several measures of efficacy including remission consistently demonstrated the treatment benefits of duloxetine as well as of fluoxetine and paroxetine compared with placebo.