Recurrent painful unilateral gynaecomastia-interactions between hyperthyroidism and hypogonadism

We report an unusual case of recurrent, painful, unilateral gynaecomastia (GM) in an elderly male with relapsing Graves' hyperthyroidism and co-existing primary hypogonadism. This patient presented to the Breast Clinic with a 4-month history of painful, right GM. Malignancy was excluded but T3 was noted to be raised at 7.3 pmol l(-1) (normal 3.5-5.5) with a suppressed thyroid-stimulating hormone. Testosterone, luteinizing hormone and follicle-stimulating hormone were consistent with primary hypogonadism. He was later referred to physicians with night sweats and painful right GM. FT3 was 7.4 and carbimazole was commenced. Within 4 months, the night sweats and right GM had resolved but he became hypothyroid. When carbimazole was stopped, right GM recurred together with hyperthyroidism. The male breast, which is sensitive to subtle changes in T/E2 ratio, is more likely to be stimulated in an elderly male with hyperthyroidism and pre-existing hypogonadism, and hence recurrence of GM with relapsing hyperthyroidism. Recognition of this association is clinically relevant to avoid unnecessary investigations and undue patient anxiety, and to facilitate appropriate early diagnosis and treatment.

The involvement of nurses in reporting suspected adverse drug reactions: experience with the meningococcal vaccination scheme

AIMS

In order to aid the monitoring of the new Meningococcal serogroup C Conjugate (Men C) vaccine, the Yellow Card Scheme was extended to allow nurses for the first time to report any suspected adverse reactions associated with these vaccines. We have analysed the Yellow Cards received by the Committee on Safety of Medicines (CSM) Wales from nurses reporting a suspected reaction in association with these vaccines during the first 16 months of the programme.

METHODS

CSM Wales receives Yellow Cards from healthcare professionals in Wales. Details of Yellow Cards reporting a suspected adverse reaction associated with Men C vaccines during the study period were extracted from the CSM Wales database and analysed according to health professional category [nurses, General Practitioners (GP), hospital doctors or pharmacists].

RESULTS

During the study period 534 117 doses of Men C vaccines were administered in Wales; in the same period CSM Wales received 1095 Yellow Cards containing 1952 suspected reactions. Nurses completed 529 [48.3%, 95% confidence interval (CI) 43.6, 53.1] Yellow Cards compared with 294 (26.8%, 95% CI 22.7, 30.8) from GPs, 262 (23.9%, 95% CI 20.1, 27.6) from hospital doctors and 10 (0.91%, 95% CI 0.43, 1.73) from others, which include hospital pharmacists, community pharmacists and health visitors. The proportion of Yellow Cards sent by nurses was significantly higher than those sent by GPs and hospital doctors. Ninety-five percent CIs for differences in proportions (CI diff prop) were (0.175, 0.254) and (0.204, 0.282), respectively. The majority (90.9%, 95% CI 88.7, 93.5) of the Yellow Cards from nurses reported suspected reactions children in over the age of 5 (95% CI diff prop 0.861, 0.917). The spectrum of suspected adverse drug reactions (ADRs) involved the skin and subcutaneous tissue, central nervous system, general reactions, and the gastrointestinal tract. Of the suspected reactions reported by nurses, GPs and hospital doctors, 13.4% (95% CI 10.5, 15.8), 12.9% (95% CI 9.6, 16.8) and 9.1% (95% CI 6.5, 11.8), respectively, were of serious reactions. Nurses reported 52.5% (95% CI 45.4, 60.6) of all the suspected serious reactions, which was statistically more significant than hospital doctors [chi2 = 5.864, degree of freedom (DF) = 1, P < 0.05] but not GPs (chi2 = 0.066, DF = 1, P > 0.05).

CONCLUSIONS

Nurses were the health professionals who provided the largest proportion of reports of suspected ADRs and almost half of all reports during the Men C vaccination campaign. Their reports contained an equal proportion of serious suspected ADRs and the reports were documented as completely as those from GPs and hospital doctors.

Snoring, daytime sleepiness and stroke: a case-control study of first-ever stroke

Previous reports have shown an association between snoring and stroke but it is not clear whether this reflects confounding factors nor whether the association is attributable to obstructive sleep apnoea (OSA). We performed a case-control study of 181 patients admitted to hospital with first-ever stroke and community control subjects matched individually for age, sex and general practitioner. Subjects were interviewed with a structured questionnaire to identify snoring, daytime sleepiness and stroke risk factors. The association between snoring alone and stroke was not statistically significant: odds ratio (95% CI) 1.44 (0.88, 2.41). Daytime sleepiness was, however, significantly associated with stroke: odds ratio 3.07 (1.65, 6.08). Multiple logistic regression showed that hypertension, current smoking, taking alcohol regularly (negatively) and a higher Epworth sleepiness score were independently associated with stroke. The results suggest that the previously reported association between 'simple' snoring and stroke might have been due to poor controlling for confounding variables. Our study suggests an association with greater sleepiness prestroke, the cause of which is unclear, although OSA is a possible candidate.

Randomized double-blind controlled trial on the effects on iron status in the first year between a no added iron and standard infant formula received for three months

Recent research has not only questioned the necessity of iron supplementation in human milk substitutes prior to weaning, but also suggested some potential adverse effects. This study investigated the hypothesis that infant formula need not contain added iron in the first 3 mo. Healthy term infants were recruited into a double-blind controlled trial and randomized to receive either a new no added iron formula (New; <0.1 mg Fe 100 ml(-1)) or a standard formula (Standard; 0.5 mg Fe 100 ml(-1)) for the first 3 mo of life. A breastfed reference group was also studied. Iron status was assessed at 3 and 12 mo from heel-prick capillary blood samples evaluated by full blood-count analysis, including reticulocytes and serum ferritin. In total, 149 infants were entered (51 New, 49 Standard, 49 breastfed) with no differences between the groups in gender distribution, birthweight, gestation or numbers completing the study. There were no significant differences between the principal outcome measures: mean values for haemoglobin, mean cell volume and ferritin, between the two formula-fed groups, and the proportion with a haemoglobin level <11 g dl(-1) or ferritin <10 microg l(-1) did not differ.

CONCLUSION

The use of a "no added iron" infant formula in place of an iron-fortified formula during the first 3 mo of life did not clinically affect iron status at 3 and 12 mo of age. The universal supplementation of formulae with iron during this initial period needs further consideration.

Vitamin D deficiency in pregnant women from a non-European ethnic minority population--an interventional study

OBJECTIVE

To determine the vitamin D status of pregnant women from non-European ethnic minorities in South Wales.

DESIGN

Prospective study.

SETTING

Llandough Hospital, Cardiff, South Wales.

SAMPLE

One hundred and sixty pregnant women from a non-European ethnic minority population in South Wales.

METHODS

Biochemical screening of vitamin D status was carried out at the first antenatal visit. Women found to be deficient in vitamin D were subsequently supplemented and vitamin D status was rechecked at delivery.

MAIN OUTCOME MEASURE

Vitamin D status at delivery.

RESULTS

Eighty of 160 women had a vitamin D level below 8 ng/mL at their first antenatal visit and were treated with oral vitamin D. Factors that could influence vitamin D status such as religion, fluency in English and dressing habits did not appear to have any effect, although a higher proportion of women who had lived in Britain for longer than three years had subnormal vitamin D levels. In 58 of those checked at delivery, the mean plasma vitamin D level increased from 6 to 11 ng/mL although the mean parathyroid hormone level was unchanged.

CONCLUSION

In view of the high incidence of subnormal vitamin D levels in women from ethnic minorities, we recommend biochemical screening of these women in early pregnancy, with subsequent supplementation where indicated.

Growth and nutrition of Hong Kong children aged 0-7 years

OBJECTIVE

To study the early dietary practices in relation to growth of Hong Kong children from birth to 7 years.

METHODOLOGY

One hundred and seventy-three full-term Hong Kong Chinese babies were recruited at birth and were followed up for anthropometric measurements using standardized methods and dietary assessment using a combination of dietary history, 24 h recall and food frequency. At 7 years, 125 children remained in the study.

RESULTS

Mean (SD) birthweight was 3.3 (0.38) kg for boys and 3.1 (0.38) kg for girls. Mean (SD) weight at 7 years was 22.4 (4.2) kg for boys and 21.1 (3.7) kg for girls, and mean (SD) height was 120.3 (4.8) cm for boys and 119.8 (5.1) cm for girls. Hong Kong children were lighter and shorter than Australian children and the National Centre for Health Statistics (NCHS) references, but the magnitude is less than one standard deviation score. Mean weight and height of Hong Kong children were lower compared to Caucasian and Beijing children, with more obvious differences between 1 and 5 years. At 1 year, mean (SD) daily energy intake was 98 (24) kcal/kg/day for boys and 100 (26) kcal/kg/day for girls. By 7 years, it decreased to 82 (18) kcal/kg/day for boys and 73 (22) kcal/kg/day for girls. Between 2 to 4 years of age the energy intake of studied children were slightly lower than the Australian and Finnish children, but the protein intake was higher. Percentage of fat contributing to total daily energy intake was lower throughout at a level of 30%. Such differences in diet reflect a lower consumption of milk fat, higher consumption of meat and lower level of physical activity in Hong Kong children. Intakes of calcium, iron and vitamin C all reached 60% or above of US recommended daily allowance.

CONCLUSIONS

The smaller body build of Chinese compared to Caucasians cannot be explained by dietary differences. The diet of Hong Kong children is changing to one which is more Westernized with a higher consumption of animal products.

Endothelial function is impaired in fit young adults of low birth weight

OBJECTIVE

Non-insulin-dependent diabetes, hypertension and ischaemic heart disease, with insulin resistance, are associated with low birth weight (the 'Small Baby Syndrome'). Common to these adult clinical conditions is endothelial dysfunction. We tested the hypothesis that endothelial dysfunction could precede their development in those of low birth weight.

METHODS

Endothelial function was measured by ultrasonic 'wall-tracking' of flow-related brachial artery dilatation in fit 19-20 year old subjects randomly selected (blind to the investigators throughout the study) from low (< 2.5 kg) and normal (3.0-3.8 kg) birth weight subjects in the 1975-7 cohort of the Cardiff Births Survey and with no known cause for endothelial dysfunction.

RESULTS

Flow-related dilatation was impaired in low birth weight relative to normal birth weight subjects (median 0.04 mm [1.5%] [n = 22] cf. 0.11 mm [4.1%] [n = 17], p < 0.05; 0.04 mm [1.5%] [n = 15] cf. 0.12 mm [4.4%] [n = 12], p < 0.05 after exclusion of inadvertently included ever-smokers).

CONCLUSION

The findings suggest that endothelial dysfunction is a consequence of foetal malnutrition, consistent with contributing to the clinical features of the 'Small Baby Syndrome' in later adult life.

Meningitis in Hong Kong children, with special reference to the infrequency of haemophilus and meningococcal infection

OBJECTIVE

To study the epidemiologic and aetiologic features of meningitis in children in Hong Kong.

METHODOLOGY

A retrospective study of 85 children resident in the New Territory East region of Hong Kong admitted to a teaching Hospital because of meningitis during a 9 year period.

RESULTS

Mycobacterium tuberculosis was the most common aetiological agent accounting for 13 cases (15.3%). Other bacteria accounted for 41 cases (48%); among these one fifth were caused by Haemophilus influenzae type b. The overall admission rates for tuberculous meningitis in Chinese children were 0.76/100,000 (95% CI 0.25-1.78) and 0.42/100,000 (CI 0.19-0.8) per year, respectively, for under 5 year olds and under 15 year olds. The overall annual incidence rates of bacterial meningitis other than tuberculous were 5.2/100,000 (CI 3.72-7.43) and 1.6/100,000 (CI 1.14-2.29) for Chinese children under 5 years and under 15 years, respectively. The annual incidence of H. influenzae meningitis in Chinese children under 5 years old was low at 1.1/100,000 (0.43-2.2). All five cases of meningococcal meningitis were in Vietnamese children (under 5 years of age incidence: 13.0/100,000 per year, CI 4.2-30.3). There were no cases of meningococcal meningitis in Chinese children during the 9 year period.

CONCLUSION

M. tuberculosis was the most common aetiological agent of meningitis in Hong Kong children. The incidence of haemophilus or meningococcal meningitis was very low.

SIDS: parental awareness and infant care practices in contrasting socioeconomic areas in Cardiff

Parental awareness of risk factors for sudden infant death syndrome (SIDS) and infant care practices were compared in an area of relative deprivation and one of relative affluence in Cardiff. Awareness was high in both areas. More infants slept on the side in the deprived area (p < 0.02). One in three babies was exposed to cigarette smoking, significantly more in the deprived area (p < 0.001). Health professionals should discourage side sleeping and smoking, especially in areas of deprivation.

Faecal chymotrypsin in small for gestational age infants: effects of nucleotides and breast feeding

The effect of diet on pancreatic exocrine function, measured by faecal chymotrypsin activity (FCA), was studied longitudinally in three groups of small for gestational age (SGA) infants in the first six months of life. The three groups comprised breastfed infants (group B), those randomly allocated to receive a standard infant formula (group S), or the same formula supplemented with nucleotides (group N). The three groups did not differ in their birthweight or gestational age. Nucleotide supplementation of infant formula improves catchup growth in SGA infants but whether this is due to effects on the gastrointestinal mucosa or the exocrine pancreas is not known. There were no differences in FCA at study entry but by one month group B had significantly lower values than the other groups, and this was maintained at 2, 4, and 6 months. Groups N and S did not differ significantly at any time point. Nucleotide supplementation of infant formula does not influence pancreatic exocrine function and its effect on growth is unlikely, therefore, to be mediated through the pancreas. This study shows that breast feeding is associated with lower FCA which may be related to the lower protein content of human milk. Reliable interpretation of FCA in young infants requires information about their diet.

Body size and subcutaneous fat patterning in adolescence

Factors that influence low birth weight at term may also be associated with subcutaneous fat patterning in later life. This hypothesis was investigated in a comparative (retrospective) cohort study. The subjects, born in Cardiff between 1975 and 1977, were of mean age 15.7 years. Cases (low birth weight (< 2500 g) at term) were matched with controls (normal birth weight (3000-3800 g) at term) for sex, parity, place of birth, date of birth, and gestation. Subscapular skinfold (an index of central subcutaneous fat) and triceps skinfold (an index of peripheral subcutaneous fat) were measured using a Holtain skinfold caliper. The differences (cases minus controls) (95% confidence interval) for subscapular and triceps skinfolds were respectively -0.3 mm (-1.74 to 1.14) and -0.48 mm (-1.75 to 0.79). These findings are inconsistent with the hypothesis that low birth weight at term is associated with subcutaneous fat patterning in adolescence.

Urinary D-glucaric acid excretion in idiopathic neonatal jaundice

OBJECTIVE

To determine the extent to which immaturity of hepatic microsomal enzyme activity might contribute to physiological jaundice.

METHODS

Urinary excretion of D-glucaric acid, expressed in mumol glucaric acid/ mmol creatinine, was measured in 122 Chinese full-term healthy newborn babies during the first five days of life. Among the 122 babies, 22 were born by normal spontaneous delivery at the British Military Hospital and 100 were born by caesarean section at the Prince of Wales Hospital.

RESULTS

In all babies the excretion of D-glucaric acid was highest on the first day of life and gradually decreased over the following 5 days. Five babies born by spontaneous delivery and six babies born by caesarean section developed jaundice during the study period. The excretion of D-glucaric acid in the jaundiced babies was significantly higher on the first two days than in the non-jaundiced babies.

CONCLUSIONS

D-glucaric acid excretion was increased in jaundiced newborn babies in the first few days of life. This finding does not indicate less liver microsomal enzyme activity in the jaundiced babies compared to those non-jaundiced. On the contrary, it suggests that in idiopathic neonatal jaundice compensatory mechanism might operate from a very early stage to excrete a higher bilirubin load that might be present through haemolysis.

Nucleotide supplementation and the growth of term small for gestational age infants

A double blind randomised controlled trial in small for gestational age (SGA) infants, whose intestinal mucosa was shown to be functionally impaired as a result of intrauterine undernutrition, was carried out to investigate the hypothesis that nucleotide supplementation of a milk formula could improve catchup growth. Anthropometric data were collected on 74 infants, 39 randomly allocated to the nucleotide supplemented group (group N) and 35 to a standard formula group (group S). From study entry to 2 months of age, infants in group N had significantly higher mean rates of weight gain (106.3 compared with 94.7 g/kg baseline weight/week) and length gain (21.8 v 19.7 mm/m baseline length/week). Over the whole six months for which the trial formula was provided group N had significantly higher mean rates of gain of weight (80.1 compared with 71.8 g/kg baseline weight/week), length (16.2 compared with 15.0 mm/m baseline length/week), and head circumference (11.8 compared with 10.8 mm/m baseline head circumference/week). Catchup growth in SGA infants is therefore improved by nucleotide supplementation of infant formula.

Audit of medical students' experiences of paediatric teaching: a tool to monitor and improve clinical teaching

We provide clear aims and objectives for our students during their attachment in child health. To assess how well these are being met we reviewed their experience over the 3-year period 1991-1994. The audit was based on a questionnaire and was anonymous and voluntary; 45.4% of the students completed the questionnaire. These students' experiences were generally satisfactory and covered a wide variety of common childhood disorders. Of concern was that 32% of them received less than 1 hour per week of teaching in protected time and that they seemed reluctant to avail themselves of the opportunity of attending casualty; 54% did not visit the casualty department at all during their attachment. We have identified several areas where improvements in our teaching can be made and we are confident that our system of regular audit constitutes a valuable tool to monitor and improve clinical teaching.

Birth weight at term and lung function in adolescence: no evidence for a programmed effect

It has been suggested that factors which influence low birth weight at term may be associated with reduced lung function in later life. This hypothesis was investigated in a comparative (retrospective) cohort study of 164 matched pairs of subjects where the observers responsible for tracing and studying the subjects were unaware of their case or control status. The subjects, born in Cardiff between 1975 and 1977, were of mean age 15.7 years. Cases (low birth weight (< 2500 g) at term) were matched with controls (normal birth weight (3000-3800 g) at term) for sex, parity, place of birth, date of birth, and gestation. Lung function was measured using a portable spirometer. The corrected mean differences (95% confidence interval) in forced vital capacity (FVC) and flow when 50% or 25% of the FVC remains in the lungs between the cases and controls were respectively -41 ml (-140 to 58), -82 ml/sec (-286 to 122), and -83 ml/sec (-250 to 83). None of these differences were statistically significant. These results are inconsistent with the hypothesis that low birth weight at term is associated with reduced lung function in adolescence.

Child health surveillance: development of a multicentre course and its evaluation

With increasing numbers of general practitioners wishing to provide child health surveillance during the 1980s and the expected further increase with the 1990 General Practice Contract, a course in child health surveillance was developed. The content of the course was determined by a needs assessment of Welsh general practitioners in combination with the expectations of paediatricians already involved in educating doctors in community child health. A multicentre course with prepared materials was developed. Teaching methods reflected adult learning needs, included practical clinical competencies and was centred in small groups each led by local tutors. The course was held annually on three occasions, with 220 participants in total. The materials and teaching methods were highly acceptable to the participants, and evaluation demonstrated a significant increase in knowledge and confidence. All participants reached the required clinical competence, six after further teaching. The content, teaching methods, and evaluation methods were altered in the light of feedback, resulting in a 'stand alone' course with built-in evaluation, which is now being provided by local tutors. This study has demonstrated the feasibility of providing a course for large numbers of doctors, using predominantly small-group teaching and discussion with local tutors. We are grateful to all the participants and especially the tutors.

Assessing undergraduates' practical clinical skills

A list of practical skills to observe or learn was included in an undergraduate child health core curriculum. The ability of students to perform these tasks was assessed in a short objective test. This testing has encouraged them to become more proficient in these important skills.

Infant feeding and growth of Chinese infants: birth to 2 years

A cohort of 174 healthy full-term Chinese infants was followed up regularly for 2 years for their weight, length, head circumference, triceps and subscapular skinfold thickness, and their feeding practice. The majority of babies (92% at 2 months) were bottle fed with full strength infant formula. The energy intake over the first year of life was comparable with that of healthy Caucasian infants. The mean protein intake during the weaning period exceeded fourfold that of the WHO recommendation. At 2 years, infants were -0.6 standard deviation score (SDS) lighter and -0.4 SDS shorter than the National Centre for Health Statistics (NCHS) reference.

Comparative study of growth of Chinese infants: Hong Kong versus Guangzhou

The growth of 174 infants from Hong Kong and 221 infants from Guangzhou from birth to 2 years were compared. Ethnic origins, parental size, and birth weights were similar. Common illnesses in the two groups were upper respiratory tract infection and diarrhoea. The early infant feeding practices were different, with more breastfeeding and earlier introduction of solids in Guangzhou. Compared to those of Hong Kong, Guangzhou babies had lower weight for length in the first year of life. Within the Guangzhou group, babies totally breastfed for the first 2-4 months were heavier than those given rice cereals as supplement and they had less diarrhoea in the first 6 months. Hong Kong infants suffered more diarrhoea than the Guangzhou group. It was concluded that breastfeeding should be promoted and supported in these two cities.

Relation between birth weight at term and systolic blood pressure in adolescence

OBJECTIVE

To examine whether birth weight is related to systolic blood pressure during adolescence.

DESIGN

Retrospective (comparative) cohort study. The observers who traced and studied the subjects were unaware of their case-control status.

SUBJECTS

330 subjects were born in Cardiff in 1975-7. Cases who were low birth weight at term (< 2500 g) were matched with controls of normal birth weight (3000-3800 g) at term.

MAIN OUTCOME MEASURES

Systolic blood pressure measured by random zero sphygmomanometry in the subject's right arm with the subject supine, corrected for size and age.

RESULTS

The mean age at examination was 15.7 years. The mean systolic blood pressure of the cases was 105.8 mm Hg and of the controls 107.5 mm Hg. The corrected difference (95% confidence interval) in systolic blood pressure between the cases and controls was 1 mm Hg (-3 to +1 mm Hg; two tailed probability 0.33).

CONCLUSION

Systolic blood pressure in adolescents of low birth weight is not significantly different from that of adolescents of normal birth weights.

Student-initiated revision in child health

Most teaching of child health in Cardiff takes place in block attachments of 8 weeks. There is an introductory seminar of 2 days followed by a 6-week clinical attachment in a district general hospital in Wales, and then a revision period of one week designed to help students formalize and structure their basic knowledge and to clarify aspects of child health which they may have had difficulty in understanding. The revision programme has to take into account: the short time available, the small number of teaching staff, the most relevant basic knowledge and active participation by the student. This paper describes how this week has been improved through the use of student-initiated revision (SIR). The students' appraisal of this revision and in particular SIR is presented.

Mothers' awareness of risk-reducing measures for the sudden infant death syndrome

A questionnaire was given to 37 mothers of infants under 12 months admitted to a hospital paediatric ward in August 1992 to assess their awareness of current risk-reducing recommendations for the sudden infant death syndrome (SIDS) and the role of health professionals in providing this information. Three mothers had not heard of SIDS; all were Bangladeshi. Twenty-seven mentioned lateral or supine lying, 18 overheating and 15 smoking. Only one mother actually volunteered that, as a risk-reducing measure, medical advice should be promptly sought if the baby became unwell. About one half of the mothers could name three of the four 'official' risk-reducing recommendations. In only seven mothers could there be recalled any information being given by health workers (hospital and community midwives, health visitor, general practitioner, etc.). For the best possible benefit to be derived from current risk-reducing campaigns we need to improve our understanding of how parents obtain relevant information and what role health professionals should have in this.

Sudden infant death syndrome: links with infant care practices

OBJECTIVES

To investigate infant care practices in a small ethnic minority population within Britain that might suggest possible factors contributing to the low incidence of the sudden infant death syndrome in Asian populations.

DESIGN

Ethnographic interviewing, a qualitative comparative method drawn from social anthropology.

SETTING

Central Cardiff.

SUBJECTS

Non-random sample of 60 mothers of Bangladeshi or Welsh ethnic origin and working or middle class occupational status, who had infants under one year old. None of the families interviewed had experienced a sudden infant death.

RESULTS

Broad cultural contrasts emerged as a series of themes from the interview data: living patterns, family networks, sleeping patterns, and concepts of time and dependence.

CONCLUSION

Bangladeshi infants were cared for in a consistently rich sensory environment; Welsh infants, in contrast, were more likely to experience alternating periods of high and low sensory input. Long periods of lone quiet sleep may be one factor that contributes to a higher rate of sudden deaths in white than in Asian infants.

Are medical students missing out?

Increasing discontent, even boredom, shown by many clinical medical students is in marked contrast to the enthusiasm of school children interviewed for a place at medical school. The roots of the problem are sown in the pre-clinical years with too much teaching that is of little relevance to clinical practice and insufficient contact with clinical problems that are needed to keep the youthful flame of idealism alive. In clinical years disillusion continues with less time available for teaching by NHS colleagues because of clinical directorates and other administrative chores and a far from ideal balance between teaching and research activities amongst academic staff. To help enthusiasm return we recommend greater clinical involvement in the pre-clinical years, teaching to be better valued and teaching and examination methods reassessed. More self-directed learning, though desirable, will be difficult unless adequate resources are made available. At a time of increased pressure on all sides if we cannot meet the challenge of modern undergraduate clinical education disillusion amongst our students will continue with serious implications for the whole continuum of medical education.

Case study. Erythropoietin for anaemia in a preterm Jehovah's Witness baby

An infant born at 24 weeks gestation to Jehovah's Witness parents was made a Ward of Court and treated against their wishes with blood products. Erythropoietin was used without obvious benefit, but the child did well. The parents did not reject the child and maintained a good relationship with medical and nursing staff. We present this case in the light of current discussions on child welfare and recent reform of the law relating to child protection and highlight the many difficult dilemmas faced by the medical team.