probably accelerated the fatal course in one of them. ' The same cause might explain the outcome in other cases of fatal side effects of valproate.' The families ofsuch children need to be investigated because (a) a common cause offatal valproate toxicity might be found, (b) a procedure to detect people at risk might be advised-for example, measuring plasma ammonia concentrations for initial monitoring oftreatment-and (c) confidence about using the drug for children and adults without a metabolic abnormality might be restored.
We compared the penetration of five aminoglycosides into interstitial fluid (IF). IF was obtained in rabbits from Silastic tissue cages. Intramuscular injections were made: 1.5 mg/kg per dose for gentamicin (G), tobramycin (T), sisomicin (S), and netilmicin (N) and 7.5 mg/kg per dose for amikacin (A). Serum levels and IF concentrations were studied for 12 h after a single injection. IF levels were also compared in a six-injection study (one injection every 8 h). Peak serum levels were significantly higher with A than with G, T, S, and N, which gave similar concentrations. In IF, G gave the highest levels 1 h after the first injection. At 4 and 8 h, the concentrations achieved with G and A were similar but significantly greater than those achieved with T, S, and N. Twelve hours after a single injection, N gave higher IF levels than the other drugs except A. In the six-injection study, the IF levels of G and A reached 4.6 +/- 1.5 and 5.27 +/- 1.1 microgram/ml, respectively, at 48 h. S and N gave identical concentrations (2.07 +/- 0.25 and 2.42 +/- 0.42 microgram/ml, respectively). T induced the lowest levels (1.17 +/- 0.30 microgram/ml). Thus, in this rabbit model, the IF concentrations achieved with G and A were above the minimal inhibitory concentrations for most susceptible strains. Possible relations between IF aminoglycoside concentrations and therapeutic efficiency or toxicity are pointed out but deserve further studies.
The impact of a multi-dimensional geriatric assessment (MDGA) programme on the reorientation of the elderly person at discharge is described. One hundred and six elderly persons from a hospital catchment area identified for its poor level of social services, poor living conditions and high prevalence of dependency were allocated to either an experimental or control group. The experimental group was given the multi-dimensional assessment in the first three days of admission while the control group was subject to the usual hospital procedures. The study shows that the provision to the medical staff of easily obtained information relating to the individual's level of dependency and living conditions, in conjunction with recommendations for possible post-discharge placement, significantly reduced prolongation of stay due to non-medical reasons, albeit without a measurable impact on the whole duration of hospital stay.
To date, the rules and state of development of the processes of continuing education and the evaluation of skills and competence vary considerably from one European Member State to another. The recognition of the freedom of establishment of health professionals throughout Europe must be made conditional upon the possession of a given qualification, and also the demonstration of maintained level of expertise, knowledge and skills. This appears to be of primary importance in order to maintain a good quality of care and to improve the performances and responsibilities of the infection of specialists, within the healthcare system. The role of scientific societies such as the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) can be envisaged as follows: (1) to play a key role in the coordination of the processes; definition of the main topics and visions, accreditation of the teaching courses and modalites of evaluation (which supposes a high level of cooperation with the platform for professional qualification) (2) to manage training courses (e.g., ESCMID School, postgraduate courses, technical workshops, educational activities within congresses). In order to make the system clearer and easier to apply, a proposal for a single, comprehensive directive is highly necessary.
The European Union of Medical Specialists (UEMS) core curricula for training in infectious diseases and medical microbiology are adequate with the exception of one deficiency which is the absence of training in epidemiology, public health and infection control. Infectious disease curricula should include training in HIV, tuberculosis, hepatitis and sexually transmitted diseases. There is a need for a core curriculum in infection control. Infection control should have a basis in both medical microbiology and infectious diseases, and should become a specialty dealing with healthcare hygiene in hospitals, in outpatient clinics and also in institutions for the elderly. In the UK, a specialty training in infection is offered and includes internal medicine, clinical infectious diseases and medical microbiology for a total of 9 years. The UEMS should be contacted about the creation of a single specialty of infection, allowing for various degrees of sub-specialisation in infectious diseases or medical microbiology. It is unlikely that a European board examination validating the training of specialists will become a reality soon. Meanwhile, national systems should be created, documenting the content of the training and evaluating the quality of the training institutions. A medical specialist has a constant need for further education. This is generally a national matter, with requirements varying throughout Europe. It should be possible to accumulate continuing medical education/continuing professional development merits on a European level as well as on a national one. With the expansion of the European Union, it is important that the quality and content of specialist training can be verified and training curricula be harmonised. The UEMS should assist in this, in collaboration with scientific societies such as the ESCMID.
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