Formal Advice Research Articles

Telemedicine in Pediatric Cardiac Critical Care

To describe our international telemedicine experience in pediatric cardiac critical care. This is a case series of pediatric patients teleassisted from the Cardiac Intensive Care Unit (CICU) at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, to the CICU at Hospital Valle del Lili, Cali, Valle, Colombia, between March and December 2010. An attending intensivist from the CICU in Pittsburgh reviewed cases, monitored real-time vital signs, and gave formal medical advice as requested by the attending physician in Cali. The network connection is a Cisco (San Jose, CA)-based Secure Sockets Layer virtual private network via the Internet that allows access to the web-based interface of the Dräger(®) (Lübeck, Germany) physiological monitor system. The videoconferencing equipment consists of a standard component on a custom-made mobile cart that uses an APC(®) (West Kingston, RI) uninterruptible power supply for portable power and 3Com(®) (Hewlett-Packard, Palo Alto, CA) for wireless connectivity. A post-intervention survey regarding satisfaction with the telemedicine service was conducted. Seventy-one recommendations were given regarding 53 patients. Median age and weight were 10 months and 7.1 kg, respectively. Ventricular septal defect, transposition of the great vessels, and single ventricle accounted for most cases. The most frequent recommendations were related to surgical conduct, management of arrhythmias, and performance of cardiac catheterization studies. No technical difficulties were experienced during the monitoring of the patients. Satisfaction rates were equally high for technical and medical aspects of telemedicine service. Telemedicine is a feasible option for pediatric intensivists seeking experienced assistance in the management of complex cardiac patients. Real-time remote assistance may improve the medical care of pediatric cardiac patients treated in developing countries.

Planned Pregnancy in a Chronic Myeloid Leukemia Patient in Molecular Remission

Excellent response rates and a good quality of life have been observed since the introduction of tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML) treatment. Consequently, some challenges began to appear in CML women in child-bearing age wishing to become pregnant. Currently, many women around the world are in stable major/complete molecular response MMR/CMR (MMR: <0.1% BCR-ABL/ABL and CMR: undetectable BCR-ABL mRNA by RQ-PCR transcript levels on the international scale). The condition of stable MMR/CMR is linked to a long-term virtual absence of progression to the accelerated and blastic phase and to the possibility of stopping the TKI treatment with the maintenance of a condition of CMR in a proportion of cases. Imatinib teratogenic and prescribing information prohibits the use of it during pregnancy. We describe the case of a 36-year-old female patient with CML in chronic phase who stopped imatinib after 2 years in major molecular response (MMR) to plan a pregnancy. Molecular monitoring by RQ-PCR was performed quarterly. She achieved a safe pregnancy and delivery maintaining an optimal molecular response throughout the pregnancy. Isolated literature reports have been described, but no formal advice has been described at present time.

An information revolution: time for the NHS to step up to the challenge

An information revolution: time for the NHS to step up to the challenge

The Prevalence of Vitamin Supplementation in Ultraendurance Triathletes

Ultraendurance exercise training places large energy demands on athletes and causes a high turnover of vitamins through sweat losses, metabolism, and the musculoskeletal repair process. Ultraendurance athletes may not consume sufficient quantities or quality of food in their diet to meet these needs. Consequently, they may use oral vitamin and mineral supplements to maintain their health and performance. We assessed the vitamin and mineral intake of ultraendurance athletes in their regular diet, in addition to oral vitamin and mineral supplements. Thirty-seven ultraendurance triathletes (24 men and 13 women) completed a 7-day nutrition diary including a questionnaire to determine nutrition adequacy and supplement intake. Compared with dietary reference intakes for the general population, both male and female triathletes met or exceeded all except for vitamin D. In addition, female athletes consumed slightly less than the recommended daily intake for folate and potassium; however, the difference was trivial. Over 60% of the athletes reported using vitamin supplements, of which vitamin C (97.5%), vitamin E (78.3%), and multivitamins (52.2%) were the most commonly used supplements. Almost half (47.8%) the athletes who used supplements did so to prevent or reduce cold symptoms. Only 1 athlete used supplements on formal medical advice. Vitamin C and E supplementation was common in ultraendurance triathletes, despite no evidence of dietary deficiency in these 2 vitamins.

International students in the higher education classroom: initial findings from staff at two post‐92 universities in the UK

A significant body of work has emerged over the last 10 years investigating the experiences of international university students. These studies have covered various challenges faced by some groups of international students relating to culture, language and integration and have been prompted by the increase in international students studying in the UK, Australia and New Zealand. A smaller strand of research has also begun to focus on the experiences, perspectives and reactions of academic staff who have seen the composition of their cohorts change substantially over recent years in terms of numbers of international participants. This article reviews relevant literature in this field, reporting on a questionnaire study based at two UK post‐92 universities. Respondents associated a range of traits with international students and suggested that the increasing number of international students enhanced the environment, but also required a higher level of support. This study also found that staff resorted to informal methods when developing means of adapting their practices to the increasing number of international students, preferring discussion with colleagues and students themselves to formal development programmes or advice from specialist departments such as student support. The article concludes that in order to encourage diversity in a meaningful way, universities need to recognise the challenge of increased numbers of international students and support staff accordingly.

PTH-015 Specialist gastroenterology involvement inStreptococcus bovispositive cultures

Introduction There is well documented evidence linking Streptococcus bovis (S bovis) bacteraemia to colonic neoplasms and polyps. As patients with S bovis bacteraemia can be found across various specialities, our aim was to audit the consistency of appropriate specialist referral for assessment of colonic pathology. Methods All cases of S bovis bacteraemia occurring between October 2000 and June 2009 were identified using information provided by the department of microbiology. Medical records were reviewed for clinical details, evidence of features of endocarditis and referral to gastroenterologists. The standard of best practice was all cases should be referred for appropriate specialist review. Results There were 20 cases of S bovis bacteraemia from the total of 3454 positive cultures (0.6%). There were 11 male and 9 female and all were Caucasian with a mean age of 80.7 years. Four (20%) had endocarditis and four had abnormal liver enzymes. Seventeen patients had a microbiology report in the notes and 13 had Microbiologist advice to consider cardiac and/or colonic pathology. The gastroenterology team9s opinion was sought for 10 (50%) patients and 10 patients underwent one or more investigations including gastroscopy, colonoscopy, flexible sigmoidoscopy and CT of the abdomen. 60% of these investigations were performed on gastroenterology team9s advice and the rest were done on the admitting team9s initiative. In seven patients (35%) their prognosis at the time the bacteraemia was judged to be so poor as to preclude further investigation. Of the 10 patients who were investigated, six (60%) had positive findings. Two patients had colorectal adenocarcinoma (one rectum and one sigmoid); one had a stricture diagnosed on CT abdomen; and three had significant polyps (one or more tubulovillous adenomas with low grade dysplasia >1 cm). 60% of the patients in the study (12) were already deceased at the time of the audit and one patient had had a repeat colonoscopy after 1 year and had further polyps removed. Conclusion A lack of uniformity was observed in proper referral for gastroenterologist assessment and investigation. The age and multiple comorbidities of these patients made further investigations clinically inappropriate in 35% in this study. In the absence of proper guidelines regarding investigation of patients with S bovis bacteraemia for bowel pathology, we recommend seeking formal gastroenterology advice in all such patients. At the Royal Bournemouth Hospital, the department of microbiology has decided to inform the gastroenterology team of all S bovis positive cultures. Following these measures, this audit will be repeated.

A postal survey of doctors' attitudes to becoming mentally ill

A postal survey of 3512 doctors in Birmingham was carried out to assess attitudes to becoming mentally ill. The response rate for the questionnaire was 70% (2462 questionnaires). In total, 1807 (73.4%) doctors would choose to disclose a mental illness to family and friends rather than to a professional. Career implications were cited by 800 (32.5%) respondents as the most frequent reason for failure to disclose. For outpatient treatment, 51.1% would seek formal professional advice. For inpatient treatment, 41.0% would choose a local private facility, with only 21.1% choosing a local NHS facility. Of respondents 12.4% indicated that they had experienced a mental illness. Stigma to mental health is prevalent among doctors. At present there are no clear guidelines for doctors to follow for mental healthcare. Confidential referral pathways to specialist psychiatric care for doctors and continuous education on the vulnerability of doctors to mental illness early on in medical training is crucial.

A matter of life and death

Following Debbie Purdy's landmark court victory last month, prosecutors are now to clarify the law—the Law Lords have backed Ms Purdy's call for formal advice on the legal position of those who help a loved one to die. (Debbie Purdy suffers from MS and has been campaigning for the legal protection of her husband should he assist in her right to die—see BJHCM 14(10).)

Help-Seeking Behavior of Women with Self-Reported Distressing Sexual Problems

The objective was to describe the healthcare and information-seeking behavior of women with self-reported sexual problems and accompanying sexually related personal distress identified from a large, population-based U.S. survey. Women (n = 3,239) aged > or =18 years with self-reported sexual problems of desire, arousal, and/or orgasm accompanied by sexually related personal distress were identified from a cross-sectional mailed survey of 50,002 U.S. households sampled from a national research panel. Healthcare and information-seeking behavior was examined as four ordered categories: sought formal medical advice, sought informal advice, sought information from anonymous sources, and did not seek help or information. Correlates of help seeking for each type of distressing sexual problem were modeled with multivariable proportional odds regression. Just over a third of women with any distressing sexual problems had sought formal care, most often from a gynecologist or primary care physician; about 80% of the time, the woman, rather than the physician, initiated the conversation. Only 6% of women who sought medical advice scheduled a visit specifically for a sexual problem. Factors related to help seeking were having a current partner and interacting with the healthcare system. Barriers were poor self-perceived health and embarrassment about discussing sexual topics with a physician. Our results suggest inadequacies in the U.S. medical care system in addressing sexual problems in women. Gynecologists and primary care physicians, by including discussions about sexual health during routine visits, can increase the likelihood that adequate care can be offered.

Change in trend of contraceptive uptake — effect of educational leaflets and counseling

Background The study was conducted to determine the impact of counseling and educational leaflets on contraceptive practices of couples. Study Design Randomization of 600 women was done in two groups matched for age, parity and socioeconomic status at the Department of Obstetrics and Gynaecology, Shifa Foundation Community Health Centre, Shifa International Hospital, Islamabad, Pakistan. In Group A, the intervention group was exposed to contraceptive counseling and educational leaflets in the postnatal ward after delivery, whereas in Group B, the nonintervention group was not given any formal contraceptive advice. Later on, both groups were assessed regarding their contraceptive practices. Results At their follow-up visit (8–12 weeks) postpartum, 19 (6.3%) women in the nonintervention group had started contraceptive use, whereas 153 (50.8%) had decided to start contraception in the next 6 months, and 129 (42.8%) women were still undecided. The main contraceptive user was the male partner ( n=117, 38.8%), and the most common method used was coitus interruptus ( n=62, 36.3%). In the intervention group, 170 women (56.9%) had started using contraceptives, whereas 129 (43.1%) had decided to start contraceptive use in the next 6 months. The predominant contraceptive user was the females ( n=212–70.9%), and the most popular method chosen was oral contraceptive pills ( n=111, 37.1%). Conclusion There is a definite increase in contraceptive uptake in women provided with educational leaflets and counseling session with a shift toward use of more reliable contraceptive methods.

Salmond, Necessity, and the State

This article explores the varying approaches of Sir John Salmond as government adviser, judicial office, and legal theorist, to the State and the circumstances under which it might act under "necessity" in disregard of law. An epilogue provides the writer's own attempt in formal advice to delineate the boundaries of the doctrine in modern jurisprudence.

Reforming the Coroner

This article traces the evolution of coroners’ manuals as published in nineteenth-century Canada West and Ontario. Rather than study the individual men who investigated suspicious deaths and then held inquests, it examines the coroner as an imagined and ideal type. The first three editions of A Practical Treatise on the office and duties of Coroners, embody not just formal rules and practical advice on doing the job, but the hopes and aspirations of their acknowledged author, William Fuller Alves Boys, and his ghostwriter the respected jurist James Robert Gowan. The article examines trends and changes in the three editions of the manual as both Boys’ career and the government in Ontario develop. Boys’ story, reflected in the evolving manuals, is that of an emerging class of experts and professionals involved in the administration of government and justice in Ontario.

Providing medical advice to support children with special educational needs

The academic and social lives of children in school can be significantly affected by their Health needs. This article discusses the ways in which paediatricians can work with education services to support children and young people with Special Educational needs. Paediatricians may be involved in directly advising schools, writing formal advice for education departments and joining in relevant planned reviews. Partnership with parents and the involvement of children and young people themselves is vital. Advice should cover all areas of the child’s health relevant to the child’s success and integration in school and should always be understandable to both the education staff and the family.

Changing Fortunes: Results from a Randomized Trial of the Offer of Debt Advice in England and Wales

A randomized trial was conducted to assess whether the offer of advice to those experiencing debt problems and who had yet to obtain any formal advice, had a positive impact on their financial and general circumstances. The participants were drawn from 16 Jobcentres (welfare offices) in 13 areas of England and Wales. In all, 402 participants were included in the trial at its outset; 234 participants remained in the trial at the 20‐week followup. There was no significant difference in the rate at which intervention and control group respondents had resolved their debt problems at the 20‐week followup. However, the former were significantly more likely to describe their financial position as “better” than at baseline. There was also evidence that they became more knowledgeable about their financial circumstances, more focused on dealing with priority debt, and more optimistic about their future prospects, relative to control group counterparts. These findings, though, fell short of statistical significance. The findings provide the first experimental evidence of a positive impact of the offer of debt advice. The study also highlights the difficulties of applying experimental methods in a social setting. One lesson drawn from the difficulties encountered in running this trial is that takeup is likely to be low for some forms of pro‐active advice for sensitive problem types experienced among disadvantaged communities.

Optimal Decision Processes: On the Choice Between Environmental Valuation Methods

Decision-makers have a wide variety of competing and complementary methods for non-market valuation, but there is little formal advice on the choice of method. I offer a formal approach, using a loss function (the mean square error) to compare contingent valuation, Citizens' Jury and methods where by intention only a portion of total value is estimated, when a) preferences vary across the population and b) methods are more or less susceptible to framing effects. Illustrative simulations suggest conditions under which the Citizens' Jury may dominate contingent valuation when framing effects are significant.

Changing Fortunes: Results from a Randomized Trial of the Offer of Debt Advice in England and Wales

Study Objective: Design: A randomized trial of the offer of debt advice to persons experiencing debt problems who had yet to obtain any formal advice. Setting: 16 Jobcentres in 13 areas of England and Wales. Participants: 402 participants were included in the trial at its outset. 234 participants remained in the trial at 20-week follow-up. Main results: We found no significant difference in the rate at which intervention and control group respondents resolved their debt problems after 20 weeks. However, we found that the former were significantly more likely to describe their financial position as 'better' than at baseline. There were also indications that they may have been better focused on dealing with priority debt and more optimistic about their future prospects, relative to control group counterparts. These findings, though, fell short of statistical significance. Conclusions: Our results provide some evidence of a positive impact of the offer of debt advice; one that manifests in people better targeting their debt-reduction efforts, feeling more in control of their situation and gaining a better outlook. Our study also highlights the difficulties of applying experimental methods in a social setting. One lesson drawn from the difficulties encountered in running this trial is that take-up is likely to be low for some forms of pro-active advice for sensitive problem types and disadvantaged communities.

Understanding of blood pressure and behavioural risk factors amongst British adolescents

To survey students aged 16-18 years in secondary education establishments in one school district in the south of England in order to: assess knowledge about the importance of blood pressure (BP) for health; investigate associations between knowledge and health-related behaviours; and explore home, school and health service influences on knowledge. Observational. Self-reported data from a structured questionnaire administered to convenience samples of students in schools were analysed by Chi-squared tests and multiple linear regression. The questionnaire assessed knowledge about BP risks, symptoms, consequences and measurement, and collected information on BP-related instruction, health behaviours (smoking, exercise, alcohol and nutrition) and family background. A cross-section of 569 students completed questionnaires, representing 19.6% of the total age cohort. Most students recognized the major behavioural risks and consequences of high BP, but 104 (18.3%) could not describe how BP is measured, and 401 (88.1%) had no idea what a normal BP reading should be. In multivariate analysis, BP knowledge was associated with previous academic attainment, having received advice or instruction about BP, and having BP measured in the last 2 years. Family experience was not significant. Many students reported unhealthy behaviours: current smoker (n = 87, 15.3%); less than three exercise sessions per week (n = 172, 30.2%); and two portions or less of fruit/vegetables per day (n = 223, 39.2%). BP knowledge was significantly associated with regular exercise but not with other health-promoting behaviours. One hundred and twenty-one (21.3%) students acknowledged having received instruction about BP, mainly from doctors/nurses (32%) and schools (28%). Gaps in adolescents' knowledge about BP were identified. Greater awareness was associated with having received formal advice and instruction, so health services and schools could play an important part in improving BP knowledge among adolescents. More understanding of cumulative risks may encourage fuller engagement in health-promoting activities.

Environmental Knights of the Roundtable: Stirring the Pot in Environmental Health

The Roundtable on Environmental Health Sciences, Research, and Medicine can be thought of as a think tank—a neutral, nonofficial setting where scientists, government officials, academics, industry representatives, and members of advocacy groups can gather to consider and discuss new scientific findings and emerging issues in environmental health. The roundtable, based at the Institute of Medicine (IOM) in Washington, D.C., is purposefully deliberative in nature. Its 34 members do not recommend specific actions or provide formal advice. Despite that policy, the group has become highly influential in helping to shape the research agenda for fields in its purview. It has also helped what some observers felt was a disparate, fractured discipline to define itself more clearly and more broadly. By articulating a more holistic approach to environmental health, incorporating the natural, social, and built environments, the roundtable seeks to expand the dialogue, encouraging collaborations and partnerships among stakeholders. By identifying potential approaches to deal with new challenges, the group seeks to enhance the effectiveness of environmental health research and medicine in improving and protecting public health. “We try to find approaches toward making a contribution that would be unique to a body like the roundtable,” says NIEHS deputy director and roundtable member Samuel Wilson. Roundtable workshops are designed to educate participants so that they can make informed decisions in their own arenas, whether they come from federal or state agencies, industry, or academia. The regional meetings are intended not only to provide information about regional environmental issues and concerns, but also to serve as outreach mechanisms, allowing local stakeholders to learn about new approaches while interacting with each other in the neutral roundtable setting. Roundtable co-chair Lynn Goldman, a professor of environmental health sciences at the Johns Hopkins Bloomberg School of Public Health, finds the group’s many forms of interaction to be exciting and valuable. “Suddenly there’s an ‘a-ha’ in the room, where connections and collaborations are forming that weren’t there, and it’s out of that kind of stirring the pot that something like the roundtable can produce enormous benefits,” she says.

Vaccine INDs: review of clinical holds

A sponsor developing a vaccine or related product for clinical study in the U.S. must submit an Investigational New Drug Application (IND) to the Food and Drug Administration (FDA). Evaluation of information submitted to the IND may prompt a clinical hold, for reasons described in 21 CFR 312.42. Our review of clinical hold letters issued to sponsors during a 2-year period identified the most often cited reason for a clinical hold, insufficient information (21 CFR 312.42 (b) (1) (iv)), and indicated that the majority of INDs were specifically deficient in clinical information. In addition, sponsors who sought formal pre-IND advice decreased the likelihood of their resulting IND being placed on clinical hold.

Succeeding as a Hospital Doctor

How to succeed as a hospital doctor, in a book, and in only 200 pages? Surely this is not possible. Roger Kirby and Tony Mundy took on a tall order in accommodating the intricacies of success but they have contrived to produce an informative, up-to-date and pertinent guide to survival in the ever-changing National Health Service. In their first edition, the aim was to cover the financial and medicolegal issues encountered by surgeons. Since both are surgeons, there is still a distinct bias towards surgery, but the new edition includes a vast array of topics ranging from ‘making your mark in the NHS’, through ‘research’ to ‘management issues’. Although the book is aimed at ‘clinicians at all stages of their careers’, I think that specialist registrars stand to benefit the most. It is they who are in greatest need of information on the pitfalls that await them on the way to their goals. In the first paragraph of the introduction, Kirby and Mundy define a successful doctor as ‘one who has gained a good reputation and credibility from the approval and respect of patients and colleagues alike’. But in the remainder of the text they seem to overlook this and redefine success in financial, legal and political terms. We all have our own definition: if you do not agree with theirs, this book is not for you. The first chapter, ‘Training for success’, offers sound practical advice that many of us take for granted, but few follow. They instruct us how to make the most out of our training and write a CV, and guide us through the rigmaroles of specialist training. Unfortunately they do not tell us how to succeed at interview, which many potential readers will wish to know. A chapter entitled ‘Research’ may be helpful to research-virgins but offers little to those established in their career and aiming at success; this section could have been a lot more informative. The subsequent chapters, ‘Making your name in private practice’, ‘Effective communication’ and ‘Crisis management’, are straightforward, clear and appropriate. Also, the authors offer enlightening disquisitions on clinical governance and management issues—important topics in the present climate. They describe the historical development of and justification for clinical governance and advise us to ‘play our part’. Specialist contributors are brought in to deal with certain matters, and this works well for ‘Finance’: we are offered clear advice on mortgages, record keeping, taxation, pensions and retirement. (But what about investments? Surely this is a relevant topic if we are to be financially successful.) Another of these special sections is on ‘Hiring and firing’, with an account of the legal ramifications of employing staff. This contains not only formal advice but also wisdom. There is a lot in this book that is good. A standard form is maintained throughout with helpful comments highlighted in the margins, numerous tables with bullet headings, all chapters referenced and even a final section written by ‘voices of experience’—an encyclopaedia of eminent doctors. A list of useful addresses is provided, ranging from research trusts to political establishments and the Royal Colleges. My only criticism here is that there is no index. In outlining their thoughts on success and how to achieve it, Kirby and Mundy have produced a meritorious publication. Some might argue that the title should have been ‘surviving’ rather than ‘succeeding’. As I read it, a line from Twelfth Night came to mind: ‘some men are born great, some achieve greatness, and some have greatness thrust upon them’. Overall, I think this book is for those who wish ‘success’ to be thrust upon them.