I would like to thank the authors for making this important point and highlighting the error in Illuminations (ADC E&P, 102(5), pp. 265-266.); ‘A source of tension’. A check for appropriate placement of support lines and tubes is just as important as identifying pathology when reviewing imaging. In small infants variations in head position may significantly alter the endotracheal tube (ETT) tip position and the difference between one vertebral body level and the next may be as little as 5-10mm. Therefore careful examination of the chest radiograph followed by any necessary alteration of the ETT will reduce the likelihood of complications secondary to misplacement.
It is also important to carefully check your manuscript when submitting material for publication. My intention was to point out the suboptimal positions of both the ETT and nasogastric (NG) tubes, in addition to the large tension pneumothorax. The ETT tip is too low in the distal trachea, and the NG tube tip is in the lower oesophagus and should be advanced into the stomach. Unfortunately, somewhere in the process of author checking and internal review this was omitted in error. Thanks once again for pointing this out.
I read with interest the review by Green and Lillie[1] of the NICE guideline (N29) on intravenous fluid therapy in children[2]. The new guideline correctly questions the routine use of the Holliday-Segar formula for calculation of maintenance fluids[3], but the recommendation of 0.9% saline as the maintenance fluid must still be questioned.
The review opens with two contradictory statements in the first two paragraphs:
“The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal.”
and, in reference to the NICE guideline:
“…its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.”
I agree wholeheartedly with the first statement but it does not fit with the second proposal of a “standardised” approach. The problem hinges around the idea of “replacement” and “maintenance” fluids and this was reviewed in an excellent paper by Malcolm Coulthard in 2007 when he questioned the switch from 0.18% saline to 0.45% saline as the recommended maintenance fluid[4]. The arguments he used are now doubly relevant when you move to 0.9% saline.
Patients who need fluid “replacement” need an iv fluid matching extracellular fluid composition and 0.9% saline fits the bill. Patients who need iv “maintenance” fluid need some...
I read with interest the review by Green and Lillie[1] of the NICE guideline (N29) on intravenous fluid therapy in children[2]. The new guideline correctly questions the routine use of the Holliday-Segar formula for calculation of maintenance fluids[3], but the recommendation of 0.9% saline as the maintenance fluid must still be questioned.
The review opens with two contradictory statements in the first two paragraphs:
“The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal.”
and, in reference to the NICE guideline:
“…its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.”
I agree wholeheartedly with the first statement but it does not fit with the second proposal of a “standardised” approach. The problem hinges around the idea of “replacement” and “maintenance” fluids and this was reviewed in an excellent paper by Malcolm Coulthard in 2007 when he questioned the switch from 0.18% saline to 0.45% saline as the recommended maintenance fluid[4]. The arguments he used are now doubly relevant when you move to 0.9% saline.
Patients who need fluid “replacement” need an iv fluid matching extracellular fluid composition and 0.9% saline fits the bill. Patients who need iv “maintenance” fluid need something that matches what they would normally be drinking. If we take a 10kg child for simplicity, assume a sodium requirement of 2.5 mmol/kg and a water requirement of 100 ml/kg this equates to 1000 ml of a solution containing 25 mmol of sodium. The nearest iv solution matching this recipe is 0.18% saline containing 31 mmol of sodium in the litre administered (still a bit too much!). If you use the same volume of 0.9% saline you will be giving 154 mmol of sodium i.e. 15.4 mmol/kg which should be considered excessive.
The key to fluid management is being able to tailor the fluids to the individual as advocated in the first paragraph of the review. It has correctly been recognised that children do not usually need the volume of maintenance fluid previously advocated and it was this excess volume of water that led to problems of hyponatraemia not the lack of sodium.
The syndrome of inappropriate antidiuretic hormone (SIADH) is rare and is not the reason for the development of hyponatraemia in most cases. As a medical student I was taught by Professor George Haycock at the same hospital as the authors of this review and he was an authority on this subject. He would tell us that rather than SIADH these patients would usually have “appropriate” ADH secretion. These patients would have an unrecognised fluid deficit and needed “replacement” fluid that should be isotonic and the administration of a hypotonic solutions would lead to a dilutional hyponatraemia. Once the patient is fluid replete the solution should be changed to a hypotonic one administered at an appropriate rate. A volume of 50-80% of the previous calculated routine maintenance would be reasonable. In our patients we do not use 0.9% saline as a "maintenance " fluid, instead giving 0.45% saline plus dextrose, which is still probably too much sodium. The key is regular review of the patient with daily checking of serum electrolytes. Urine electrolytes can also be useful and I am confident that very few patients will be found to be producing urine containing 150 mmol/l of sodium unless that is what they are being given as "maintenance" fluid.
I feel that the guideline has been developed in response to the practice of poor medicine and the failure to recognise the needs of individual patients. I believe that with these guidelines poor medicine is at risk of continuing.
References
1. Green J, Lillie J. Intravenous fluid therapy in children and young people in hospital N29. Arch Dis Child Educ Pract Ed 2017; 102: 327–331.
2. Intravenous fluid therapy in children and young people in hospital NICE guideline N29. nice. org. uk/ guidance/ ng29
3. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957; 19: 823–32.
4. Coulthard MG. Will changing maintenance intravenous fluid from 0.18% to 0.45% saline do more harm than good? Arch Dis Child 2008; 93: 335–340
Preschool recurrent wheeze affects many children in the UK and causes great strain in their families (1). The pharmacological management during the acute episodes of wheeze offers significant relief. However, the evidence around the maintenance therapy is not conclusive.
The majority of these children grow out of the condition. The current pharmacological treatment though has not been shown to change the natural course of the disease (2, 3). Therefore, it could be argued that addressing the actual concerns of their parents/carers should be the focus that makes a significant difference to their everyday lives.
Defining personalised outcomes for preschool children with recurrent wheeze requires an understanding of what really matters for these families. A major step towards an efficient treatment would then involve reaching these outcomes and a measurement tool could monitor this.
Asthma Action Plans for children with a diagnosis of asthma have been shown to reduce the rates of hospital admissions, emergency department visits and school absence rates (4). In Australia, the introduction of a personalised wheeze action plan shows the potential to reduce the treatment with corticosteroids and to improve the education of these families around acute management but this is not clear as to whether this is related to a decrease in emergency department admissions (5).
Although education and management plans are an important part of the non-pharmacological mana...
Preschool recurrent wheeze affects many children in the UK and causes great strain in their families (1). The pharmacological management during the acute episodes of wheeze offers significant relief. However, the evidence around the maintenance therapy is not conclusive.
The majority of these children grow out of the condition. The current pharmacological treatment though has not been shown to change the natural course of the disease (2, 3). Therefore, it could be argued that addressing the actual concerns of their parents/carers should be the focus that makes a significant difference to their everyday lives.
Defining personalised outcomes for preschool children with recurrent wheeze requires an understanding of what really matters for these families. A major step towards an efficient treatment would then involve reaching these outcomes and a measurement tool could monitor this.
Asthma Action Plans for children with a diagnosis of asthma have been shown to reduce the rates of hospital admissions, emergency department visits and school absence rates (4). In Australia, the introduction of a personalised wheeze action plan shows the potential to reduce the treatment with corticosteroids and to improve the education of these families around acute management but this is not clear as to whether this is related to a decrease in emergency department admissions (5).
Although education and management plans are an important part of the non-pharmacological management of these children, other aspects should also be considered. In the UK, navigation, or signposting, through healthcare services, especially for new parents, as well as the co-ordination between primary and secondary care for the management of these children, are emerging as important interventions in order to address what really matters for families. It is therefore recommended that healthcare professionals should start their consultation by asking these parents which are their main concerns and then try to address them by the end of the consultation. In the case that they realise that these parents need further navigation around the healthcare system, they should use or highlight to them the available sources of information. Appropriate interventions need to focus on coordinating primary secondary care and eliminate unnecessary confusion for these families.
Healthcare systems are becoming more and more complicated. As providers of healthcare, we should ensure that our everyday role in the bedside is filled with all those core essentials that mean the world to our patients. Recurrent wheeze can be troublesome and there is a lot to be done around the pharmacological management, but we do not need to have it all figured out to move forward. We need to listen to the patients’ needs and assure them that their dreams are stronger than their demons.
We read with interest the article by Jane Armer and Christian De Goede appearing in a recent issue of the Journal (1). We congratulate the Authors for their superb job in summarizing such a difficult field represented by the differential diagnosis of disorders of copper metabolism. However, we noticed that in their accurate recognition of the causes of reduced serum values of ceruloplasmin, the Authors missed to mention the Congenital Disorders of Glycosylation (CDGs), which are rare as single disorders but not as a group. CDGs in fact represent nowadays more than 100 distinct genetic multisystem disorders characterized by defective glycosylation of glycoconjugates.(2) We previously signaled that patients with some types of CDGs may have low ceruloplasmin values and abnormal copper metabolism. (3, 4) Presently we know that in at least 3 types of CDGs with prevalent hepatic presentation ± CNS minor signs (TMEM199-CDG, CCDC115-CDG; ATP6AP1-CDG) and 2 with prevalent neurological presentation ± minor signs of hepatic involvement (PMM2-CDG, COG2-CDG) there is a documented disturbance of copper metabolism (Table 1). The mechanisms underlying these abnormalities are unclear, and may probably depend on the biochemical nature of ceruloplasmin itself (a glycoprotein with 6 N-linked glycans) and/or involve at least partial loss of copper transporting proteins. (5) In conclusion, in addition to the group of rare conditions signaled by the Authors, we suggest that the diagnostic algor...
We read with interest the article by Jane Armer and Christian De Goede appearing in a recent issue of the Journal (1). We congratulate the Authors for their superb job in summarizing such a difficult field represented by the differential diagnosis of disorders of copper metabolism. However, we noticed that in their accurate recognition of the causes of reduced serum values of ceruloplasmin, the Authors missed to mention the Congenital Disorders of Glycosylation (CDGs), which are rare as single disorders but not as a group. CDGs in fact represent nowadays more than 100 distinct genetic multisystem disorders characterized by defective glycosylation of glycoconjugates.(2) We previously signaled that patients with some types of CDGs may have low ceruloplasmin values and abnormal copper metabolism. (3, 4) Presently we know that in at least 3 types of CDGs with prevalent hepatic presentation ± CNS minor signs (TMEM199-CDG, CCDC115-CDG; ATP6AP1-CDG) and 2 with prevalent neurological presentation ± minor signs of hepatic involvement (PMM2-CDG, COG2-CDG) there is a documented disturbance of copper metabolism (Table 1). The mechanisms underlying these abnormalities are unclear, and may probably depend on the biochemical nature of ceruloplasmin itself (a glycoprotein with 6 N-linked glycans) and/or involve at least partial loss of copper transporting proteins. (5) In conclusion, in addition to the group of rare conditions signaled by the Authors, we suggest that the diagnostic algorithm of a challenging case of Wilson Disease should include also CDGs. They represent increasingly diagnosed conditions that warrant consideration especially when assessing children with liver involvement and/or CNS signs, a scenario which is typical of both conditions.
REFERENCES: 1. Armer J, De Goede C. How to use tests for disorders of copper metabolism. Arch Dis Child Educ Pract Ed. 2017 [Epub ahead of print] 2. Jaeken J, Péanne R. What is new in CDG? J Inherit Metab Dis. 2017;40:569-6. 3. Mandato C, Brive L, Miura Y, Davis JA, Di Cosmo N, Lucariello S, Pagliardini S, Seo NS, Parenti G, Vecchione R, Freeze HH, Vajro P. Cryptogenic liver disease in four children: a novel congenital disorder of glycosylation. Pediatr Res. 2006;59:293-8. 4. Nicastro E, Ranucci G, Vajro P, Vegnente A, Iorio R. Re-evaluation of the diagnostic criteria for Wilson disease in children with mild liver disease. Hepatology. 2010;52:1948-56. 5. Liu Y, Pilankatta R, Hatori Y, Lewis D, Inesi G. Comparative features of copper ATPases ATP7A and ATP7B heterologously expressed in COS-1 cells. Biochemistry. 2010;49:10006-12.
TABLE 1. LOW CERULOPLASMIN CDGs, AND THEIR MAIN LABORATORY CHARACTERISTICS
• TMEM199-CDG (CDG-IIp) TRANSMEMBRANE PROTEIN 199: < Ceruloplasmin, > Transaminases; > LDL-C; > AP; < Antithrombin; > H-Cu; Normal U-Cu
We studied the review by Macdougall et al with interest.1 In our comment, we have chosen to view continuous professional development in the later, “broader” terms described by Macdougall et al, as learning and development always incur costs.1
In considering the culture of CPD, the influence of costs on professional development has been omitted. This is a rarely researched area but of growing importance in our opinion. A recent joint statement by the Association of Surgeons in Training and British Orthopaedic Trainees Association criticised an increase in training fees, stating that it was “extremely disappointed” at this action, directed solely at trainees.2 This is against the backdrop of evidence showing that cost of junior doctor training is astronomical, averaging £17, 114, most of which are footed privately by junior doctors.3, 4 Dentists have also identified costs as possible impediment to continuing development.5
The context in the National Health Service is the continuing challenging health economic situation and declining resources in which to provide cover for practitioners’ time to study. The situation described above is more likely to be acute amongst trainees, part-time healthcare staff and doctors in non-substantive positions. This may be the reason why this issue has not gained prominence in the CPD discussions. The high cost of professional development may influence choice of personal development plans and the resulting learning activities un...
We studied the review by Macdougall et al with interest.1 In our comment, we have chosen to view continuous professional development in the later, “broader” terms described by Macdougall et al, as learning and development always incur costs.1
In considering the culture of CPD, the influence of costs on professional development has been omitted. This is a rarely researched area but of growing importance in our opinion. A recent joint statement by the Association of Surgeons in Training and British Orthopaedic Trainees Association criticised an increase in training fees, stating that it was “extremely disappointed” at this action, directed solely at trainees.2 This is against the backdrop of evidence showing that cost of junior doctor training is astronomical, averaging £17, 114, most of which are footed privately by junior doctors.3, 4 Dentists have also identified costs as possible impediment to continuing development.5
The context in the National Health Service is the continuing challenging health economic situation and declining resources in which to provide cover for practitioners’ time to study. The situation described above is more likely to be acute amongst trainees, part-time healthcare staff and doctors in non-substantive positions. This may be the reason why this issue has not gained prominence in the CPD discussions. The high cost of professional development may influence choice of personal development plans and the resulting learning activities undertaken to meet those goals.
References:
1. Macdougall C, Epstein M, Highet L. Continuing professional development: putting the learner back at the centre. Archives of Disease in Childhood - Education and Practice Published Online First: 16 March 2017. doi: 10.1136/archdischild-2016-310864.
2. The Association of Surgeons in Training. ASiT & BOTA Response to JCST Increase in Training Fees. 2017. https://www.asit.org/news/asit-bota-response-to-jcst-rise-in-fees/nwc1075 (accessed 28 March 2017).
3. Jaques H. Junior doctors spend £17 114 on postgraduate training. BMJ Careers. 2011. http://careers.bmj.com/careers/advice/view-article.html?id=20004902 (accessed 28 March 2017).
4. Stroman L, Weil S, Butler K, McDonald C. The cost of a number: can you afford to become a surgeon? The Bulletin of the Royal College of Surgeons of England. 2015;97(3):107-11.
5. Belfield, C. R., Morris, Z. S., Bullock, A. D. and Frame, J. W. (2001), The benefits and costs of continuing professional development (CPD) for general dental practice: a discussion. European Journal of Dental Education 2001; 5: 47–52. doi:10.1034/j.1600-0579.2001.005002047.x
We thank Iniobong and Itoro Udo for their interest in our article and their comments. Issues of cost (in the broadest sense, financial, personal, service provision etc.) are of course important when we consider CPD. This is also more challenging in the current financial climate with likely pressure on study leave budgets. Other specific issues and costings they raise, however, concern a separate (although related) issue, the costs of postgraduate training to trainees. We specifically did not consider this group as they are excluded from the definitions of CPD we used. We have underlined the specific phrases from the GMC and the Academy of Medical Royal Colleges respectively;
“any learning outside of undergraduate education or postgraduate training that helps you maintain and improve your performance. It covers the development of your knowledge, skills, attitudes and behaviours across all areas of your professional practice. It includes both formal and informal learning activities.”[1]
“A continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour. CPD should also support specific changes in practice” [2]
[1] Guidance on Continuing Professional Development. 2012; Available from: www.gmc-uk.org/education/co...
We thank Iniobong and Itoro Udo for their interest in our article and their comments. Issues of cost (in the broadest sense, financial, personal, service provision etc.) are of course important when we consider CPD. This is also more challenging in the current financial climate with likely pressure on study leave budgets. Other specific issues and costings they raise, however, concern a separate (although related) issue, the costs of postgraduate training to trainees. We specifically did not consider this group as they are excluded from the definitions of CPD we used. We have underlined the specific phrases from the GMC and the Academy of Medical Royal Colleges respectively;
“any learning outside of undergraduate education or postgraduate training that helps you maintain and improve your performance. It covers the development of your knowledge, skills, attitudes and behaviours across all areas of your professional practice. It includes both formal and informal learning activities.”[1]
“A continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour. CPD should also support specific changes in practice” [2]
[1] Guidance on Continuing Professional Development. 2012; Available from: www.gmc-uk.org/education/continuing_professional_development.asp.
[2] AoMRC. Core Model for Royal Colleges’ and Faculties’ Continuing Professional Development Schemes. 2007 [cited 2016 April]; Available from: http://www.gmc-uk.org/Item_6e___Annex_D_AoMRC_CPD_Report.pdf_28991004.pdf.
Reply to: Psychological Interventions have a place in Management of Paediatric Headache
Michael J Morton, Honorary Clinical Senior Lecturer in Child & Adolescent Psychiatry, University of Glasgow
We are very grateful to Dr Morton for highlighting the importance of CBT and other psychological / talking therapies for children and young people with headaches, and for drawing our attention to the recent systematic review by Ng et al. Where resources exist and permit referral, this can be offered as an adjunct to acute / rescue treatment advice and as an alternative or adjunct to preventative drug therapies and acupuncture for migraine, and may be transformative for worrying tension-type headaches. Even for the trigeminal autonomic cephalalgias (including paroxysmal hemicranias) and idiopathic stabbing headache, CBT and psychological support for the child and young person and their family and carers can be really helpful. Where access to psychological interventions is difficult or inadequate, we should still request it and support the development of these crucial services. Thank you for this important contribution.
I am very impressed indeed with your sound advice for trainees.
Senior trainees should spend more time in clinic.
Access to Outpatient referral console for all tier 2 trainees.
Suggest that senior trainees should manage all general paediatric referrals as we already do it as part of CAU referral form.
Senior trainees should be able to suggest to GP’s any investigations that might make the first consultation a one stop shop.
Admin sessions should not be eaten into because of service provision responsibilities for trainees.
Telemedicine for more urgent referrals and to avoid falsification of referrals
Every GP trainee to conduct at least one new patient clinic to understand paediatric OP dynamics and procedure.
The management of headache should be imbued with a psychological understanding that is not sufficiently emphasised in the ADC review by Whitehouse & Agrawal. Like all pain disorders, headache has an important psychological component, which should be acknowledged as part of the assessment in order to open up a conversation that may lead to an effective non-pharmacological intervention. The recent review of treatments for paediatric migraine (Ng et al, 2017) confirms the power of one specific model of intervention in relation to one specific headache diagnosis. A creative use of mental health expertise in the Headache Clinic has the potential to change practice in relation to a range of presentations.
A Systematic Review and Meta-analysis of the Efficacy of Cognitive Behavioral Therapy for the Management of Pediatric Migraine
Qin Xiang Ng, MBBS; Nandini Venkatanarayanan, BMedSci, BMBS; Lakshmi Kumar, MBBS
Headache, 2017;57(3):349-362.
Dr Kraemer is correct in pointing out that the presence of a child
mental health team integrated into the paediatric team in the hospital is,
where resources allow, often the best way to manage children and young
people with medically unexplained symptoms, and indeed with a range of
other physical and psychological presentations. See also Cottrell, 2015,
http://adc.bmj.com/content/100/4/308
Dr Kraemer is correct in pointing out that the presence of a child
mental health team integrated into the paediatric team in the hospital is,
where resources allow, often the best way to manage children and young
people with medically unexplained symptoms, and indeed with a range of
other physical and psychological presentations. See also Cottrell, 2015,
http://adc.bmj.com/content/100/4/308
I would like to thank the authors for making this important point and highlighting the error in Illuminations (ADC E&P, 102(5), pp. 265-266.); ‘A source of tension’. A check for appropriate placement of support lines and tubes is just as important as identifying pathology when reviewing imaging. In small infants variations in head position may significantly alter the endotracheal tube (ETT) tip position and the difference between one vertebral body level and the next may be as little as 5-10mm. Therefore careful examination of the chest radiograph followed by any necessary alteration of the ETT will reduce the likelihood of complications secondary to misplacement.
It is also important to carefully check your manuscript when submitting material for publication. My intention was to point out the suboptimal positions of both the ETT and nasogastric (NG) tubes, in addition to the large tension pneumothorax. The ETT tip is too low in the distal trachea, and the NG tube tip is in the lower oesophagus and should be advanced into the stomach. Unfortunately, somewhere in the process of author checking and internal review this was omitted in error. Thanks once again for pointing this out.
I read with interest the review by Green and Lillie[1] of the NICE guideline (N29) on intravenous fluid therapy in children[2]. The new guideline correctly questions the routine use of the Holliday-Segar formula for calculation of maintenance fluids[3], but the recommendation of 0.9% saline as the maintenance fluid must still be questioned.
The review opens with two contradictory statements in the first two paragraphs:
“The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal.”
and, in reference to the NICE guideline:
“…its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.”
I agree wholeheartedly with the first statement but it does not fit with the second proposal of a “standardised” approach. The problem hinges around the idea of “replacement” and “maintenance” fluids and this was reviewed in an excellent paper by Malcolm Coulthard in 2007 when he questioned the switch from 0.18% saline to 0.45% saline as the recommended maintenance fluid[4]. The arguments he used are now doubly relevant when you move to 0.9% saline.
Patients who need fluid “replacement” need an iv fluid matching extracellular fluid composition and 0.9% saline fits the bill. Patients who need iv “maintenance” fluid need some...
Show MorePreschool recurrent wheeze affects many children in the UK and causes great strain in their families (1). The pharmacological management during the acute episodes of wheeze offers significant relief. However, the evidence around the maintenance therapy is not conclusive.
Show MoreThe majority of these children grow out of the condition. The current pharmacological treatment though has not been shown to change the natural course of the disease (2, 3). Therefore, it could be argued that addressing the actual concerns of their parents/carers should be the focus that makes a significant difference to their everyday lives.
Defining personalised outcomes for preschool children with recurrent wheeze requires an understanding of what really matters for these families. A major step towards an efficient treatment would then involve reaching these outcomes and a measurement tool could monitor this.
Asthma Action Plans for children with a diagnosis of asthma have been shown to reduce the rates of hospital admissions, emergency department visits and school absence rates (4). In Australia, the introduction of a personalised wheeze action plan shows the potential to reduce the treatment with corticosteroids and to improve the education of these families around acute management but this is not clear as to whether this is related to a decrease in emergency department admissions (5).
Although education and management plans are an important part of the non-pharmacological mana...
We read with interest the article by Jane Armer and Christian De Goede appearing in a recent issue of the Journal (1). We congratulate the Authors for their superb job in summarizing such a difficult field represented by the differential diagnosis of disorders of copper metabolism. However, we noticed that in their accurate recognition of the causes of reduced serum values of ceruloplasmin, the Authors missed to mention the Congenital Disorders of Glycosylation (CDGs), which are rare as single disorders but not as a group. CDGs in fact represent nowadays more than 100 distinct genetic multisystem disorders characterized by defective glycosylation of glycoconjugates.(2) We previously signaled that patients with some types of CDGs may have low ceruloplasmin values and abnormal copper metabolism. (3, 4) Presently we know that in at least 3 types of CDGs with prevalent hepatic presentation ± CNS minor signs (TMEM199-CDG, CCDC115-CDG; ATP6AP1-CDG) and 2 with prevalent neurological presentation ± minor signs of hepatic involvement (PMM2-CDG, COG2-CDG) there is a documented disturbance of copper metabolism (Table 1). The mechanisms underlying these abnormalities are unclear, and may probably depend on the biochemical nature of ceruloplasmin itself (a glycoprotein with 6 N-linked glycans) and/or involve at least partial loss of copper transporting proteins. (5) In conclusion, in addition to the group of rare conditions signaled by the Authors, we suggest that the diagnostic algor...
Show MoreWe studied the review by Macdougall et al with interest.1 In our comment, we have chosen to view continuous professional development in the later, “broader” terms described by Macdougall et al, as learning and development always incur costs.1
In considering the culture of CPD, the influence of costs on professional development has been omitted. This is a rarely researched area but of growing importance in our opinion. A recent joint statement by the Association of Surgeons in Training and British Orthopaedic Trainees Association criticised an increase in training fees, stating that it was “extremely disappointed” at this action, directed solely at trainees.2 This is against the backdrop of evidence showing that cost of junior doctor training is astronomical, averaging £17, 114, most of which are footed privately by junior doctors.3, 4 Dentists have also identified costs as possible impediment to continuing development.5
The context in the National Health Service is the continuing challenging health economic situation and declining resources in which to provide cover for practitioners’ time to study. The situation described above is more likely to be acute amongst trainees, part-time healthcare staff and doctors in non-substantive positions. This may be the reason why this issue has not gained prominence in the CPD discussions. The high cost of professional development may influence choice of personal development plans and the resulting learning activities un...
Show MoreWe thank Iniobong and Itoro Udo for their interest in our article and their comments. Issues of cost (in the broadest sense, financial, personal, service provision etc.) are of course important when we consider CPD. This is also more challenging in the current financial climate with likely pressure on study leave budgets. Other specific issues and costings they raise, however, concern a separate (although related) issue, the costs of postgraduate training to trainees. We specifically did not consider this group as they are excluded from the definitions of CPD we used. We have underlined the specific phrases from the GMC and the Academy of Medical Royal Colleges respectively;
Show More“any learning outside of undergraduate education or postgraduate training that helps you maintain and improve your performance. It covers the development of your knowledge, skills, attitudes and behaviours across all areas of your professional practice. It includes both formal and informal learning activities.”[1]
“A continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour. CPD should also support specific changes in practice” [2]
[1] Guidance on Continuing Professional Development. 2012; Available from: www.gmc-uk.org/education/co...
Reply to: Psychological Interventions have a place in Management of Paediatric Headache
Michael J Morton, Honorary Clinical Senior Lecturer in Child & Adolescent Psychiatry, University of Glasgow
We are very grateful to Dr Morton for highlighting the importance of CBT and other psychological / talking therapies for children and young people with headaches, and for drawing our attention to the recent systematic review by Ng et al. Where resources exist and permit referral, this can be offered as an adjunct to acute / rescue treatment advice and as an alternative or adjunct to preventative drug therapies and acupuncture for migraine, and may be transformative for worrying tension-type headaches. Even for the trigeminal autonomic cephalalgias (including paroxysmal hemicranias) and idiopathic stabbing headache, CBT and psychological support for the child and young person and their family and carers can be really helpful. Where access to psychological interventions is difficult or inadequate, we should still request it and support the development of these crucial services. Thank you for this important contribution.
William Whitehouse and Shakti Agrawal
Dear Rachael,
I am very impressed indeed with your sound advice for trainees.
Senior trainees should spend more time in clinic.
Access to Outpatient referral console for all tier 2 trainees.
Suggest that senior trainees should manage all general paediatric referrals as we already do it as part of CAU referral form.
Senior trainees should be able to suggest to GP’s any investigations that might make the first consultation a one stop shop.
Admin sessions should not be eaten into because of service provision responsibilities for trainees.
Telemedicine for more urgent referrals and to avoid falsification of referrals
Every GP trainee to conduct at least one new patient clinic to understand paediatric OP dynamics and procedure.
Kindest regards,
Dr Sripriya Eachempati
ST6 Paediatrics, NNUH
The management of headache should be imbued with a psychological understanding that is not sufficiently emphasised in the ADC review by Whitehouse & Agrawal. Like all pain disorders, headache has an important psychological component, which should be acknowledged as part of the assessment in order to open up a conversation that may lead to an effective non-pharmacological intervention. The recent review of treatments for paediatric migraine (Ng et al, 2017) confirms the power of one specific model of intervention in relation to one specific headache diagnosis. A creative use of mental health expertise in the Headache Clinic has the potential to change practice in relation to a range of presentations.
A Systematic Review and Meta-analysis of the Efficacy of Cognitive Behavioral Therapy for the Management of Pediatric Migraine
Qin Xiang Ng, MBBS; Nandini Venkatanarayanan, BMedSci, BMBS; Lakshmi Kumar, MBBS
Headache, 2017;57(3):349-362.
Dr Kraemer is correct in pointing out that the presence of a child mental health team integrated into the paediatric team in the hospital is, where resources allow, often the best way to manage children and young people with medically unexplained symptoms, and indeed with a range of other physical and psychological presentations. See also Cottrell, 2015, http://adc.bmj.com/content/100/4/308
Conflict of Interest:...
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