Non-freezing cold injury.

Non-freezing cold injury can be a diagnostic challenge for clinicians in the United Kingdom Armed Forces. It is associated with operations in adverse climatic conditions, and may result in significant long-term morbidity. In this article we discuss the operational importance of this condition and the current best practice in its management and prevention.

Physician management of pediatric mental health patients in the emergency department: assessment, charting, and disposition.

OBJECTIVE: The focus of this study was to describe the clinical data that pediatric emergentologists recorded and how they were used in the mental health (MH) care of patients. METHODS: A structured chart review was conducted for all MH presentations to a pediatric emergency department in 2007. Three research assistants extracted clinical chart data and completed the Child and Adolescent Needs and Strengths Tool. RESULTS: The clinical records of 495 children and youth were reviewed. Emergentologists referred 124 (25.4%) for a psychiatric consult, and 46 (37%) of these patients were admitted to either an inpatient psychiatric or eating-disorders unit. Psychosis, suicide risk, eating disturbance, anxiety, and resistance to treatment predicted admission to the psychiatric inpatient unit or the eating-disorders unit. Of the 365 patients discharged back to the community, the majority (n = 189, 51.8%) were referred back to their family physician. For 117 patients (32%), there was no discharge documentation in the medical chart. Age, parent present, currently on medication, currently receiving counseling, depression, anxiety, and adjustment to trauma predicted provision of charted recommendation. CONCLUSIONS: This study revealed that the pediatric emergentologists' charting of MH patients is inconsistent and incomplete. Although recorded clinical data predicted psychiatric consultation and disposition for these patients, missing data were evident in a significant number of records. The results of the study point to a need to develop a more uniform approach to the collection and recording of clinical data for MH patients.

UK Role 4 military infectious diseases at Birmingham Heartlands Hospital in 2005-9.

OBJECTIVES: Infectious diseases affecting British troops are mostly due to gastrointestinal and respiratory illnesses, but these are usually minor in severity, easy to manage and short in duration. To assess the importance of infections that are more severe, difficult to manage or longer in duration, it is necessary to look at military cases that are evacuated or otherwise referred to the UK Role 4 (definitive care) medical facility for infectious diseases. METHODS: Case notes from military infectious disease patients seen at Birmingham Heartlands Hospital in 2005-2009 were reviewed to extract data on demographics, origin of infection, diagnostic categories, exact diagnoses, type and duration of care, time off duty, quality of care and costs incurred. RESULTS: Over a 4-year period, 138 cases were referred, 131 (95%) were male and 98 (71%) were from the Army. The origin of infection was Afghanistan in 52 (38%) and Belize in 19 (14%). From 131 patients (95%) that attended, 59 (45%) had dermatological illnesses and 38 (29%) had undifferentiated febrile illnesses. Diagnoses included 35 (27%) with cutaneous leishmaniasis and 21 (16%) with "Helmand Fever" due to sandfly fever, acute Q fever or rickettsial infection. For 51 in-patients, the median (range) length of stay was 3 (1-17) days and time off duty was 20 (5-127) days. For 80 out-patients, the median (range) number of attendances was 1 (1-23) and time off duty was 22 (1-228) days. All cases were seen promptly (within 7 days for in-patients and 28 days for out-patients), but only 59 (45%) had appropriate letters sent to the referring medical officer and none had F Med 85 notifications of infectious disease submitted. Aeromedical evacuation costs could not be calculated, but UK hospital care cost approximately pound 78 000 per year. CONCLUSIONS: Dermatological infections and undifferentiated febrile illnesses that require management at a UK Role 4 facility are important causes of disease non-battle injury. Prospective collection of this data in the future will be a valuable asset.

Child and youth mental health service referrals: physicians' knowledge of mental health services and perceptions of a centralized intake model.

OBJECTIVE: We conducted a survey to assess physicians' attitudes and knowledge of mental health services and centralized intake services for mental health. METHOD: A survey consisting of 51 questions was sent to 735 physicians in active practice within the catchment area of a regional centralized intake for child and youth mental health services. The survey was conducted during the summer of 2006. RESULTS: Of 735 eligible physicians, 388 completed and returned the survey (52.8% response rate). The majority of physicians were aware of mental health services offered by their hospital. Physicians reported lower confidence levels for delivering counselling and psychopharmacological treatments for mental health. Furthermore, over 72% indicated that they did not feel they had time in practice to provide mental health counselling. Over 65% of physicians reported that mental health referrals should have appropriate/defined criteria. The majority (92%) of physicians had referred to specialized mental health services provided by their hospital. With respect to centralized intake services, 57.2% of physicians indicated they were aware of the service and 73.9% said it should be continued. However, only 34% reported satisfaction with the centralized intake referral service. Predictors of satisfaction with the service were satisfaction with mental health feedback and satisfaction with response time of the centralized intake service. CONCLUSIONS: Physician confidence levels in providing mental health services vary greatly. While doctors favour a centralized intake for mental health services, their satisfaction with such a service somewhat depends on variables beyond the control of the centralized intake, such as wait times and feedback from mental health providers.

Establishing best practice in pediatric emergency mental health: a prospective study examining clinical characteristics.

OBJECTIVES: The objectives of this prospective study were to determine the demographic and clinical characteristics of children and youth presenting to the emergency department (ED) for mental health concerns through the use of a valid standardized assessment protocol. METHODS: Children and adolescents, 8 to 17 years, who presented to an ED-based crisis intervention program during fiscal years 2005 to 2006, completed self-report measures of depression, anxiety, and behavior. Clinicians completed the childhood acuity of psychiatric illness based on their assessment. RESULTS: The clinician ratings indicated that 93.1% of the sample had at least 1 risk behavior or clinical symptom in the moderate/severe range. Admittance rate for the sample was 17.9% (low-risk admissions, 5.8%; high-risk deflections, 9%). Significant differences were found in presentations by sex and age as follows: (1) female youths (12-17 years) were more likely than male youth to report clinically significant depressive symptoms and to present with suicidal ideation/gesture and self-injury. (2) Male youths (12-17 years) were more likely to present with aggression to people/objects than female youth. (3) Male children younger than 12 years were more likely to present with high activity level than female children. Self-report measures (depression, anxiety, and behavior) corelated with corresponding clinician ratings. CONCLUSIONS: This research, through the use of a multi-informant standardized assessment protocol, presents a comprehensive study of children and youth presenting to the ED with mental health issues. Identifying the clinical characteristics of this population is an important first step toward establishing best practice within an ED.

Mental health services for children and youth: a survey of physicians' knowledge, attitudes and use of telehealth services.

Rural physicians in Ontario, whose practice included children, were surveyed on their awareness, attitudes and use of telemental health services for children and young people in their region. Of 95 rural physicians, 70 completed and returned the telehealth section of the survey (74% response rate). The survey comprised 14 questions. Only 27% of responders were aware of the available videoconferencing services. The proportion of physicians who reported having referred patients for the various mental health services through videoconferencing was 0-24%. The proportion of physicians who reported that they would refer patients through videoconferencing was 55-92%. Reduced travel time and care provided closer to home were seen as the primary benefits of referring patients to mental health services through videoconferencing. Unclear referral patterns and technology compromises were seen as limitations of referring patients to videoconferencing. Access to rural populations and improved access to patients were seen as benefits to practice, and undeveloped remuneration procedures as the primary limitation. Promotion may be important to successful implementation of telemental health services for children and young people.

What is the quality of drug therapy clinical practice guidelines in Canada?

BACKGROUND: The Canadian Medical Association maintains a national online database of clinical practice guidelines developed, endorsed or reviewed by Canadian organizations within 5 years of the current date. This study was designed to identify and describe guidelines in the database that make recommendations related to the use of drug therapy, and to assess their quality using a standardized guideline appraisal instrument. METHODS: Drug therapy guidelines in the database were identified with the use of search terms and hand searching. Descriptive information about the developers, endorsement by other organizations, publication status, disease and drug focus was abstracted. Each guideline was independently assessed by 3 appraisers (a physician, a pharmacist and a methodologist) with the use of the Appraisal Instrument for Clinical Guidelines. Conditions were classified according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems. RESULTS: We identified 217 drug therapy guidelines produced or reviewed from 1994 to 1998. Guideline developers included national organizations (47.0%), paragovernment organizations (39.6%) and professional associations (30.9%); 31.3% of the guidelines were published, and 10.6% stated drug company sponsorship. The most common conditions addressed by the guidelines were infections and parasitic diseases (39.6%), neoplasms (11.5%) and diseases of the circulatory system (11.5%). Drugs most commonly cited were anti-infective agents (42.9%), antiviral agents (15.2%) and cardiovascular drugs (16.1%). Eleven organizations produced 176 (81.1%) of the guidelines. In all, 14.7% of the guidelines met half or more of the 20 items assessing rigour of guideline development on the appraisal instrument (mean quality score 30.0% [95% confidence interval (CI) 27.5%-32.6%]), 61.8% met half or more of the 12 items assessing guideline context and content (mean score 57.0% [95% CI 54.6%-59.3%]), and none met half or more of the 5 items assessing guideline application (mean score 5.6% [95% CI 4.7%-6.5%]). Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. The quality of the guidelines assessed varied significantly by developer, publication status and drug company sponsorship. No substantial improvement in guideline quality was observed over the 5-year study period. INTERPRETATION: Developers of Canadian drug therapy guidelines are producing guidelines that are often perceived to be clinically useful to physicians and pharmacists, although the methods (or the description of the methods) by which they are developed need to be more rigorous and thorough.

The revised Canadian Guidelines for the Economic Evaluation of Pharmaceuticals.

The first edition of the Guidelines for Economic Evaluation of Pharmaceuticals: Canada was published in November 1994. At that time, the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) was assigned the task of maintaining and regularly updating the Canadian Guidelines. Since their introduction, a great deal of experience has been gained with the practical application of the guidelines. Their role has also evolved over time, from being a framework for pharmacoeconomic research to the point where a wide variety of decision-makers use economic evaluations based on the principles set out in the guidelines as a means of facilitating their formulary decisions. In addition, methodologies in certain areas (and the body of related research literature in general) have developed considerably over time. Given these changes in the science and the experience gained, CCOHTA convened a multi-disciplinary committee to address the need for revisions to the guidelines. The underlying principles of the review process were to keep the guidance nature of the document, to focus on the needs of 'doers' (so as to meet the information needs of 'users') and to provide information and advice in areas of controversy, with sound direction in areas of general agreement. The purpose of this review is three-fold: (i) to outline the process which lead to the revision of the Canadian Guidelines; (ii) to describe the major changes made to the second edition of this document; and (iii) to consider the 'next steps' as they relate to the impact of such guidelines and the measurement of outcomes related to economic assessments of pharmaceuticals in general.

Confirmation of the utility of fine needle aspiration biopsy of the renal allograft.

Allograft immunobiologic theory would predict that analysis of immunocompetent cells infiltrating the renal transplant would be most instructive. Recently a new aspiration biopsy technique has been developed to permit such analysis in patients which can be safely and repetitively performed. The clinical utility of such a technique has been tested utilizing a randomized prospective trial in which an aspirate was obtained every other day from the third post-operative day until discharge. Analysis included examination of adequacy criteria and the capacity of pathologic diagnosis to corroborate clinical diagnosis from coded specimens. Ninety-six aspirates from 21 consenting transplant recipients were obtained and analyzed. In 94 instances a clinical diagnosis could be made; 80 aspirates fulfilled adequacy criteria. We found the technique to be highly sensitive (greater than or equal to 90%) and highly specific (greater than or equal to 90%) for the clinical diagnoses of acute allograft rejection, post-operative acute renal failure, cyclosporine toxicity, and normal function. We conclude that the fine needle aspiration technique is an important adjunct to analysis of clinical renal transplantation and offers a major advantage to the clinical scholar in understanding transplant biology.

Excision of tricuspid valve with later replacement in endocarditis of drug addiction.

Staphylococcal endocarditis in a drug addict was controlled only after excision of the tricuspid valve. Total absence of the tricuspid valve was tolerated well for 18 months, at which time deteriorating liver function prompted the insertion of a bioprosthetic valve into the tricuspid ring. The haemodynamic and clinical results after two years of follow-up have been excellent.

Carcinoma of the larynx - results of primary radiotherapy.

Results for 180 patients with carcinoma of the larynx treated by radiotherapy at Belvidere Hospital in Glasgow between 1958 and 1968 are presented. The policy of treatment was primary radiotherapy with surgery for recurrences. All the patients have been followed up for more than five years. Overall crude five-year survival is 57%. For stages I and II it is 70%. Surgical rescue was successful in 50% of fit patients.