Portfolios, appraisal, revalidation, and all that: a user's guide for consultants.

From April 2005 all doctors in the UK will be expected to be able to demonstrate their fitness to practice as part of the GMC revalidation procedures. The revalidation process is explicitly linked to the consultant appraisal process implemented in 2001. Central to both processes is the development of a folder (portfolio) of supporting evidence. Many consultants have no experience of developing portfolios and are unclear about how to meaningfully do so and what sort of evidence is suitable for revalidation. Furthermore, they are uncertain about whether there is any evidence to support their use for appraisal or assessment. This paper describes what a portfolio is, summarises the evidence for their use in appraisal and assessment, and provides guidance on the collection of evidence for revalidation purposes. In addition, it explores the distinction between appraisal and revalidation. Some evaluation data on perceived benefits and drawbacks by participants in appraisal in a paediatric setting is also included to inform conclusions and thoughts on planning for the future.

How should paediatric examiners be trained?

Analysis of both the content and process of examinations is central to planning the appropriate education and training of examiners in paediatric clinical examinations. This paper discusses the case for developing training, reviews the current literature, and suggests the desirable attributes of examiners and the components of a training programme. Potential areas of further research are also considered.

Airway function in infants newly diagnosed with cystic fibrosis.

The lung function of infants with cystic fibrosis is often reduced shortly after diagnosis. We measured the airway function of newly diagnosed infants to test whether this reduction is independent of clinically recognised lower respiratory illness. We compared the airway function of 33 infants with cystic fibrosis and 87 healthy controls after adjustment for sex, age, bodyweight and length, and exposure to maternal smoking. Airway function was significantly reduced in children with cystic fibrosis, even in those without clinically recognised previous lower respiratory illness. Our findings raise important questions about the onset and natural history of impaired airway function in infants with cystic fibrosis.

Training the ideal hospital doctor: the specialist registrars' perspective.

BACKGROUND: When training for junior doctors is being planned, little discussion is focused on what outcomes hospitals are trying to achieve with regard to education/training, i.e. on what makes the ideal hospital doctor. Instead, the primary focus is on the requirements of the syllabi of the Royal Colleges (credentialing) and the requirements of service delivery (job description). Current literature has no qualitative studies of any longitude in which middle-grade doctors are asked about their vision of the ideal hospital doctor, what they feel can be done to help realize this vision, and how they feel about their own training. METHODS: This study examined data principally collected through a series of semistructured interviews conducted with eight specialist registrars (SpRs), four each from the North Trent and South Thames rotations over a period of 18 months. Additional information was taken from focus groups, interviews with programme directors, and questionnaires. FINDINGS: A model was created of the SpRs' perceptions of the key attributes of an ideal hospital doctor and of how these may be achieved in training. Eight broad areas were identified: clinical knowledge and skills; key clinically related generic/non-clinical skills; self-directed learning and medical education; implementing change management; applying strategic and organizational skills in career planning; consultation skills; research; and key personal attributes. CONCLUSIONS: SpRs are articulate in expressing their own expectations of their training and have considerable insight into the components of good training. Further improvement could be made and will require significant commitment from both trainees and trainers.

Depth of insertion of a lumbar puncture needle.

The depth of lumbar puncture needle insertion was recorded in 107 children. Height provided the best guide to the minimum and maximum depths of insertion. Mean depth of insertion (cm) = 0.03 x height of child (cm).

Once a day theophylline in chronic childhood asthma?

The therapeutic effects of either morning or evening administration of a once-daily controlled release theophylline preparation (Uniphyllin) were studied in 17 asthmatic children. Neither morning nor evening administration produced therapeutic plasma theophylline levels throughout 24h. Similarly, bronchodilation was not maintained during the same period. However, morning peak expiratory flow rates were significantly improved following evening dosage, suggesting a role for evening administration when nocturnal symptoms predominate.

Split virus influenza vaccination in children: an evaluation of efficacy.

Twenty-seven children aged between 4 and 13 years were given two injections of a split virus influenza vaccine (MFV-Ject, Institut Merieux) at a dose of 0.5 ml and an interval of 1 month. Each vaccination contained A/Philippines/2/82 (H3 N2) 10 micrograms HA, A/Brazil/11/78 (H1 N1) 10 micrograms HA, B/Singapore/222/79 15 micrograms HA. The overall serological response was good although the B group virus produced slightly less response; however, no children were seropositive to B prior to vaccination, reflecting a low previous exposure. Children aged over 10 years showed a generally higher serological response. Side-effects were minimal. A favourable reactogenicity/efficacy ratio was found.

Diminished bactericidal capacity for group B Streptococcus in neutrophils from "stressed" and healthy neonates.

This study compared the bactericidal capacity of polymorphonuclear leukocytes (PMNs) from neonates and adults for type Ic group B Streptococcus (GBS), and examined the effect of severe stress on the bactericidal capacity of PMNs from newborn infants. PMNs were obtained from three study groups: 26 adults, 13 healthy neonates (cord blood), and 29 stressed neonates. Stress was defined as an acute respiratory illness or bacterial infection requiring assisted ventilation. Bacterial killing was assessed using a fluorochrome microassay and PMNs adherent to glass coverslips. PMNs from stressed infants killed significantly fewer GBS than PMNs from adults (P less than 0.001 at both time points). PMNs from healthy infants also demonstrated reduced killing compared with adults (P less than 0.01 at 60 min; P less than 0.001 at 90 min). There was no significant difference in bacterial killing between stressed and healthy neonates and no correlation between bactericidal capacity and age at time of study, gestational age, birth weight, peripheral leukocyte count, or Apgar scores. Therefore, the bactericidal capacity for GBS by PMNs from neonates is diminished; however, it is not further compromised by stress.

Phagocytosis of group B streptococcus by neutrophils from newborn infants.

The purpose of this study was to investigate the effect of severe "stress" on neonatal neutrophil (PMN) phagocytosis, and to compare the ability of neonatal and adult PMNs to ingest [3H]-labeled type Ic group B streptococcus (GBS). Three patient populations were studied: healthy and "stressed" newborn infants and healthy adults. Severe "stress" was defined as an acute, noninfectious respiratory illness, sepsis or severe birth asphyxia; 94% of these infants required assisted ventilation. Radiolabeled GBS was opsonized with 5% adult serum, and incubated with PMN monolayers adherent to glass coverslips. Bacterial uptake was determined at 0, 40, 60, and 80 min and expressed as counts per min/10(6) PMNs. Neutrophils from healthy and "stressed" newborn infants demonstrated a significant increase in bacterial uptake with time. Adult controls also showed a significant increase in phagocytosis through 60 min, but not during the 60--80 min time period. PMNs from "stressed" and healthy infants demonstrated enhanced bacterial uptake when compared to adults at 40, 60, and 80 min. There were no significant differences in bacterial ingestion between "stressed" and healthy infants. Radiolabeled GBS uptake did not correlate with birth weight, study age, Apgar scores, or peripheral leukocyte count for the "stressed" newborn population. Neutrophils from healthy and "stressed" newborn infants thus demonstrate increased phagocytosis of GBS when compared to healthy adults.

Diminished bactericidal capacity for group B streptococci of neutrophils from children with chronic granulomatous disease.

The bactericidal capacity of neutrophils from healthy adults, male children with chronic granulomatous disease, and obligate heterozygote mothers for type Ic group B streptococci was assessed, using a fluorochrome microassay. Neutrophils from patients with chronic granulomatous disease had impaired bactericidal capacity for group B streptococci when compared with adults (P less than 0.01). Carriers demonstrated intermediate killing capacity.

Acute infective pericarditis in infancy.

Infective pericarditis is rare; the characteristic presenting illness in 3 children, each aged under one year, is recorded. Early diagnosis is important since surgical drainage of the pericardium is often necessary in addition to antibiotic therapy. The clinical features may suggest pericarditis, but diagnosis is readily and reliably confirmed by echocardiography.

Use of high kilovoltage filtered beam radiographs for detection of bronchial situs in infants and young children.

Determination of atrial situs is of cardinal importance in the analysis of complex congenital heart lesions, and is best predicted from bronchial situs. Previous methods for assessing bronchial morphology, however, are unsuited to the very young patient. To assess bronchial morphology, 100 consecutive patients under 18 months of age (medium 57.5 days) with suspected congenital heart disease were studied by high kilovoltage filtered beam radiographs, before cardiac catheterisation. This low radiation dose technique clearly defined bronchial anatomy in 95 patients. The lengths of the left and right main bronchi were compared and 10 cases (10%) had a ratio less than 1.5 suggesting bronchial isomerism. Discriminant function analysis based on tracheal width and bronchial length enabled clear distinction of right from left bronchi. Four patients had bilateral right and six had bilateral left bronchi. Four of these 10 cases died and had necropsy confirmation of the radiological diagnosis. Practical prediction about cardiac anatomy, particularly the systemic and pulmonary venous return, may be made when bronchial morphology is known.