Child and adolescent psychiatry training in Australia and New Zealand.

The specialty of Child and Adolescent Psychiatry was formally recognised in the 1930s. The Faculty of Child and Adolescent Psychiatry was established in 1964 in Australia, as a subspecialty in The Royal Australian and New Zealand College of Psychiatrists (RANZCP). The aim of the current article is first to provide a brief summary and overview of the current status of Child and Adolescent Psychiatry (CAP), followed by an outline of the requirements of the Training Program for CAP in Australia and New Zealand. The training required to become a fully qualified child and adolescent psychiatrist in Australia and New Zealand consists of different stages and takes the form of competency-based training. Information relating to assessment types, supervision and research requirements is also described. Accreditation procedures for the training program are stipulated by RANZCP to monitor standards and to ensure consistency within the programs delivered across Australia and New Zealand. Employment opportunities for trainees upon completion of the program are discussed. In summary, this article highlights the requirements of the training programs for CAP in Australia and New Zealand.

Final Results of the Prospective FH02 Mammographic Surveillance Study of Women Aged 35-39 at Increased Familial Risk of Breast Cancer.

BACKGROUND: Many women who are at increased risk of breast cancer due to a mother or sister diagnosed with breast cancer aged under 40 do not currently qualify for surveillance before 40 years of age. There are almost no available data to assess whether mammography screening aged 35-39 years would be effective in this group, in terms of detection of breast cancer at an early stage or cost effective. METHODS: A cohort screening study (FH02) with annual mammography was devised for women aged 35-39 to assess the sensitivity and screening performance and potential survival of women with identified tumours. FINDINGS: 2899 women were recruited from 12/2006-12/2015. These women underwent 12,086 annual screening mammograms and were followed for 13,365.8 years. A total of 55 breast cancers in 54 women occurred during the study period (one bilateral) with 50 cancers (49 women) (15 CIS) adherent to the screening. Eighty percent (28/35) of invasive cancers were ≤ 2 cm and 80% also lymph node negative. Invasive cancers diagnosed in FH02 were significantly smaller than the comparable (POSH-unscreened prospective) study group (45% (131/293) ≤ 2 cm in POSH vs 80% (28/35) in FH02 p < 0.0001), and were less likely to be lymph-node positive (54% (158/290, 3 unknown) in POSH vs 20% (7/35) in FH02: p = 0.0002. Projected and actual survival were also better than POSH. Overall radiation dose was not higher than in an older screened population at mean dose on study per standard sized breast of 1.5 mGy. INTERPRETATION: Mammography screening aged 35-39 years detects breast cancer at an early stage and is likely to be as effective in reducing mortality as in women at increased breast cancer risk aged 40-49 years.

Mammographic surveillance in women aged 35-39 at enhanced familial risk of breast cancer (FH02).

Although there have been encouraging recent studies showing a potential benefit from annual mammography in women aged 40-49 years of age with an elevated breast cancer risk due to family history there is little evidence of efficacy in women aged <40 years of age. A prospective study (FH02) has been developed to assess the efficacy of mammography screening in women aged 35-39 years of age with a lifetime breast cancer risk of ≥ 17 % who are not receiving MRI screening. Retrospective analyses from five centres with robust recall systems identified 47 breast cancers (n = 12 in situ) with an interval cancer rate of 15/47 (32%). Invasive tumour size, lymph node status and current vital status were all significantly better than in two control groups of unscreened women (including those with a family history) recruited to the POSH study. Further evaluation of the prospective arm of FH02 is required to assess the potential added value of digital mammography and the cancer incidence rates in moderate and high risk women in order to inform cost effectiveness analyses.

Evaluation of mammographic surveillance services in women aged 40-49 years with a moderate family history of breast cancer: a single-arm cohort study.

BACKGROUND: Women with a significant family history of breast cancer are often offered more intensive and earlier surveillance than is offered to the general population in the National Breast Screening Programme. Up to now, this strategy has not been fully evaluated. OBJECTIVE: To evaluate the benefit of mammographic surveillance for women aged 40-49 years at moderate risk of breast cancer due to family history. The study is referred to as FH01. DESIGN: This was a single-arm cohort study with recruitment taking place between January 2003 and February 2007. Recruits were women aged < 50 years with a family history of breast or ovarian cancer conferring at least a 3% risk of breast cancer between ages 40 and 49 years. The women were offered annual mammography for at least 5 years and observed for the occurrence of breast cancer during the surveillance period. The age group 40-44 years was targeted so that they would still be aged < 50 years after 5 years of surveillance. SETTING: Seventy-four surveillance centres in England, Wales, Scotland and Northern Ireland. PARTICIPANTS: A total of 6710 women, 94% of whom were aged < 45 years at recruitment, with a family history of breast cancer estimated to imply at least a 3% risk of the disease between the ages of 40 and 50 years. INTERVENTIONS: Annual mammography for at least 5 years. MAIN OUTCOME MEASURES: The primary study end point was the predicted risk of death from breast cancer as estimated from the size, lymph node status and grade of the tumours diagnosed. This was compared with the control group from the UK Breast Screening Age Trial (Age Trial), adjusting for the different underlying incidence in the two populations. RESULTS: As of December 2010, there were 165 breast cancers diagnosed in 37,025 person-years of observation and 30,556 mammographic screening episodes. Of these, 122 (74%) were diagnosed at screening. The cancers included 44 (27%) cases of ductal carcinoma in situ. There were 19 predicted deaths in 37,025 person-years in FH01, with an estimated incidence of 6.3 per 1000 per year. The corresponding figures for the Age Trial control group were 204 predicted deaths in 622,127 person-years and an incidence of 2.4 per 1000 per year. This gave an estimated 40% reduction in breast cancer mortality (relative risk = 0.60; 95% confidence interval 0.37 to 0.98; p = 0.04). CONCLUSIONS: Annual mammography in women aged 40-49 years with a significant family history of breast or ovarian cancer is both clinically effective in reducing breast cancer mortality and cost-effective. There is a need to further standardise familial risk assessment, to research the impact of digital mammography and to clarify the role of breast density in this population. TRIAL REGISTRATION: National Research Register N0484114809. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 11. See the HTA programme website for further project information.

Phaeochromocytoma diagnosed during labour.

The diagnosis of phaeochromocytoma during pregnancy is rare. We present the management of vaginal delivery in a woman diagnosed with the condition during labour. A Medline search and follow-up of references failed to find any similar report in the last 30 years.

Determining patients' suitability for thrombolysis: coronary care nurses' agreement with an expert cardiological 'gold standard' as assessed by clinical and electrocardiographic 'vignettes'.

BACKGROUND: Thrombolytic therapy is an established treatment for acute myocardial infarction, the benefits of which are time-dependent. Coronary care nurses are often the first professionals to assess patients with suspected myocardial infarction on hospital admission, and there are a number of reports of nurseled practices for immediate assessment and 'cardiac triage'. OBJECTIVE: To assess coronary care nurses' ability to determine patients' suitability for thrombolysis as judged by an expert cardiological 'gold standard'. METHODS: Ten coronary care units in the Northern and Yorkshire region of England were sent packs comprising 10 sets of 10 'vignettes' and accompanying electrocardiograms together with a questionnaire regarding treatment decisions. An expert 'gold standard' for correct responses to the questionnaire was derived following independent assessment of the vignettes by three nurse specialists and three consultant cardiologists. Respondents' treatment decisions were subsequently compared with the 'gold standard'. RESULTS: Of 42 (42%) completed sets of questionnaires returned for analysis, 37 (87%) of respondents indicated management decisions in absolute agreement with the 'gold standard'. Where there was not absolute agreement, most treatment decisions were acceptable as safe practice. CONCLUSION: The majority of nurses indicated safe and appropriate management decisions. These limited data provide further support for ongoing developments of nurse-initiated thrombolysis, although there is a need for further, larger trials to determine the safety and efficacy of such an approach to patient care.

Nitrous oxide exposure on the labour ward.

Occupational exposure to nitrous oxide may be increased in confined working environments where ventilation and scavenging are either ineffective or unavailable. This is particularly the case on the labour ward. To assess the exposure of midwives working on the labour ward, midwives were asked to wear personal nitrous oxide samplers during their shift periods. The nitrous oxide exposure during a total of 242 midwife shift periods was monitored in two hospitals. Seven (3%) of these midwife shifts demonstrated mean exposure levels of over 500 parts per million (ppm), the highest reaching 1638 ppm. Fifty-six (23%) had NZO levels over 100 ppm and 129 (53%) had levels above 25 ppm. During the 111 midwife shift periods where midwives did not work in a room where Entonox was in use, their mean exposure was 22 ppm (median 12 ppm), however in four of these midwife shift periods the mean exposure level exceeded 100 ppm. Chronic exposure to high levels of nitrous oxide which exceed the recently proposed UK standard of 100 ppm and those in force in the USA (25 ppm) and Sweden (100 ppm) are frequently encountered by midwives.

Anaesthetic management of labour in two patients with Klippel-Feil syndrome.

Two patients with Type I Klippel-Feil syndrome presented at the antenatal clinic. The first patient, who suffered from sleep apnoea, was delivered of a healthy infant by vacuum extraction. The second, who was profoundly deaf and had marked kyphoscoliosis, developed pregnancy-induced hypertension and urinary tract infection and was delivered at 38 weeks by vacuum extraction. In both cases epidural analgesia was employed to allow pain relief during labour. Anaesthetic management of Klippel-Feil syndrome is discussed and the benefits of early anaesthetic assessment and continued involvement of senior anaesthetic and obstetric staff emphasized.

Anaphylactoid reaction following local anaesthesia for epidural block.

A potentially serious complication of epidural bupivacaine used for a repeat, elective Caesarean section is presented. The main features of this reaction were erythema, itching, generalised and pulmonary oedema. In addition, pulmonary oedema was subsequently noted in the baby. An immunological hypersensitivity to bupivacaine or lignocaine is the likely cause.

The changing role of coronary care nurses.

The purpose in this article is to give an overview of the role of a coronary care nurse. No attempt is made to give a detailed account of any particular aspect of care but rather to inspire coronary care nurses to think about their practice and what can be achieved. In the 1960s Coronary Care Units (CCUs) were shown to reduce mortality from fatal arrhythmias and nursing care was based around observation and emergency treatment. The focus of coronary care is now moving towards infarct size reduction and the prevention of infarction in patients with unstable angina. Nurses are adapting their role accordingly--the skill, knowledge and judgement required to recognise reversible ischaemic episodes in the early pre- or post-infarctional period is paramount. It is equally and vitally important that nurses are able to recognise and assess the psychological and rehabilitation needs of patients. These aspects of care can be met ideally by using a system based on primary nursing and focusing on the patients' individual needs. Nursing practice should be research-based, and under constant review with positive change encouraged.

Policies for oral intake during labour. A survey of maternity units in England and Wales.

A postal survey was conducted to gain information on the use of policies on oral intake, selection of mothers and type of intake given during established labour by all maternity units in England and Wales. A response rate of 91.6% (351 out of 383) was achieved; 79.5% of units had a written policy for oral intake, 96.4% of units allowed mothers some form of oral intake and 68.3% of these units selected mothers according to risk categories. Of the 268 units allowing oral intake, 67.2% gave drink only and 32.8% drink and food. Of those allowing food, all but 13.6% had a selection policy. Of the 85 units not selecting mothers, 78.8% gave water only; the remaining 21.2% gave water and other drink or food. This survey demonstrates a wide variation in policies for oral intake during labour.

Anaesthesia in a gravid achondroplastic dwarf.

A patient with achondroplasia presented for elective Caesarean section under epidural anaesthesia. A block from C5 to S4 developed over 20 minutes after 12 ml plain bupivacaine 0.5%. This case serves to highlight the difficulties of regional anaesthesia in the gravid achondroplastic dwarf.

Gimbal for aligning laser and lenslet arrays for coherent operation in an external cavity.

We describe a miniature alignment stage designed for use with semiconductor diode laser and lenslet arrays. The device achieves 0.03-mrad angular and 0.3-microm linear precision utilizing metal flexures and piezoelectric transducers in a mechanical arrangement that provides compactness and repeatability not obtainable with other types of components. It has been used successfully to coherently combine output of a linear diode laser array of five elements and can accommodate a 2-D array.

Compact CO2 laser for infrared heterodyne radar.

A compact CO(2) laser has been developed for field use as part of an infrared heterodyne radar. The laser, which contains a separate local oscillator, transmits 10.5 W cw or 7 W average in the electrooptically Q-switched mode at a repetition rate of 50 kHz. The applicability of this laser to active imaging is discussed.

Postanesthetic care. Respiratory care.

Careful management of all severely patients, traumatized particularly those undergoing general anesthesia and surgery, is essential to prevent the development of serious pulmonary problems in the postoperative period. In addition to insuring adequate oxygenation, humidification, and analgesia, particular attention should be paid to careful monitoring of volume therapy, efficient filtration of banked blood, and the prevention of aspiration.