W. Ur-Gosh. West Texas A&M University.

Les hommes : s’ouvrir à leurs réalités et répon- Public Health purchase zenegra 100 mg overnight delivery, 2005 order zenegra uk, 96(Suppl 2): S78-S96 buy zenegra 100 mg low price. Intervention, 2002, 116: 37-51 23 Men’s health in Denmark Svend Aage Madsen PhD The current state of male health in Denmark Although Denmark is a welfare society and a country When you look at healthy life years at 50 years of age with high standards in health and gender equality, life for the same 25 European countries however, Denmark expectancy for Danish men is among the lowest in the is in frst place with 23. Danish men are When it comes to men’s use of health care system it has number sixteen of twenty. Danish men hospital patients seem to want the the attitudes to all kind of health and especially men’s disease and health services to take up only a small part health has been very laissez-faire and against any kind of their daily life and identity yet they occupy most of the of restrictions in Denmark. This point to a need for developing a have lower all-cancer survival than countries with better understanding of gender differences in patients’ similar national expenditure on health. The development of more ‘male- survival rate for prostate cancer among Danish men is sensitive’ health services should be a central issue in the only 47% compared with 75% in Europe as a whole. Presentation of the 2005 Men’s Health Prize; a well established activ- ity of the Danish Men’s Health Week. The prize was given by Else Smidt (right), head of prevention at the National Board of Health to Kristian Ditlev Jensen (left) for his famous autobiography about sexually abused boys. Health services have (the Prostate Cancer Patient Organisation); the Danish been slow to recognise particular issues affecting men Cancer Society; the Danish Family Planning Association; in relation to health. These issues include men’s in- the Confederation of Danish Industry; and Men’s Health creased risk of developing poor health because of risk- Society Denmark. The reason for this is more lack of in- terest and conservatism among health professionals than resistance from politicians. This is very much due to a refusal to accept gender as an important issue in health politics among medical staff. This is especially related to the laws and regu- that men will have more contact with and get more ac- lations and health services for men as fathers. Further- matter there has been a positive development, and it more the men’s taking active part in childcare seems to seems that men’s participation in at the birth, parental prevent divorces and it has been established that divorce leave (many places there are two to three months pa- is a threat to several aspects of a man’s health. Finally it rental leave with full salary for men), and caring for their seems that being engaged in parenthood also increases small children has a positive impact on men’s health a man’s taking care of his health and wellbeing. The future for male health in Denmark What we would like to see happen is the development An important way to achieve the goals of better cir- of a much bigger awareness on men’s health in public, cumstances for men’s health is the educational pro- political, and health opinion. There is a need to make changes in men’s health behaviours and in to include all kind of gender aspects, and not the least health services for men. In this area there are no positive develop- This might have an important impact on the lifestyle of ments for the time being but it is hoped that the Men’s Danish men, which is in imperative need of improve- Health Week 2009 in Denmark, which has ‘Men and ment in several areas, especially in the areas of smok- Cancer’ as focus will have a positive infuence on that. About the author Men’s Health Society, Denmark is a multidisciplinary organisation dedicated to the feld of men’s health in all its aspects. The society was founded in 2003 in connection with the frst Men’s Health Week in Denmark, and Men’s Health Week continues to be an important and highly prioritised activity. Through the Men’s Health Weeks the Danish Men’s Health Society collaborates with all kinds of national and local health organisations and authorities in the health areas. These co-operations contribute to the dissemination of knowledge on men’s health issues in different health spheres and around the country. Men’s Health Society, Denmark is engaged in the Nordic Network on Men’s Health and in organising the Nordic Men’s Health Conferences. Men’s Health Society, Denmark is also a member of the European Men’s Health Forum. He is the President of Men’s Health Society, Denmark and a member of the Board of Directors of the European Men’s Health Forum. Feminist objectives in the later veloped countries, men in England & Wales live shorter decades of the century focused most strongly on mat- lives than women (77. Overall, women’s activism has dence of the ten most common cancers that affect both succeeded in bringing about the acceptance by most sexes is almost twice as high in men). Men are also more people and most institutions, that discrimination on likely to develop most forms of serious illness earlier in the grounds of gender is unacceptable. This has been the lifespan (for example men aged 50 – 54 are fve times a signifcant political achievement and is arguably the more likely to die of coronary heart disease). It can be diffcult to see that gender ine- than women in personal health issues, and less likely qualities also sometimes affect men and boys. Health to engage with community processes built around mu- is the most signifcant case in point. This basic truth is way to address the health needs of men is to position the of course at the centre of the present wave of inter- issue where it properly belongs - within the debate about national interest in the links between masculinity and gender equalities. This approach – as in England & Wales has largely been led by men and we shall see later – has been crucial to the signifcant women with a professional or academic interest in the progress in the past two or three years in particular. These people have tended to be driven by profes- An essay explaining why the differences in health status sional concern. In other words, the campaign for bet- between men and women (whether to the disadvantage ter male health has differed fundamentally from the of either sex) should properly be regarded as a health in- activism on women’s health, which was essentially a equality forms the introduction to a report published by “grass roots” or “consumer” movement. It came ence of a reasonably-sized base among health work- in April 2006, when the Equality Act 2006 became law. This support was welcomed by ing was the greater willingness of funding bodies government departments keen to demonstrate that, to support research projects in the field. This latter although the primary political impetus was to build included government funding of an important two on the progress since the 1970s in achieving greater year project aimed at increasing uptake of chlamy- equality for women, there were benefts for both sexes dia screening by young men, the findings from which in the new law. This is of met on a number of occasions with health ministers central importance, since, in the feld of health specif- in the Labour administration who were interested in cally, outcomes are inarguably poorer for men. Rather it has given a solid base in law for the ar- health campaigners if it had not come at a time when there guments that the wisest advocates of better male health had already been several years of hard work and aware- were already making. If there had not been such a frame- the rate of progress and a sense that the improvements work in place then the Equality Act might have been noth- that are now steadily accruing are more likely to be lasting. Having said this, it should be added that the Equality Act Instead, and as a direct consequence of policy-makers thinking in a more concentrated way about gender inequalites, England & Wales have seen specifc account taken of male health at the highest possible level. Furthermore the Depart- tackle poorer outcomes in men; the National Chlamy- ment of Health’s own guidance to the Equality Act6 includes dia Screening Programme has published a detailed a strong emphasis on men’s health needs and behaviours. This would certainly require a long term commit- ancy are not keeping pace with the rest of the ment to the support and education of future generations population. Overall therefore, the ment “working together” with total of eleven non-gov- present situation in for male health England & Wales ernmental organisations “to improve knowledge and seems a positive one and, with good management skill”. The Department of Health promises that Stra- and a little bit of luck, promises to remain so for the tegic Partners will be “at the heart of shaping policy. He has written policy papers on several specifc aspects of men’s health and led a number of research projects. He is currently leading a three year government- funded project looking for ways to close the gap between men and women in the uptake of bowel cancer screening. He is also conducting a review (also government-funded) examining the most important issues in men’s mental health. David has represented the “men’s health interest” on a number of national and re- gional committees.

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Paul O purchase 100mg zenegra, Lepper M buy zenegra pills in toronto, Phelan W order zenegra 100mg without prescription, Dupertuis G, MacMillan A, McKean H (1963) A longitudinal study of coronary heart disease. People’s Republic of China—United States Cardiovascular and Cardiopulmonary Epidemiology Research Group (1992) An epidemiological study of cardio- vascular and cardiopulmonary disease risk factors in four populations in the People’s Republic of China. Progress Collaborative Group (2001) Randomised trial of a perindopril- based blood-pressure-lowering regimen among 6105 individuals with previ- ous stroke or transient ischaemic attack. SarrafZadegan N, AminiNik S (1997) Blood pressure pattern in urban and rural areas in Isfahan, Iran. Shelley E, Daly L, Kilcoyne D, Graham I, Mulcahy R (1991) Risk factors for coronary heart disease: a population survey in county Kilkenny, Ireland, in 1985. Strachan D, Rose G (1991) Strategies of prevention revisited: Effects of im- precise measurement of risk factors on the evaluation of “high-risk” and “population-based” approaches to prevention of cardiovascular disease. Suh I (2001) Cardiovascular mortality in Korea: a country experiencing epi- demiologic transition. Vartiainen E, Jousilahti P, Alfthan G, Sundvall J, Pietinen P, Puska P (2000) Car- diovascular risk factor changes in Finland, 1972–1997. Vartiainen E, Puska P, Pekkanen J, Tuomilehto J, Jousilahti P (1994) Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. Wietlisbach V, Paccaud F, Rickenbach M, Gutzwiller F (1997) Trends in car- diovascular risk factors (1984–1993) in a Swiss region: results of three pop- ulation surveys. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. Cryan Editors M icrobial ndocrinology: T he icrobiota-G ut-B rain A xis in ealth and isease Editors Mark Lyte John F. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. The use of general descriptive names, registered names, trademarks, service marks, etc. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www. Mark Lyte: “To my loving wife and my two remarkable sons who are my pillars of strength” Prof. The first volume published by Springer in 2010, “Microbial Endocrinology: Interkingdom Signaling in Infec- tious Disease and Health”, contained little in regard to brain and behavior, but instead focused almost exclusively on aspects of infectious disease. Health conse- quences as such were mainly concerned with the role that stress could play in altering the interface between host and microbiota. The present volume is therefore a testament to the great strides during the intervening years which have illuminated the myriad ways in which microbiota interfaces with the host. It is anticipated that future volumes in this series will reflect the ever increasing acceleration of research into the microbiota–gut–brain axis. Preface If one was to ask whether a book dealing with the ability of the microbiota to influence the brain, and ultimately cognition and behavior, would have been possible just a few short years ago, the answer would most likely be no. However, this would not be an accurate reflection of the work that has been ongoing for many decades, but yet remained on the outer fringes of the disciplines that constitute the study of the mechanisms by which the microbiota and the brain communicate with each other. A comprehensive series of articles by Bested and colleagues [1] catalog the numerous studies going back over a century which amply demonstrate that the investigation of the role of the microbiota in brain function, and by extension mental health, has a long and varied (some may say checkered) scientific history. During this time it remained, for large measure, outside mainstream scientific inquiry following an initial burst of enthusiasm both in the scientific and public arenas at the turn of the twentieth century. That such scientific skepticism remained, and in many cases became entrenched, in the very scientific disciplines that form the basis of the microbiota–gut–brain axis is owed to a number of factors. One of these is surely the increasing specialization that occurred within each discipline over the years and the inherent lack of interdisciplinary thought that accompanied such specialization. With the advent of the concerted research into the microbiota and the microbiome, as best evidenced by the tremendous strides that the Human Microbiome Project has made over the last decade in cataloging the incredible diversity in the microbiota in health and disease, the realization that the microbiota has a role to play in the development and function of the nervous system and hence behavior and cognition, has once again entered into mainstream scientific and medical thought. In many conservative Learned Societies the concept that the gut and indeed the gut microbiota can have such an influence on brain & behavior is still looked upon with incredulity. In considering the microbiota as an interactive player in the host that can both respond to signals from the host and influence the host through the provision of the very same host signaling molecules (i. As such, the book is organized along three thematic lines which will provide the reader not only a fuller understanding of the capabilities of the microbiota to interface with the brain and form the microbiota–gut–brain axis, but will also provide detailed examination of the consequences of the microbiota-driven gut- to-brain communication for both health and disease. The first four chapters cover the “Basic Concepts Underlying the Microbiota–Gut–Brain Axis”; the next eight chapters examine the “Mechanistic Factors Influencing the Microbiota–Gut–Brain Axis” and the concluding seven chapters address the “Microbiota–Gut–Brain Axis in Health and Disease”. We have assembled a group of contributors who are recognized to be at the front of their respective fields to review the state of the art of this growing field. As the chapters in this book amply demonstrate, the field of microbiota–gut–brain axis is still in its infancy although its origins are now over a century old. With the advent of modern techniques ranging from deep pyrosequencing of the microbiota to brain imaging, the tools are in place to address those questions which were raised many decades ago. Given our evolving understanding of the complexity of the microbiota which when one couples that to the complexity of the brain and nervous system, this book represents only one more chapter in what promises to be a long and challeng- ing story. Contents Part I Basic Concepts Underlying the Microbiota-Gut-Brain Axis 1 Microbial Endocrinology and the Microbiota-Gut-Brain Axis. Dinan, and Catherine Stanton 11 Multidirectional Chemical Signalling Between Mammalian Hosts, Resident Microbiota, and Invasive Pathogens: Neuroendocrine Hormone-Induced Changes in Bacterial Gene Expression. Anjam Khan 12 Influence of Stressor-Induced Nervous System Activation on the Intestinal Microbiota and the Importance for Immunomodulation. Gareau 17 The Impact of Microbiota on Brain and Behavior: Mechanisms & Therapeutic Potential. Borre, PhD Neurogastroenterology Lab, Alimentary Pharmabiotic Center, University College Cork, Cork, Ireland Brid P. Cryan, PhD Department of Anatomy and Neuroscience, University College Cork, Cork, Ireland Timothy G. As such, microbial endocrinology represents the intersection of the fields of microbiology and neurobiology. The acquisition of neurochemical-based cell-to-cell signaling mechanisms in eukaryotic organisms is believed to have been acquired due to late horizontal gene transfer from prokaryotic microorganisms. When considered in the context of the microbiota’s ability to influence host behavior, microbial endocrino- logy with its theoretical basis rooted in shared neuroendocrine signaling mecha- nisms provides for testable experiments with which to understand the role of the microbiota in host behavior and as importantly the ability of the host to influence the microbiota through neuroendocrine-based mechanisms. Earlier that year I had submitted an application for the Pioneer Award entitled “The Microbial Organ in the Gut” where I proposed that bacteria in the gut were not only able to communicate with the brain and influence behavior, but also that the brain could likewise communicate with the gut bacteria to achieve regulation of microbial populations that would benefit the host. The mechanism by which this bi-directional communication was governed was proposed to be that of microbial endocrinology—the ability of bacteria to respond to as well as produce the same neurohormones found in the host.

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Since 400 μg daily is probably the upper limit of safety buy zenegra 100 mg visa, daily doses of 100 to 200 μg may be more realistic objectives for inhibiting genetic damage and cancino- genesis in humans proven 100 mg zenegra. Yeast-based selenium is approximately 40% selenomethionine zenegra 100mg without prescription, 20% other amino acid conjugates (e. Selenite and selenate are more bioavailable than selenomethionine; however, selenomethionine appears more effective at increasing selenium status. In one animal study, co-administration of vitamin C nullified the chemopreventive effect of inorganic selenium (selenite), but not that of selenomethionine. Animal studies have confirmed that the dose and form of selenium compounds are critical factors in determining cellular responses, inorganic selenium at doses up to 10 μmol, and organic selenium compounds Chapter 91 / Selenium (Se) 643 at doses equal to or greater than 10 μmol eliciting distinctly different cellular responses. Nonetheless, such findings are sup- ported by epidemiologic studies, which have shown that low selenium sta- tus is associated with an increased total cancer incidence, particularly of gastrointestinal, prostate, and lung cancers. While the protective effect of selenium against cancer is fairly well docu- mented, there is less clinical evidence to support the anti-inflammatory effect of selenium in arthritis. A recent clinical trial failed to demonstrate that selenium treatment (200 μg/day) achieved any clinical benefit in rheuma- toid arthritis. It is possible that selenium deficiency and vitamin E deficiency can activate latent viruses such as herpes. It appears that a normally avirulent viral genome may become pathogenic in a nutritionally deprived host. An experimental animal study has also found that growth retardation induced by selenium deficiency is associated with impaired bone metabolism and a reduction in bone mineral density. Hepatorenal damage, nausea, a metallic taste, nervous irritability, depression, weakness, unusual fatigue, and nausea and vomiting have also been reported. Clinically, findings consistent with selenium deficiency include fingernail and skin changes, cardiomyopathy, and skeletal muscle fatigue, tenderness, and weakness. Lu J, Jiang C: Antiangiogenic activity of selenium in cancer chemoprevention: metabolite-specific effects, Nutr Cancer 40(1):64-73, 2001. Brighthope I: Nutritional medicine tables, J Aust Coll Nutr Env Med 17:20-5, 1998. El-Bayoumy K: The protective role of selenium on genetic damage and on cancer, Mutat Res 475(1-2):123-39, 2001. Peretz A, Siderova V, Neve J: Selenium supplementation in rheumatoid arthritis investigated in a double blind, placebo-controlled trial, Scand J Rheumatol 30(4):208-12, 2001. Moreno-Reyes R, Egrise D, Neve J, et al: Selenium deficiency-induced growth retardation is associated with an impaired bone metabolism and osteopenia, J Bone Miner Res 16(8):1556-63, 2001. Sodium, the major cation in extracellular fluid, is critical for regulation of body fluids. It influences acid-base balance, nerve function, water balance, and blood pressure. The intake of sodium tends to be much higher than the recommended allowance, and a major source is from salt added to processed food. This active transport system main- tains an electrical potential with the inside of the cell being more negative than the outside. The excitability of nerve and muscle cells results from their ability to change this resting potential in response to electrochemical stimuli. Passive movement of sodium in distal renal tubular cells also influences fluid bal- ance. The epithelial sodium channel expressed in aldosterone-responsive epithe- lial cells of the kidney and colon plays a critical role in the control of sodium balance, blood volume, and blood pressure. Aldosterone conserves sodium by increasing activity of the sodium pump in the kidney. It is found in fruits and vegetables, but more concen- trated sources of sodium are table salt, sea salt, processed food, kelp, and cel- ery. This is far in excess of any physiologic need, and it is likely the harmful effects of sodium are expressed above a threshold of approximately 2. Two determinants of blood pressure are circulating blood volume and vascular tone, both of which are influenced by sodium. Sodium restriction is routinely recommended for borderline and definitive cases of hypertension. However, the hypothesis that suggests higher levels of salt in the diet leads to higher levels of blood pressure and increases the risk of cardiovascular disease remains unproven. Four of the popula- tions did have low levels of salt and blood pressure, but across the other 48 populations, blood pressures went down as salt levels went up. Recent rig- orous reviews of salt restriction trials in normal subjects show extremely small effects ranging from 1 to 2 mm Hg for systolic blood pressure and 0. Population studies have not been able to show an association between salt intake and unfavorable health outcome. Experimental evidence suggests that the effect of a large reduction in salt intake on blood pressure is modest. Furthermore, based on population and randomized studies, the effect of an extreme salt reduction of 100 mmol on blood pressure in hypertensive persons only accounts for about one third of the effect of antihypertensive medication. Despite sodium restriction being a popular clinical recommendation, the health conse- quences of sodium reduction have yet to be determined. Salt reduction may have unfavorable effects on heart rate and serum lev- els of renin, aldosterone, catecholamines, and lipids. In short-term clinical studies, very low sodium intakes (<50 mmol/day) have been associated with greater values for total and low-density lipoprotein cholesterol, fasting and postglucose insulin, uric acid, and plasminogen activator inhibitor-1. Routinely, advocating salt restriction in the management of hypertension is being questioned. Calculation of specific individual “salt-sensitive risk profiles” based on knowledge of hypertension genes and environmental risk factors influenc- ing the pressor response to salt is desirable. Genetically defined forms of a salt sensitivity and salt resistance in human monogenic diseases and in ani- mal models have been reviewed,8 as has the pathophysiology of essential hypertension. Swales J: Population advice on salt restriction: the social issues, Am J Hypertens 13(1 Pt 1):2-7, 2000. Graudal N, Galloe A: Should dietary salt restriction be a basic component of antihypertensive therapy? Zoccali C, Mallamaci F: The salt epidemic: old and new concerns, Nutr Metab Cardiovasc Dis 10(3):168-71, 2000. Kurokawa K: Salt, kidney and hypertension: why and what to learn from genetic analyses? Brighthope I: Nutritional medicine tables, J Aust Coll Nutr Env Med 17:20-5, 1998. Soybeans, and particularly the isoflavones contained in soy, have generated interest as chemopreventive agents.

Formal advice and support is normally appropriate when the student demonstrates: A continuing pattern of minor defcits which when viewed in isolation may seem insignifcant but when seen cumulatively indicate an issue which has not been resolved by informal advice and support An isolated (but not gross) lapse from previously high standards buy cheap zenegra 100mg on-line. Formal advice and support including remediation therefore may buy zenegra 100 mg amex, depending on the nature of the defcit buy discount zenegra on line, be based on the outcome of initial informal advice and support, which was found to be insuffcient to produce the necessary improvement, or may be the frst recourse. All those involved in teaching and administrative support should be aware that there is a framework and clear channels for referral of a student for formal advice and support including remediation. Medical schools are best placed to decide on the requisite level of seniority, experience and competency that an effective evaluation group would comprise. Consideration should be given however as to whether it is appropriate for an individual who has been involved in providing informal advice and support to a particular student to participate in formal advice and support for the same student: it may be that these roles are best played by different individuals. While a number of individuals are likely to be involved in the process, an individual should be identifed as the focal point for liaison with the student regarding their identifed defcit. They should, after appropriate consultation, including with the student, draw up an action plan intended to address and resolve the student’s professionalism defcit(s). The action plan should be a joint commitment between the student and the identifed focal point of the Stage One group and should be: Relevant to the student and the issue(s) Transparent in terms of timescale and expected outcome(s) Realistic Measurable in terms of evaluation of the students’ progress and the scope for attainment of the plan. An action plan could include commitments regarding: Attending remedial teaching Attending a support service Additional mentoring or supervision Adhering to specifed behaviour(s) Discontinuing a specifed behaviour. If there is a positive outcome, there should be a sign off to this effect by the student and the school. The student may be advised to use informal support and advice to maintain that improvement. It is anticipated that in many cases attempted remediation via an action plan will be tried as a frst option, and that it is only if that attempt is unsuccessful that the student will be referred to Stage Two. However, it must be emphasised that there is no onus on the medical school to take this course of action. If the nature of the professional defcit is such as to make it appropriate, then the student should be directly referred to Stage Two, without frst going through Stage One. This would be the normal course of action in the case of a potential gross breach of professionalism. Defnitions in these Guidelines of what constitutes a potential gross breach cannot be too prescriptive. However, defcits which fall into categories 1 (criminality), 2 (attitudes and behaviour towards patients), 3 (abuse, aggression, threat of violence, use of violence) or 7 (alcohol or substance misuse) of the Annex to these Guidelines indicates that the course of action that should normally be taken by the medical school would be direct referral to Stage Two. Defcits in other categories may depending on the nature of the defcit indicate direct referral. In particular, the medical school should always consider the possibility of a gross breach, and direct referral to Stage Two, where the defcit includes but is not limited to: Potential signifcant compromising of patient safety, dignity or well-being Potential signifcantly compromising of the safety, dignity or well-being of fellow students, medical school / university staff, or staff on clinical training sites Potential or actual criminal activity (including online). In the case of potential signifcant compromising of the safety, dignity or well-being of others, or of potential or actual criminal activity, the referral to Stage Two would normally be accompanied by suspension from the programme pending the outcome of Stage Two; or by curtailment of the student’s activities so as to remove the opportunity for further potential breaches, e. The process for formation of the pool and the panel should be clear and comply with good practice in equality and diversity. There should be clear Therms of Reference detailing the composition, remit and responsibilities of the pool and the panel. The panel’s reporting arrangements within the medical school and the university should be clear, including the various levels of approval that are required post-panel, and the appeals process. The relationship between this process and other codes, policies and processes within the school or university should be clear. There should be generic timelines which are intended to apply to all stages of all cases. If for good reasons the school cannot meet the anticipated milestones, this should be clearly communicated to the student. The school should be prepared to adjust timelines if the student presents reasonable grounds for that adjustment. The majority of the members of each panel should be from the student’s own medical school, but each panel should have at least one external member. Members of staff who have been closely involved in providing informal or formal advice and support to a particular student should not be members of the panel hearing that student’s case. As well as medical school staff, schools should also consider whether the following should be included in the pool: Externs from outside the State Nominees from patient representative groups Nominees from healthcare organisations Students Those with legal qualifcations/experience Those with counselling qualifcations/experience. If a pool of assessors is jointly established by the schools, consideration should be given to joint training of assessors. It would also tend to promote consistency of approach among panel members and thereby consistency in the decision-making process, both within medical schools and among medical schools. Training should include developing comprehensive knowledge and understanding of the relevant internal polices and processes and their application and (in due course) comprehensive knowledge and understanding of these Medical Council Guidelines. Proceedings should be fair and transparent and, among other things, the process should: Provide the student in advance with the information upon which the Panel will adjudicate Advise the student in advance of their right to representation and/or support Ensure that the conduct of meetings is in line with best practice Ensure that the student (if they chose to attend) has an opportunity to make their case Make their decision on the grounds of balance of probability Prescribe an appropriate course of action Provide a report to both parties that clearly specifcs the decision and the reason for it Maintain all relevant records are kept of all panel deliberations, confdentially and in line with university policies and relevant data protection legislation. The range of options open to the panel should be specifed, and normally include: No defcit (no action required, informal advice and support may be indicated) Some defcit, such as to warrant a course of action not amounting to exclusion from the programme, which may include: ◊ An admonition/reprimand and/or ◊ A requirement to undertake an additional course of study/period of study, or to repeat a period of study, or undertake some other prescribed action and/or ◊ Restitution and/or ◊ Suspension for a specifed period. The fnding of some defcit should be reserved for cases where the Panel believes that there is at least the potential for the student to be remediated, and where the student is willing to take the action required. In a fnding of some defcit, the action taken should: Be appropriate for the specifc case and the issues that prompted the Panel meeting Include a timescale and an expected outcome that can be measured and used to benchmark progress Be proportionate, realistic and achievable. In all cases, the outcome should be communicated to the student in a timely manner. The process for formation of the pool and the panel should be clear and comply with good practice in equality and diversity. Those who have been closely involved in informal or formal advice and support for a particular student, and those who served on the panel that considered that student’s case, should not sit on the Appeals Panel. There should be clear Therms of Reference detailing the remit, responsibilities and composition of the Appeals pool and the panel. The Therms of Reference should include: The grounds on which an appeal may be made, including extenuating circumstances that may be taken into account The student’s representation at the appeal panel Admission or otherwise of fresh evidence The powers of the appeal panel The reporting arrangements of the appeal panel The potential outcomes, e. As always, patient safety and well-being and the interests of the public should be uppermost in the decision-making process. All panel-related information, including the outcome, should be dealt with in a confdential manner, in line with university policies and in accordance with relevant data protection legislation. It refects a decision that is taken based on all the evidence available, the student is not ft to proceed to the next year of the programme or to graduate as a doctor. If the panel fnds that exclusion is the only way of protecting patients, peers, staff or the public, then it is the appropriate action to take. Schools will have to strike the balance between allowing a student the time and opportunity to beneft from the framework that is in place for formal advice and support including remediation, and prolonging the student’s career beyond the point at which improvement is feasible, which benefts neither the student, the school, patients nor the public. It is not possible to provide a defnitive list of professionalism defcits that provide grounds for expulsion. However, the severity of a single transgression, or a pattern of repeated and apparently intractable transgressions of a less serious but still signifcant nature, should be taken into account. Some potential grounds for exclusion are that the student has: Behaved in a way that is fundamentally incompatible with being a doctor Shown a reckless disregard for patient safety Done serious harm to others, patients or otherwise, either deliberately or through incompetence, particularly when there is a continuing risk to patients Abused their position of trust 37 Medical Council A Foundation For The Future Violated a patient’s rights or exploited a vulnerable person Committed offences of a sexual nature, including involvement in child pornography Committed offences involving violence Been dishonest, including covering up their actions, especially when the dishonesty has been persistent Put their own interests before those of patients Persistently shown a disregard or lack of insight into the seriousness of their actions or the consequences. Possessing insight (having or showing an accurate and deep understanding; being perceptive) is not a panacea. A student may have an awareness of the underlying cause(s) of their unprofessionalism, and an awareness of the impact of that on others, without being willing or able to address it.