The state of measles and rubella in the WHO European Region, 2013

Measles and rubella persist in the World Health Organization European Region despite long-standing and widespread use of vaccines against them. Our aim was to review the epidemiology of measles and rubella in relation to the goal of eliminating these diseases from the Region by 2015. We report on the number of measles and rubella cases by country in 2012 and present an analysis of preliminary measles and rubella surveillance data for 2013. We analysed data of these diseases for 2013 by age group, diagnosis confirmation (clinical, laboratory-confirmed and epidemiologically linked), and vaccination, hospitalization and importation status. We also report on measles-related deaths. For 2012, there were 26,785 [corrected] measles cases and 29,601 rubella cases reported in the Region. For 2013, these figures were 31,520 and 39,367 respectively. Most measles cases in 2013 (96%; n = 30,178) were reported by nine countries: Georgia (7830), Germany (1773), Italy (2216), the Netherlands (2499), Romania (1074), the Russian Federation (2174), Turkey (7404), Ukraine (3308) and the United Kingdom (1900). In 2013, most measles cases were among unvaccinated persons and over one in three patients were aged 20 years and older. For 2013, almost all rubella cases were reported by Poland (n = 38,585; 98%). High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. Without sustained political commitment and accelerated action by Member States and partners, the elimination of measles and rubella in the WHO European Region may not be achieved.

The Impact of the Australian and New Zealand College of Anaesthetists’ Specialist Examinations on Trainee Learning and Wellbeing: A Qualitative Study

Assessment is an essential component of any medical specialist training program and should motivate trainees to acquire and retain the knowledge and skills essential for specialist practice, and to develop effective approaches to learning, essential for continuous professional development. Ideally, this should be achieved without creating an unreasonable burden of assessment. In this qualitative study we sought to investigate the underlying processes involved in trainees’ preparation for Australian and New Zealand College of Anaesthetists’ examinations, focusing on how the examinations helped trainees to learn the Australian and New Zealand College of Anaesthetists’ curriculum, and to identify any potential areas for improvement. We also explored the effect the examinations had on trainees’ lives, to identify if the examinations were a potential threat to their wellbeing. Using a phenomenological approach and purposive sampling, we conducted semi-structured interviews with post-fellowship trainees (n=20) selected from three different regions, with sampling continuing to achieve data saturation. We undertook a thematic analysis of the transcribed interview data utilising a general inductive approach. Our preliminary data suggest that, while the examinations are an important extrinsic motivator to learn and important for professional development, interviewees described many test-driven learning strategies, including rote learning and memorising past examination questions. A strong theme was the considerable impact on participants’ relationships and social activities for prolonged periods. Our findings support further research in this area and, in particular, into alternative testing strategies that might increase the proportion of time spent in useful study while decreasing less useful study time.

Strategies for recruitment of relatives of BRCA mutation carriers to a genetic testing program in the Bahamas

The prevalence of BRCA1 and BRCA2 mutations among unselected breast cancer patients in the Bahamas is 23%. It is beneficial to advise relatives of mutation carriers that they are candidates for genetic testing. Women who test positive are then eligible for preventive interventions, such as oophorectomy. It is not clear how often relatives of women with a mutation in the Bahamas wish to undergo genetic testing for the family mutation. Furthermore, it is not clear how best to communicate this sensitive information to relatives in order to maximize patient compliance. We offered genetic testing to 202 first-degree relatives of 58 mutation carriers. Of 159 women who were contacted by the proband or other family member, only 14 made an appointment for genetic testing (9%). In contrast, among 32 relatives who were contacted directly by the genetic counselor, 27 came for an appointment (84%). This study suggests that for recruitment of relatives in the Bahamas, direct contact by counselor is preferable to using the proband as an intermediary.

Exploiting the architecture and the features of the microsporidian genomes to investigate diversity and impact of these parasites on ecosystems

Fungal species play extremely important roles in ecosystems. Clustered at the base of the fungal kingdom are Microsporidia, a group of obligate intracellular eukaryotes infecting multiple animal lineages. Because of their large host spectrum and their implications in host population regulation, they influence food webs, and accordingly, ecosystem structure and function. Unfortunately, their ecological role is not well understood. Present also as highly resistant spores in the environment, their characterisation requires special attention. Different techniques based on direct isolation and/or molecular approaches can be considered to elucidate their role in the ecosystems, but integrating environmental and genomic data (for example, genome architecture, core genome, transcriptional and translational signals) is crucial to better understand the diversity and adaptive capacities of Microsporidia. Here, we review the current status of Microsporidia in trophic networks; the various genomics tools that could be used to ensure identification and evaluate diversity and abundance of these organisms; and how these tools could be used to explore the microsporidian life cycle in different environments. Our understanding of the evolution of these widespread parasites is currently impaired by limited sampling, and we have no doubt witnessed but a small subset of their diversity.

A cautionary lesson on the use of targeted methods for EGFR mutation analysis: a case report

Epidermal growth factor receptor (EGFR) mutation analysis is recommended for lung cancer patients prior to the prescription of first-line EGFR tyrosine kinase inhibitors in order to predict response to treatment. There are many methods available to identify mutations in the EGFR gene; a large number of clinical laboratories use the therascreen EGFR RGQ PCR kit (Qiagen). We report a case where this kit detected an exon 19 deletion, predicting sensitivity to tyrosine kinase inhibitors (TKIs), which on further analysis was found to be a 2 bp indel (c.2239_2240delinsCC, p.(Leu747Pro)). Two of four published cases with this mutation were found to be associated with resistance to EGFR TKI. The sample was also tested using two other commercial kits, one of which indicated a deletion. This is a rare mutation making the erroneous detection of a deletion unlikely; however, it is important that clinical laboratories are aware of the potential failings of two commercial kits for EGFR mutation analysis.

A feasibility study testing four hypotheses with phase II outcomes in advanced colorectal cancer (MRC FOCUS3): a model for randomised controlled trials in the era of personalised medicine?

BACKGROUND

Molecular characteristics of cancer vary between individuals. In future, most trials will require assessment of biomarkers to allocate patients into enriched populations in which targeted therapies are more likely to be effective. The MRC FOCUS3 trial is a feasibility study to assess key elements in the planning of such studies.

PATIENTS AND METHODS

Patients with advanced colorectal cancer were registered from 24 centres between February 2010 and April 2011. With their consent, patients' tumour samples were analysed for KRAS/BRAF oncogene mutation status and topoisomerase 1 (topo-1) immunohistochemistry. Patients were then classified into one of four molecular strata; within each strata patients were randomised to one of two hypothesis-driven experimental therapies or a common control arm (FOLFIRI chemotherapy). A 4-stage suite of patient information sheets (PISs) was developed to avoid patient overload.

RESULTS

A total of 332 patients were registered, 244 randomised. Among randomised patients, biomarker results were provided within 10 working days (w.d.) in 71%, 15 w.d. in 91% and 20 w.d. in 99%. DNA mutation analysis was 100% concordant between two laboratories. Over 90% of participants reported excellent understanding of all aspects of the trial. In this randomised phase II setting, omission of irinotecan in the low topo-1 group was associated with increased response rate and addition of cetuximab in the KRAS, BRAF wild-type cohort was associated with longer progression-free survival.

CONCLUSIONS

Patient samples can be collected and analysed within workable time frames and with reproducible mutation results. Complex multi-arm designs are acceptable to patients with good PIS. Randomisation within each cohort provides outcome data that can inform clinical practice.

[Progress in the elimination of measles and rubella in the WHO European Region]

Substantial progress has been made in the World Health Organization (WHO) European Region toward reaching the goal of measles and rubella elimination. We analyzed the surveillance data of 2012 on measles and rubella for age-group, diagnosis confirmation status (clinical, laboratory-confirmed and epidemiologically linked), vaccination status, and measles-related deaths. For 2012, there were 23,871 measles cases and 29,361 rubella cases reported in the region, mostly among unvaccinated persons. Almost one in three patients with measles and one in five patients with rubella were aged 20 years and older. In a few countries, widespread outbreaks or indigenous transmission of measles persisted in 2012. While most countries in the region have controlled rubella, a small number still reported a high incidence and several outbreaks. Therefore, more efforts are required to achieve the goal of eliminating measles and rubella in the WHO European Region by 2015, particularly in high-incidence countries. The WHO measles and rubella elimination plan stipulates that all countries should achieve and maintain the required high vaccination coverage while conducting high-quality surveillance.

Reproductive decision making after the diagnosis of multiple sclerosis (MS)

OBJECTIVE

This study aimed to determine reproductive practices and attitudes of North Americans diagnosed with multiple sclerosis (MS) and the reasons for their reproductive decision making.

METHODS

A self-administered questionnaire on reproductive practices was mailed to 13,312 registrants of the North American Research Committee on Multiple Sclerosis (NARCOMS) database who met inclusion criteria for the study. Completed questionnaires were then returned to the authors in an anonymous format for analysis.

RESULTS

Among 5949 participants, the majority of respondents (79.1%) did not become pregnant following diagnosis of MS. Of these, 34.5% cited MS-related reasons for this decision. The most common MS-related reasons were symptoms interfering with parenting (71.2%), followed by concerns of burdening partner (50.7%) and of children inheriting MS (34.7%). The most common reason unrelated to MS for not having children was that they already have a "completed family" (55.6%). Of the 20.9% of participants who decided to become pregnant (or father a pregnancy) following a diagnosis of MS, 49.5% had two or more pregnancies.

CONCLUSION

This study indicates that an MS diagnosis does not completely deter the consideration of childbearing in MS patients of both genders.

Functional movement test scores improve following a standardized off-season intervention program in professional football players

The purpose of this study was to determine if an off-season intervention program was effective in improving Functional Movement Screen(™) (FMS) scores in professional American football players. Pre- and post-intervention FMS scores were obtained on 62 subjects who completed a 7-week off-season intervention program. A repeated measures ANOVA was conducted to determine the effectiveness of the training program on FMS scores. A chi-square was performed to determine if there were a greater number of players who met the injury threshold and if asymmetries were reduced following intervention. Logistic regression was used to predict what factors were associated with failure (post-test score of <14). There was a positive main effect for time (P<0.01) and a greater number of individuals with a score >14 following the intervention. At post-test, 41 players were free of asymmetry as compared with 31 at the pre-test. The strongest predictor of program failure was a low squat score at pre-test. This study demonstrated that fundamental movement characteristics do change with a standardized intervention. Further research is required to determine if injury risk is reduced when a player's score improves beyond the established cut-off of 14 and/or asymmetry is resolved.

Who attends a UK diabetes screening programme? Findings from the ADDITION-Cambridge study

AIMS

One of the factors influencing the cost-effectiveness of population screening for Type 2 diabetes may be uptake. We examined attendance and practice- and individual-level factors influencing uptake at each stage of a diabetes screening programme in general practice.

METHODS

A stepwise screening programme was undertaken among 135, 825 people aged 40-69 years without known diabetes in 49 general practices in East England. The programme included a score based on routinely available data (age, sex, body mass index and prescribed medication) to identify those at high risk, who were offered random capillary blood glucose (RBG) and glycosylated haemoglobin tests. Those screening positive were offered fasting capillary blood glucose (FBG) and confirmatory oral glucose tolerance tests (OGTT).

RESULTS

There were 33 539 high-risk individuals invited for a RBG screening test; 24 654 (74%) attended. Ninety-four per cent attended the follow-up FBG test and 82% the diagnostic OGTT. Seventy per cent of individuals completed the screening programme. Practices with higher general practitioner staff complements and those located in more deprived areas had lower uptake for RBG and FBG tests. Male sex and a higher body mass index were associated with lower attendance for RBG testing. Older age, prescription of antihypertensive medication and a higher risk score were associated with higher attendance for FBG and RBG tests.

CONCLUSIONS

High attendance rates can be achieved by targeted stepwise screening of individuals assessed as high risk by data routinely available in general practice. Different strategies may be required to increase initial attendance, ensure completion of the screening programme, and reduce the risk that screening increases health inequalities.