Shifting attitudes: the National Education Programme for work and health

BACKGROUND

Evidence suggests that general practitioners (GPs) find fitness for work certification and work- related consultations challenging. The Royal College of General Practitioners was commissioned in 2009 to develop and roll out a National Education Programme (NEP) funded by the Department for Work and Pensions for a period of 2 years.

AIMS

To develop and evaluate a face-to-face educational programme that shifts GPs' attitudes to the management of the consultation about work and health.

METHODS

A 3 hour interactive programme that addressed both knowledge and skills for the management of the health and work consultation using behaviour-change principles was developed. Evaluation focused on delegates' confidence in managing the work and health consultation and the importance (priority) they gave to the subject. Questionnaires at three time points were constructed: pre, immediately post and 3 months post training.

RESULTS

A total of 152 workshops were evaluated across the UK between July 2009 and March 2011. A total of 2865 GPs attended the workshops. Questionnaire response rates were 78% pre workshop, 80% post workshop and 14% 3 months post workshop. Evaluation showed a significant increase in GPs' confidence in managing the consultation regarding work and health, and GPs gave higher priority to these types of consultations after the training.

CONCLUSIONS

The NEP has brought the training about health and work to prominence in general practice, and has also influenced policy and practice in other medical specialties.

Surface-enhanced Raman spectroscopy using gold-coated horizontally aligned carbon nanotubes

Gold-coated horizontally aligned carbon nanotube (Au-HA-CNT) substrates were fabricated for surface-enhanced Raman spectroscopy (SERS). The Au-HA-CNT substrates, which are granular in nature, are easy-to-prepare with large SERS-active area. Enhancement factors (EFs) of ∼10(7) were achieved using the Au-HA-CNTs as substrates for rhodamine 6G (R6G) molecules. Maximum enhancement was found when the polarization direction (E-field) of the incident laser beam was parallel to the aligned direction of the HA-CNTs. Simulations using the finite-difference time-domain (FDTD) method were carried out for the granular Au-HA-CNT samples. Enhancement mechanisms and determination of EFs were analyzed. Biological samples, including (13)C- and deuterium (D)-labeled fatty acids and Coccomyxa sp. c-169 microalgae cells, were also measured using this SERS substrate. The limits of detection (LODs) of D- and (13)C-labeled fatty acids on the SERS substrate were measured to be around 10 nM and 20 nM, respectively. Significantly enhanced Raman signals from the microalgae cells were acquired using the SERS substrate.

P4-08-03: Serum Autoantibodies to Breast Cancer Associated Antigens Reflect Tumor Biology: An Opportunity for Early Detection & Prevention?

Autoantibodies (AABs) are produced as an immune response to abnormal ('non-self') cancer antigens. Previous studies have reported that AABs can be measured in the blood long before cancers are presently diagnosed, e.g., up to 4 years before screening mammography identified breast cancers and up to 5 years before screening CT detected lung cancers. EarlyCDT™-Lung is currently available as an aid to early detection of lung cancer in high risk patients and measures a panel of seven AABs to general cancer antigens and also lung cancer (LC) specific antigens. These AABs have previously been reported to be associated with the two main types of LC i.e., non-small cell and small cell LC. This study looked at AABs to 4 general cancer antigens to evaluate whether their levels reflected different biology in primary breast tumors.

Methods

770 patients presented with primary breast cancer to three centers (Nottingham, UK n=323; Munich, Germany n=320; Oklahoma, USA n=127); the median ages and ranges were 61 (26-82), 61 (20-88) & 65 (54-84) years, respectively. All had serum samples taken post-diagnosis and pre-treatment. The tumors were well characterized for histological grade, estrogen receptor (ER), progesterone receptor (PgR) and HER2 status. Serum samples were tested for AABs to four generic cancer antigens(Ags) (p53, SOX2, NY-ESO-1 and Annexin1) originally included as part of Oncimmune's EarlyCDT™-Lung assay. The AABs were measured by ELISA on the Oncimmune platform, and the EarlyCDT™-Lung cutoffs were used to determine positivity.

Results

131/770 (17%) of primary breast cancers showed elevated AAB levels to one or more of the limited panel of four generic antigens. Positivity for each AAB was correlated with histological grade, ER, PgR and HER2 status. The results, which were similar for each of the three centres, were combined, and the results are shown in Table 1 below.

First Report of White Pine Blister Rust Caused by Cronartium ribicola on Immune Black Currant Ribes nigrum Cv. Titania in Preston, Connecticut

Since the relaxation of federal sanctions on the planting of Ribes crops because of the development of white pine blister rust (WPBR) immune Ribes cultivars (3), a small industry for the production of Ribes fruit for fresh and processing markets was established in New York and surrounding New England states. The majority of Ribes acreage in the region is planted to a WPBR immune black currant R. nigrum cv. Titania. From 2008 to June 2011, symptoms resembling those caused by WPBR pathogen Cronartium ribicola were observed at a large (>12 ha) R. nigrum cv. Titania planting in Preston, CT. In 2008, infection was restricted to a single field (100% incidence), but in 2009, all fields suffered from premature defoliation by late July. In 2010 and 2011, there was considerable incidence (>85%), but premature defoliation was kept in check by chemical management. Symptoms began as chlorotic lesions (0.5 to 4.3 mm in diameter) on both sides of the leaf. These chlorotic lesions had margins delineated by leaf veins and many developed necrotic (0.3 to 0.9 mm in diameter) centers on the upper surface of leaves within 2 to 3 weeks. The undersides of lesions developed blisters containing orange uredinia (0.1 to 0.33 mm in diameter) with smooth peridia that broke with the production of yellow-orange urediniospores (30 × 15 to 25 μm). Symptoms and signs were consistent with published descriptions of C. ribicola (1) and with WPBR infections on highly susceptible R. nigrum cv. Ben Alder planted at the New York State Agricultural Experiment Station in Geneva. Additional confirmation was provided by sequencing the two internal transcribed spacer (ITS) regions and the 5.8S gene (GenBank Accession No. JN587805; 98% identity with No. DQ533975) in the nuclear ribosomal repeat using primers ITS1-F and ITS4 as described previously (2,4). Furthermore, an attempt was made to confirm pathogenicity in the greenhouse by inoculating shoots of potted nursery stock of R. nigrum cv. Titania. Shoots were inoculated by rubbing leaves with either an uninfected currant leaf or a currant leaf from Preston, CT sporulating with urediniospores. Plants were subsequently misted with dH20 and covered with plastic bags for 24 h. Plants were watered biweekly and kept in a greenhouse with 39 to 65% relative humidity at 21 to 26°C. Shoots were monitored for symptom development on a weekly basis. After 3 weeks, 2 of the 10 plants inoculated with infected leaves developed chlorotic lesions and uredinia identical to those on leaves from Preston, CT, while all others remained healthy. Although not easily reproducible in a greenhouse, the breakdown of immunity in R. nigrum cv. Titania was observed for the last 4 years in Connecticut. Given that WPBR immunity was one of the conditions for legalized planting of Ribes, the breakdown of immunity has potentially deleterious implications particularly for nearby states like Massachusetts and New York, in which the Ribes industries are expanding. Moreover, Ribes growers may need to rely on chemical management programs to manage WPBR in the future. References: (1) G. B. Cummins. Illustrated Genera of Rust Fungi. Burgess Publishing Company, Minneapolis, MN, 1959. (2) M. Gardes and T. D. Bruns. Mol. Ecol. 2:113, 1993. (3) S. McKay. Hortic. Technol. 10:562, 2000. (4) T. J. White et al. PCR Protocols: A Guide to Methods and Applications. Academic Press, Inc., San Diego, CA, 1990.

Clinical and laboratory features of patients with myophosphorylase deficiency (McArdle disease)

Mutations of PYGM, the gene encoding human myophosphorylase, produce a metabolic myopathy characterised by exercise intolerance and, in some patients, myoglobinuria. To illustrate the clinical and laboratory features of myophosphorylase deficiency, we describe 10 patients diagnosed in Auckland, New Zealand, between 1989 and 2009. We review the clinical, biochemical, and histologic features and the results of mutation analysis. All patients reported exercise intolerance since childhood or the teenage years, starting within minutes of moderate or intense exertion. The "second wind" phenomenon, or myoglobinuria, were each reported in about half the patients. The serum creatine kinase concentration was elevated in all patients where this had been measured. Muscle biopsies revealed subsarcolemmal vacuolation and histochemical absence of myophosphorylase. Analysis of PYGM showed mutations in all alleles, most commonly Arg49Ter or Gly204Ser. One patient harbored a novel mutation, Pro488Arg, predicted to seriously disrupt the tertiary structure of the enzyme. Myophosphorylase deficiency produces a fairly uniform set of symptoms, and consistent elevation of the serum creatine kinase concentration. The diagnosis can be confirmed in most patients by mutation analysis using a blood sample.

Evaluation of effectiveness and satisfaction outcomes of a mental health screening and referral clinical pathway for community nursing care

The study aimed to explore the effectiveness of a mental health screening and referral clinical pathway for generalist community nursing care of war veterans and war widow(er)s in Australia on outcomes of client self-reported mental health, quality of life, and client and carer satisfaction. The pathway was developed by literature review and consultation, then trialled and evaluated. Validated screening tools were embedded within the pathway to support generalist nurses' mental health decision making. Pre- and post-measures were applied. Clients on whom the pathway was trialled were invited to complete an evaluation survey questionnaire, as were their informal carers. Most clients and carers who responded to these questionnaires were highly satisfied or satisfied with care provided through application of the pathway. This study adds understanding about one way that community nurses might identify people with mental health difficulties. The trialled pathway, which was modified and refined following the study, is now available on the Internet as an evidence-based resource for community nurses in Australia to guide practice and maximize holistic care for war veterans and war widow(er)s where that care is funded by Department of Veterans' Affairs.

The Non-Aqueous Titration of Phenolic Compounds

The published methods for the titration of very weak acids are reviewed and the choice of a suitable solvent, electrode system and titrant discussed. Ethylenediamine as a solvent is rejected for routine purposes because it is toxic and unpleasant in use. Dimethylformamide is a suitable solvent for phenolic substances and gives a titration curve with a step at the end point of at least 75 mV. This is nearly the bottom limit of practicability, using tetrabutylammonium hydroxide in benzene and methanol as titrant. The electrode system preferred for its reliability is a glass indicator electrode and a saturated calomel half cell, slightly modified, as reference electrode.

Review article: reflux and its consequences--the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP) Kingston-upon-Hull, UK, 21-23 April 2010

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is one of the commonest diseases of Western populations, affecting 20 to 30% of adults. GERD is multifaceted and the classical oesophageal symptoms such as heartburn and regurgitation often overlap with atypical symptoms that impact upon the respiratory system and airways. This is referred to as extra-oesophageal reflux disease (EERD), or laryngopharyngeal reflux (LPR), which manifests as chronic cough, laryngitis, hoarseness, voice disorders and asthma.

AIM

The 'Reflux and its consequences' conference was held in Hull in 2010 and brought together a multidisciplinary group of experts all with a common interest in the many manifestations of reflux disease to present recent research and clinical progress in GERD and EERD. In particular new techniques for diagnosing reflux were showcased at the conference.

METHODS

Both clinical and non-clinical key opinion leaders were invited to write a review on key areas presented at the `Reflux and its consequences' conference for inclusion in this supplement.

RESULTS AND CONCLUSION

Eleven chapters contained in this supplement reflected the sessions of the conference and included discussion of the nature of the refluxate (acid, pepsin, bile acids and non-acid reflux); mechanisms of tissue damage and protection in the oesophagus, laryngopharynx and airways. Clinical conditions with a reflux aetiology including asthma, chronic cough, airway disease, LPR, and paediatric EERD were reviewed. In addition methods for diagnosis of reflux disease and treatment strategies, especially with reference to non-acid reflux, were considered.

Towards a Personal Health Management Assistant

We describe design and prototyping efforts for a Personal Health Management Assistant for heart failure patients as part of Project HealthDesign. An assistant is more than simply an application. An assistant understands what its users need to do, interacts naturally with them, reacts to what they say and do, and is proactive in helping them manage their health. In this project, we focused on heart failure, which is not only a prevalent and economically significant disease, but also one that is very amenable to self-care. Working with patients, and building on our prior experience with conversational assistants, we designed and developed a prototype system that helps heart failure patients record objective and subjective observations using spoken natural language conversation. Our experience suggests that it is feasible to build such systems and that patients would use them. The system is designed to support rapid application to other self-care settings.

Attitudes to work and health in doctors in training

BACKGROUND

To date initiatives about work and health issues have been focused on general practitioners (GPs). The recent change to sickness certification (fit note) now requires all hospital doctors to provide patients in their immediate care with a MED 3 where necessary.

AIMS

To investigate the attitudes and behaviours of hospital-based trainees to the management of work and health in their consultations and their sickness certification practices to inform future training in this area.

METHODS

A questionnaire was developed to gather information on the attitudes of trainees to the assessment and provision of advice about fitness for work and the frequency of providing sickness certificates. This electronic survey was sent to trainees from the London and Wales deaneries.

RESULTS

Nine hundred and eighteen trainees were recruited to the study across 23 specialities. 85% of the sample responded that they rarely or never wrote certificates. Over 70% suggested that it was important to consider work and health as part of their rehabilitation plan. However, 69% suggested that they were not confident in assessing a patient's fitness to work (FTW). Over 70% of trainees reported not having sufficient knowledge or training to assess and manage a patient's FTW.

CONCLUSIONS

This evaluation has demonstrated that trainees recognize the importance of addressing heath and work, but lack the confidence to do this effectively. They recognize their lack of knowledge in this area. This highlights the need to address current training programmes for secondary care practitioners.

Measurement of the depth of maximum of extensive air showers above 10{18} eV

We describe the measurement of the depth of maximum, X{max}, of the longitudinal development of air showers induced by cosmic rays. Almost 4000 events above 10;{18} eV observed by the fluorescence detector of the Pierre Auger Observatory in coincidence with at least one surface detector station are selected for the analysis. The average shower maximum was found to evolve with energy at a rate of (106{-21}{+35}) g/cm{2}/decade below 10{18.24+/-0.05} eV, and (24+/-3) g/cm{2}/decade above this energy. The measured shower-to-shower fluctuations decrease from about 55 to 26 g/cm{2}. The interpretation of these results in terms of the cosmic ray mass composition is briefly discussed.

Predictors of response to Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder: an exploratory study

OBJECTIVE

Few predictors of treatment outcome or early discontinuation have been identified in persons with borderline personality disorder (BPD).

AIM

The aim of the study was to examine the relationship between baseline clinical variables and treatment response and early discontinuation in a randomized controlled trial of System Training for Emotional Predictability and Problem Solving, a new cognitive group treatment.

METHOD

Improvement was rated using the Zanarini Rating Scale for BPD, the Clinical Global Impression Scale, the Global Assessment Scale and the Beck Depression Inventory. Subjects were assessed during the 20 week trial and a 1-year follow-up.

RESULTS

Higher baseline severity was associated with greater improvement in global functioning and BPD-related symptoms. Higher impulsivity was predictive of early discontinuation. Optimal improvement was associated with attending > or = 15 sessions.

CONCLUSION

Subjects likely to improve have the more severe BPD symptoms at baseline, while high levels of impulsivity are associated with early discontinuation.

Integrating a 1.5 T MRI scanner with a 6 MV accelerator: proof of concept

At the UMC Utrecht, The Netherlands, we have constructed a prototype MRI accelerator. The prototype is a modified 6 MV Elekta (Crawley, UK) accelerator next to a modified 1.5 T Philips Achieva (Best, The Netherlands) MRI system. From the initial design onwards, modifications to both systems were aimed to yield simultaneous and unhampered operation of the MRI and the accelerator. Indeed, the simultaneous operation is shown by performing diagnostic quality 1.5 T MRI with the radiation beam on. No degradation of the performance of either system was found. The integrated 1.5 T MRI system and radiotherapy accelerator allow simultaneous irradiation and MR imaging. The full diagnostic imaging capacities of the MRI can be used; dedicated sequences for MRI-guided radiotherapy treatments will be developed. This proof of concept opens the door towards a clinical prototype to start testing MRI-guided radiation therapy (MRIgRT) in the clinic.

Design of a Testing Mechanism for Stent Failure Rates and Displacement Under Extreme Bending Conditions

Stents are commonly associated with the mechanical support of the coronary arteries to improve blood flow and retain residual plaque following various angioplasty procedures. However, they are becoming more frequently used in other vessels in the human body, such as the carotid and femoral arteries. The femoral arteries transverse through the hip region, and are the sites of potential plaque build-up. Thus the design of a stent for the specific biomechanical stresses and conditions of this location is of growing interest. The effectiveness of stent designs are quantified by their ability to survive in the human body without failing mechanically, dislocating, or invoking a major inflammatory response. Common methods of failure are mechanical, including fractures and dislocations. Several different instruments are commercially available for the testing of stents under various stresses and application frequency. However, these machines generally test with small bending angles or they apply nonphysiological axial, radial and torsional loads; thus they are not idealized for motions to mimic accurate biomechanical motion. Specifically, for the design of a stent localized in the hip region, a test for significant bending cases is necessary. The placement of stress on a mock artery should be applied solely to the ends of a mock artery to remove any radial or axial stresses not caused directly from the bending motion. Furthermore, visualization of the stent inside the mock artery is desired for tracking displacement of the stent and cycle count until failure. The ability to quantify the mechanical failure and dislocation of stent designs under extreme bending conditions is a prerequisite to the optimization of physical stent designs and of stent spacing, orientation and placement. We compare a proprietary stent-like design (Innovasc Inc., Honolulu, HI) placed at fixed intervals versus a commercially available SMART stent (Cordis Corporation, Warren, NJ). Both designs are intended to retain the arterial plaque while minimizing the stress applied to the artery wall to prevent restenosis. The new stent prototype designs are uniquely configured to enable points of stress reduction along the length of interest. Early preliminary experiments with the Innovasc design show promising results in the reduction of restenosis in porcine models. Stent designs are tested in mock arteries of latex and silicone. The mock arteries are selected for internal diameters and thicknesses to match artery properties. Two symmetric cylinders holsters are allowed to rotate freely and are affixed to the ends of the mock arteries. A simple linkage system drives the two cylinders together and apart, allowing for the mock arteries to bend at a fixed angle of 120 degrees at frequencies (∼10–20 Hz) without external stresses for one million cycles. Images are captured using a X-Stream Vision High-Speed CMOS camera (Integrated Design Tools, Tallahassee, FL) via a trigger system. Failure points and dislocations are noted and measured using the NIH ImageJ imaging software.

A comprehensive view of the structure and expression of the ependymoma genome at presentation and relapse

2073

Background: Although pediatric and adult ependymomas are associated with significant mortality and morbidity, little is known about the biology of these tumors. To identify underlying genetic alterations and cellular pathways that drive this disease, we conducted a genomic study of 200 adult and pediatric ependymomas. Methods: Using 500k single nucleotide polymorphism arrays, U133 Affymetrix gene and microRNA (miRNA) expression microarrays, and appropriate bioinformatics, we characterized 56 supratentorial (ST), 104 posterior fossa (PF), and 40 spinal (SP) ependymomas. Real-Time polymerase chain reaction and fluorescence in situ hybridization validated observed genetic events. Results: Gene expression profiles segregated tumors by site and identified disease subgroups within each anatomical region (4 ST, 4 PF, 1 SP). miRNA expression profiles identified these same subgroups, indicating that they are biologically distinct. Subgroup-specific gene expression profiles were dictated partly by developmental regulatory genes and partly by large chromosomal gains (eg. 1q, 5p, 16p) and losses (eg. 9p, 22q). Integrated genetic and expression mapping revealed key candidate tumor suppressor (TSG) and onco- genes, likely drivers of these large alterations. While large chromosomal changes occurred more frequently in SP tumors (p < 0.0001), ST tumors averaged more focal changes (n = 13.2) than PF (n = 6.2) or SP tumors (n = 3.0) (p < 0.0001). A total of 29 and 33 non-random focal amplifications and deletions, respectively, encompassing 402 known genes and miRNA clusters, were validated, of which 80 displayed copy number driven expression. These genetic alterations targeted specific cellular functions (e.g., cell adhesion, cell-cycle, neuronal development) and pathways (e.g., NOTCH, EPHRIN, TP53). Our cohort also included five sample sets consisting of primary tumor and at least two corresponding relapses. Genomic analysis of these tumors identified large chromosomal alterations as well as focal gains and losses associated with disease relapse. Conclusions: We present a highly comprehensive view of the ependymoma genome, including 80 previously unrecognized candidate TSG and oncogenes that may afford diagnostic and therapeutic targets.

No significant financial relationships to disclose.

Integrating a 1.5 T MRI scanner with a 6 MV accelerator: proof of concept

At the UMC Utrecht, The Netherlands, we have constructed a prototype MRI accelerator. The prototype is a modified 6 MV Elekta (Crawley, UK) accelerator next to a modified 1.5 T Philips Achieva (Best, The Netherlands) MRI system. From the initial design onwards, modifications to both systems were aimed to yield simultaneous and unhampered operation of the MRI and the accelerator. Indeed, the simultaneous operation is shown by performing diagnostic quality 1.5 T MRI with the radiation beam on. No degradation of the performance of either system was found. The integrated 1.5 T MRI system and radiotherapy accelerator allow simultaneous irradiation and MR imaging. The full diagnostic imaging capacities of the MRI can be used; dedicated sequences for MRI-guided radiotherapy treatments will be developed. This proof of concept opens the door towards a clinical prototype to start testing MRI-guided radiation therapy (MRIgRT) in the clinic.