GenSLMs: Genome-scale language models reveal SARS-CoV-2 evolutionary dynamics

We seek to transform how new and emergent variants of pandemic-causing viruses, specifically SARS-CoV-2, are identified and classified. By adapting large language models (LLMs) for genomic data, we build genome-scale language models (GenSLMs) which can learn the evolutionary landscape of SARS-CoV-2 genomes. By pre-training on over 110 million prokaryotic gene sequences and fine-tuning a SARS-CoV-2-specific model on 1.5 million genomes, we show that GenSLMs can accurately and rapidly identify variants of concern. Thus, to our knowledge, GenSLMs represents one of the first whole genome scale foundation models which can generalize to other prediction tasks. We demonstrate scaling of GenSLMs on GPU-based supercomputers and AI-hardware accelerators utilizing 1.63 Zettaflops in training runs with a sustained performance of 121 PFLOPS in mixed precision and peak of 850 PFLOPS. We present initial scientific insights from examining GenSLMs in tracking evolutionary dynamics of SARS-CoV-2, paving the path to realizing this on large biological data.

Intelligent resolution: Integrating Cryo-EM with AI-driven multi-resolution simulations to observe the severe acute respiratory syndrome coronavirus-2 replication-transcription machinery in action

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) replication transcription complex (RTC) is a multi-domain protein responsible for replicating and transcribing the viral mRNA inside a human cell. Attacking RTC function with pharmaceutical compounds is a pathway to treating COVID-19. Conventional tools, e.g., cryo-electron microscopy and all-atom molecular dynamics (AAMD), do not provide sufficiently high resolution or timescale to capture important dynamics of this molecular machine. Consequently, we develop an innovative workflow that bridges the gap between these resolutions, using mesoscale fluctuating finite element analysis (FFEA) continuum simulations and a hierarchy of AI-methods that continually learn and infer features for maintaining consistency between AAMD and FFEA simulations. We leverage a multi-site distributed workflow manager to orchestrate AI, FFEA, and AAMD jobs, providing optimal resource utilization across HPC centers. Our study provides unprecedented access to study the SARS-CoV-2 RTC machinery, while providing general capability for AI-enabled multi-resolution simulations at scale.

OA16 A great imitator of scleroderma

Introduction/Background

Eosinophilic fasciitis is a rare disease of idiopathic aetiology, which can often mimic scleroderma in presentation and has been associated with haematological diseases. We present a case of eosinophilic fasciitis where the diagnosis was delayed due to the attribution of skin manifestations to scleroderma. This case highlights the importance of careful history and examination to recognize these differential diagnoses, prevent delay and improve outcome.

Description/Method

A 69-year-old gentleman was referred to the Rheumatology clinic with suspected diffuse cutaneous systemic sclerosis. He presented with a 9-month history of skin tightening, pain and swelling affecting his legs, finding it difficult to fully extend at the knees, to drive or walk. His symptoms progressed overtime with skin changes spreading to all four extremities, abdomen and back. He reported weight loss of 12Kg associated with early satiety. He also experienced intermittent numbness of his hands. There were no respiratory symptoms, dysphagia or Raynaud’s phenomenon reported. His medical history includes atrial fibrillation and asbestos exposure. Currently on Apixaban 5mg/daily and Bisoprolol 2.5mg/daily.

Physical examination revealed diffuse brown hyperpigmentation, erythema and thickened skin on his upper and lower limbs, abdomen and back, it was difficult to crease the skin and there was ‘peau d’orange’ appearance in his forearms. His face and hands were spared. Phalen's and Tinel’s tests were negative.

Prior to clinical review he was investigated for paraneoplastic disease: a CT chest, abdomen and pelvis showed an incidental cyst in the thymus and emphysema with no underlying malignancy. Laboratory tests showed normocytic normochromic anaemia with haemoglobin 112 g/L and eosinophilia 1.5 x 10⁹/L, elevated erythrocyte sedimentation rate 62mm/h, CRP 57mg/L, polyclonal hypergammaglobulinaemia IgA 4.3g/L and IgG 24.85g/L. The myeloma screen were negative.

The absence of Raynaud’s, and the distribution of skin changes sparing his face, hands and feet, eosinophilia and raised inflammatory markers, made the diagnosis of eosinophilic fasciitis. Histological analysis of a full thickness skin biopsy confirmed patchy lymphoplasmacytic inflammatory cell infiltrate within the fascia and spilling into subcutis, with eosinophils.

Subsequently, he was commenced on prednisolone 40mg/daily reducing regimen and Methotrexate 20mg/weekly, with a good response and regression of the swelling and pain. He is now able to walk without difficulty.

Discussion/Results

Eosinophilic fasciitis is rare. Symptoms can be similar to those of scleroderma, sometimes considered a variant. The exact aetiology is unknown; however, the literature mentions a potential paraneoplastic, inflammatory, infectious or physical trigger, leading to an abnormal response with accumulation of eosinophils in different tissues. Consequently, this may release transforming growth factor beta to activate fibroblasts, increasing expression of other factors in the connective tissue, resulting in fibrosis.

This case highlights that eosinophilic fasciitis present with hardening and thickening of the skin and surrounding tissue similar to that of scleroderma, however, lacks Raynaud’s phenomenon, sclerodactyly. Another striking features from his examination which helped us distinguishing from scleroderma was that his skin changes spare his face, hands and feet.

Carpal tunnel syndrome is described in the literature which can progress if untreated.

Typical blood tests findings documented in the literature include eosinophilia in 80% of the cases, elevated ESR and C-reactive protein (CRP), polyclonal hypergammaglobulinaemia, are usually present, however, eosinophilia may be transient, therefore normal eosinophil count does not exclude the disease. ANA and Rheumatoid factor can be positive in up to 10 % of the cases.

MRI of the extremities to look for thickening of the fascia has been used in other cases, however, it was not required in our case because our Orthopaedics colleagues helped us with performing an urgent full thickness biopsy.

Recommended treatment includes high dose steroids and immunosuppressive medication such Methotrexate is most often used for severe or resistant cases.

The prognosis is good, however if treatment is delayed patients can develop joint contractures in 85% of patients and skin hardness may persist.

In conclusion, careful history and examination is essential in differentiating scleroderma from the scleroderma-mimics especially when there is an atypical distribution, no sclerodactyly and no autoantibodies.

Key learning points/Conclusion

1. This case suggest that clinicians should be aware that eosinophilic fasciitis typically spare the hands, feet and face.

2. Eosinophilia may be transient, therefore normal count does not exclude the disease.

3. Recognizing this rare but great imitator of scleroderma set the stage for prompt therapy in either condition and reduce morbidity.

Neuropeptide-Y Levels in ST-Segment-Elevation Myocardial Infarction: Relationship With Coronary Microvascular Function, Heart Failure, and Mortality

Background

The sympathetic cotransmitter, neuropeptide Y (NPY), is released into the coronary sinus during ST‐segment–elevation myocardial infarction and can constrict the coronary microvasculature. We sought to establish whether peripheral venous (PV) NPY levels, which are easy to obtain and measure, are associated with microvascular obstruction, myocardial recovery, and prognosis.

Methods and Results

NPY levels were measured immediately after primary percutaneous coronary intervention and compared with angiographic and cardiovascular magnetic resonance indexes of microvascular function. Patients were prospectively followed up for 6.4 (interquartile range, 4.1–8.0) years. PV (n=163) and coronary sinus (n=68) NPY levels were significantly correlated (r=0.92; P<0.001) and associated with multiple coronary and imaging parameters of microvascular function and infarct size (such as coronary flow reserve, acute myocardial edema, left ventricular ejection fraction, and late gadolinium enhancement 6 months later). We therefore assessed the prognostic value of PV NPY during follow‐up, where 34 patients (20.7%) developed heart failure or died. Kaplan‐Meier survival analysis demonstrated that high PV NPY levels (>21.4 pg/mL by binary recursive partitioning) were associated with increased incidence of heart failure and mortality (hazard ratio, 3.49 [95% CI, 1.65–7.4]; P<0.001). This relationship was maintained after adjustment for age, cardiovascular risk factors, and previous myocardial infarction.

Conclusions

Both PV and coronary sinus NPY levels correlate with microvascular function and infarct size after ST‐segment–elevation myocardial infarction. PV NPY levels are associated with the subsequent development of heart failure or mortality and may therefore be a useful prognostic marker. Further research is required to validate these findings.

Safety of Rotational Atherectomy Using the Radial Access in Patients With Severe Aortic Stenosis

Despite frequent percutaneous coronary intervention (PCI) in calcified vessels of older patients, rotational atherectomy (RA) has not been endorsed in patients with severe aortic stenosis (AS) due to safety concerns and lack of data. We explored periprocedural safety and mortality in severe AS patients undergoing RA. Prospective anonymized clinical, echocardiographic, procedural and outcome data of patients undergoing RA PCI between January 2012 and July 2018 were retrospectively extracted from the institutional coronary database. Patients with severe AS undergoing RA PCI were 1:1 propensity matched with patients undergoing RA PCI in the absence of AS. Outcomes of interest were RA related periprocedural complications, 30-day and 1-year mortality. A prespecified subgroup analysis examined the influence of transcatheter aortic valve replacement on mortality following RA PCI. A total of 544 patients underwent RA PCI; 478 without AS and 66 with AS. Propensity matching yielded 35 matched pairs with improved balance in covariates of interest and no significant differences in baseline characteristics postmatching. In the matched cohort (n = 70) slow flow/no-reflow, coronary dissection, perforation, and hemodynamic instability were rare and not significantly different. Survival analyses revealed significantly higher 30-day (Log-Rank p = 0.02) and 1-year mortality (Log rank p = 0.02, HR 5.24 [95% CI 1.13 to 24.28]) in the severe AS group; driven by a fivefold increase in the hazard of death among patients who did not undergo transcatheter aortic valve replacement HR 4.98 [95% CI 1.03 to 24.1]. In conclusion, our study of 70 patients undergoing radial RA PCI suggests that it can be safely performed in patients with severe AS. Long-term outcomes after RA in patients with severe AS are determined by the presence of the valve disease and other co-morbidities.

Prognostic Value of Quantitative Stress Perfusion Cardiac Magnetic Resonance

OBJECTIVES

This study sought to evaluate the prognostic usefulness of visual and quantitative perfusion cardiac magnetic resonance (CMR) ischemic burden in an unselected group of patients and to assess the validity of consensus-based ischemic burden thresholds extrapolated from nuclear studies.

BACKGROUND

There are limited data on the prognostic value of assessing myocardial ischemic burden by CMR, and there are none using quantitative perfusion analysis.

METHODS

Patients with suspected coronary artery disease referred for adenosine-stress perfusion CMR were included (n = 395; 70% male; age 58 ± 13 years). The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, aborted sudden death, and revascularization after 90 days. Perfusion scans were assessed visually and with quantitative analysis. Cross-validated Cox regression analysis and net reclassification improvement were used to assess the incremental prognostic value of visual or quantitative perfusion analysis over a baseline clinical model, initially as continuous covariates, then using accepted thresholds of ≥2 segments or ≥10% myocardium.

RESULTS

After a median 460 days (interquartile range: 190 to 869 days) follow-up, 52 patients reached the primary endpoint. At 2 years, the addition of ischemic burden was found to increase prognostic value over a baseline model of age, sex, and late gadolinium enhancement (baseline model area under the curve [AUC]: 0.75; visual AUC: 0.84; quantitative AUC: 0.85). Dichotomized quantitative ischemic burden performed better than visual assessment (net reclassification improvement 0.043 vs. 0.003 against baseline model).

CONCLUSIONS

This study was the first to address the prognostic benefit of quantitative analysis of perfusion CMR and to support the use of consensus-based ischemic burden thresholds by perfusion CMR for prognostic evaluation of patients with suspected coronary artery disease. Quantitative analysis provided incremental prognostic value to visual assessment and established risk factors, potentially representing an important step forward in the translation of quantitative CMR perfusion analysis to the clinical setting.

A structured assessment of newly qualified medical graduates

INTRODUCTION

While there is extensive published experience with the assessment of procedural skills in undergraduate students, this is limited in newly qualified medical graduates at the time of entry to the pre-registration (internship) year. The few studies that have been published suggest that these skills are frequently deficient when objectively tested. We therefore chose to assess the competence of a group of South African medical graduates on entry to their pre-registration year.

METHODS

A total of 58 graduates of South African medical schools were assessed. Each subject participated in a 7-station objective structured clinical examination (OSCE); 6 of these assessed individual competence in phlebotomy, intramuscular injection, female pelvic examination, bladder catheterisation, tracheal intubation and prescription writing, while competence in cardiopulmonary resuscitation was assessed in a seventh station in randomly allocated teams of 3 candidates. Candidates' opinions of their own competence was sought by questionnaire.

RESULTS

There was a wide variation in competence between subjects and across the range of tasks studied. Mean scores ranged from 85.4% for phlebotomy to 55.3% for prescription writing. The average score across all stations was 67.5%, and no student obtained an overall cut-off score of 85% or more, which was established using a modified Angoff method. Subjects' assessment of their own performance was unduly optimistic; most believed that they had demonstrated competence despite clear shortcomings in technique. Objective scores for subjects who had been exposed to a structured skills laboratory programme were not significantly higher than for those who had not, although their self-assessed performance was indeed higher.

DISCUSSION

Most of the South African medical graduates who participated in this study were unable to satisfactorily perform technical procedures appropriate to the house officer on entry to the pre-registration year. This is in line with the conclusions of the few studies published in other countries. We suggest that the learning outcomes of undergraduate medical programmes should include an explicit statement of the competencies required for practice in the pre-registration year, and that these should be adequately taught and rigorously assessed before graduation.

Developing an evidence base for interdisciplinary learning: a systematic review

AIM OF THE STUDY

The overall aim of the study was to explore the feasibility of introducing interdisciplinary education within undergraduate health professional programmes. This paper reports on the first stage of the study in which a systematic review was conducted to summarize the evidence for interdisciplinary education of undergraduate health professional students.

METHODS

Systematic reviews integrate valid information providing a basis for rational decision making about health care which should be based on empirical and not anecdotal evidence. The accepted principles for systematic reviews were adapted in order to allow integration of the literature to produce recommendations for educational practice and guidelines for future research.

FINDINGS

The literature on interdisciplinary education was found to be diverse, including relatively small amounts of research data and much larger amounts of evaluation literature. Methodological rating schemes were used to test for confounding influences in the research studies. The number of studies found was 141 but only 30 (21%) were included in the analysis because of lack of methodological rigour in the research and poorly developed outcome measures.

CONCLUSIONS

Student health professionals were found to benefit from interdisciplinary education with outcome effects primarily relating to changes in knowledge, skills, attitudes and beliefs. Effects upon professional practice were not discernible and educational and psychological theories were rarely used to guide the development of the educational interventions.

Learning gross anatomy in a clinical skills course

Recent developments in undergraduate medical education in the United Kingdom have produced changes in the content and delivery of component courses, including human anatomy. Anatomy can retain its place in the medical course in the new world of problem-based learning and clinical skills teaching by gaining recognition as an integral part of the curriculum which underpins much of the practice of clinical medicine. In these new courses, anatomical information is clinically relevant and discussed in the context of medical problems and the acquisition of clinical skills. Students are encouraged to study in a manner in which information is retained (deep learning) and where understanding replaces rote learning of facts. Students take responsibility for their own learning, with appropriate support and resources. In clinical skills courses, anatomy underpins the development and retention of clinical knowledge and skills.

Training, job demands and mental health of pre-registration house officers

OBJECTIVES

This study aims to explore pre-registration house officer (PRHO) perceptions of work role, job requirements and mental health, in order to enhance work role preparation by means of identifying potential areas for curriculum development.

DESIGN

Phase 1 took place 6 weeks before completion of the pre-registration year. A total of 56 PRHOs completed questionnaires which included a diary of activities, recorded daily over a 2-week period (ward rounds, on-call, audit, administration, continuing medical education, etc.), items relating to perceived occupational control, and the Maslach Burnout Inventory. In phase 2, in the final 2 weeks of the preregistration year, 36% (n=18) of phase 1 participants were randomly selected for interview.

SETTING

Three hospitals in the North-west of England.

RESULTS

The average working week was 56 h, with 10% working in excess of this figure. The average weekly proportion of time spent on organized continuing medical education was 5%. Routine administrative tasks took up one-fifth of PRHO time and were perceived as lacking in training or educational elements. Of the PRHOs, 52% (n=29) desired further advice/training on the technical and management aspects of the job. Additional training was required on topics such as chest drains, delegation and time management. PRHOs felt this should be given prior to commencement of the pre-registration year. In terms of mental health, 25% (n=14) were experiencing burnout. Occupational control was external; many individuals perceived events as often occurring outside individual control.

CONCLUSIONS

These findings have implications for the undergraduate curriculum and support General Medical Council recommendations for curriculum reform. It is suggested that organizational skills such as managing responsibility/delegation and additional training in practical procedures should be an integral part of the medical undergraduate curriculum.

Familial lipoprotein lipase (LPL) deficiency: a catalogue of LPL gene mutations identified in 20 patients from the UK, Sweden, and Italy

The aim of this study was to identify mutations in the lipoprotein lipase (LPL) gene in 20 unrelated patients with familial lipoprotein deficiency (FLLD) and to investigate the genotype/phenotype relationship. The previously reported G188E mutation (Monsalve et al., J Clin Invest 86:728-734, 1990) was screened for and found to be present in seven individuals (12/40 alleles). In addition, three patients were heterozygous for the 2.0 kb insertion (Langlois et al., Proc Nalt Acad Sci US 86:948-952, 1989). Two approaches were taken for new mutation detection; single-strand conformation polymorphism and sequencing to identify micro-mutations in the proximal promoter and exons 1-9 of the LPL gene and Southern blotting to identify gross mutations. Ten different point mutations were found (W86G, A158T, H183Q, G188E, S193R, P207L, L252X, N291S, M301T, L303P). Additionally, a two nucleotide deletion in exon 6 (delta1006-1007), a six nucleotide deletion in exon 8 (delta1441-1447), and a silent substitution in the wobble position of codon E118 were identified. In vitro mutagenesis and expression in COS-B cells suggested that the A158T and S193R substitutions virtually abolished enzyme activity. In analysing the genotype/phenotype relationship, there was no strong association between age at diagnosis, severity of symptoms, lipid levels, and the nature/position of the mutation. Triglyceride levels, however, were higher in compound heterozygotes compared to true homozygotes, possibly reflecting increased instability of heterodimers. Overall, 29 of 40 (72.5%) mutant alleles were identified. Failure to identify the mutation in 11 alleles might reflect the inadequacy of the method or the possibility that mutations lie within regions of the gene not screened in the study because of lack of availability of sequence.

The burden of infection with HSV-1 and HSV-2 in England and Wales: implications for the changing epidemiology of genital herpes

OBJECTIVE

To measure the burden of infection with herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2) in the general population of England and Wales and to assess temporal changes in the incidence of HSV-1 infection in childhood.

METHODS

4930 residual blood samples taken from people aged 0-69 years and submitted to 15 public health laboratories in England and Wales between January 1994 and June 1995, and 500 samples taken from people aged 10-14 years between November 1986 and December 1987, were screened for IgG antibody to HSV-1 and HSV-2 using type specific ELISA assays.

RESULTS

The prevalence of antibody to HSV-1 in 10-14 year olds declined from 34% in samples collected in 1986-7 to 24% in samples collected in 1994-5 (p < 0.001). HSV-1 antibody prevalence in adults increased with age and was higher in females than males, reaching 54% in females aged 25-30 years in 1994-5. In samples collected in 1994-5 from people aged 16-69 years HSV-2 antibody was detected in sera from 3.3% of men and 5.1% of women.

CONCLUSIONS

The incidence of HSV-1 infection in childhood is falling in England and Wales. The prevalence of HSV-2 infection in the general population is low, with the rate of infection significantly lower than that described for the general population in the United States and developing countries. The falling rate of HSV-1 infection in childhood may be one factor contributing to the increasing incidence of genital HSV-1 infection.

A monoclonal blocking EIA for herpes simplex virus type 2 antibody: validation for seroepidemiological studies in Africa

A competitive type-specific enzyme-linked immunosorbent assay (ELISA) for herpes simplex virus type 2 (HSV-2) antibody was developed using an infected cell antigen and a monoclonal antibody to glycoprotein G-2. This assay has been validated for use for epidemiological studies using a large panel of sera collected in rural Uganda and a panel of 143 sera characterised previously by Western blotting, the 'gold standard' for HSV type-specific serology. This evaluation was found to have a sensitivity of 96% and a specificity of 91% in comparison with Western blot on 143 sera from clinic patients. The ELISA had a sensitivity of 93% and a specificity of 91% in comparison with Western blot on 495 sera collected in Uganda. The assay showed good reproducibility and a low percentage of sera gave equivocal results, indicating its suitability for epidemiological studies.

Illicit drug use related attendances at accident and emergency services in Aberdeen: a prospective six month survey

OBJECTIVE

To quantify and examine the nature of known illicit drug related attendances at the Accident and Emergency Department of Aberdeen Royal Hospital over a six month period.

DESIGN

A structured questionnaire was completed by Accident and Emergency staff.

SETTING

The Accident and Emergency Department of Aberdeen Royal Hospital.

SUBJECTS

All patients presenting at the Accident and Emergency Department as a result of known illicit drug use between November 1996 to April 1997 inclusive.

RESULTS

One hundred and fifty seven subjects presented at Accident and Emergency during the six month period. Peak attendance was between 18.00 and 21.00 hours. Twenty seven percent of patients chose to visit Accident and Emergency rather than their own general practitioner. Thirty seven percent had no involvement with any health care professional regarding their drug use. Heroin was used by 62% of cases of which the majority (94.9%) had injected and stimulants such as amphetamine and ecstasy were used by a large proportion of cases. Only 4.5% of subjects admitted to not using clean equipment yet 15% admitted to have loaned equipment (to someone else) and 22% of subjects had injecting related problems. Thirteen percent of subjects were considered unco-operative by staff. Fifty four percent of subjects required admission to a ward and ten patients (6%) died.

CONCLUSION

Heroin continues to be the main drug causing major health problems. Harm reduction messages are not adequately reaching/or being taken up by drug users given the high proportion with injecting related problems and those being prepared to lend needles. The receptive attitude amongst subjects highlighted the opportunity for patient education as well as giving contact addresses of relevant organisations.

Bcl-2 overexpression protects the neonatal cerebellum from ethanol neurotoxicity

The developing nervous system is extremely sensitive to ethanol, and exposure often produces a condition known as the fetal alcohol syndrome. Although mechanisms underlying developmental ethanol toxicity have long been sought, they remain poorly understood. In this study, we examined the ability of the cell death repressor gene bcl-2 to protect against ethanol neurotoxicity. Transgenic mice overexpressing bcl-2 in neurons were exposed to ethanol vapor on postnatal days 4 and 5, which is the peak period of vulnerability of cerebellar Purkinje cells to ethanol. While exposure of wild-type animals to ethanol resulted in significant loss of Purkinje cells by P5, similar exposure of homozygous and heterozygous transgenics had no effect on the number of these neurons. This study suggests that bcl-2 can protect neurons from ethanol neurotoxicity and that modulation of cell death effector or repressor gene products may play a significant role in developmental ethanol neurotoxicity.

Antibody to herpes simplex virus type 2 as a marker of sexual risk behavior in rural Tanzania

A serosurvey was conducted in a random sample of 259 women and 231 men in 12 rural communities in Mwanza Region, Tanzania, using a type-specific ELISA for Herpes simplex virus type 2 (HSV-2) infection. Seroprevalence rose steeply with age to approximately 75% in women >=25 years old and 60% in men >=30. After adjusting for age and residence, HSV-2 prevalence was higher in women who were married, in a polygamous marriage, Treponema pallidum hemagglutination assay (TPHA)-positive, had more lifetime sex partners, or who had not traveled. Prevalence was higher in men who were married, had lived elsewhere, had more lifetime partners, had used condoms, or were TPHA-positive. HSV-2 infection was significantly associated with recent history of genital ulcer. The association between HSV-2 infection and lifetime sex partners was strongest in those <25 years old in both sexes. This association supports the use of HSV-2 serology as a marker of risk behavior in this population, particularly among young people.

Three visual techniques to enhance interprofessional learning

Many changes in the delivery of healthcare in the UK have highlighted the need for healthcare professionals to learn to work together as teams for the benefit of patients. Whatever the profession or level, whether for postgraduate education and training, continuing professional development, or for undergraduates, learners should have an opportunity to learn about and with, other healthcare practitioners in a stimulating and exciting way. Learning to understand how people think, feel, and react, and the parts they play at work, both as professionals and individuals, can only be achieved through sensitive discussion and exchange of views. Teaching and learning methods must provide opportunities for this to happen. This paper describes three small-group teaching techniques which encourage a high level of learner collaboration and team-working. Learning content is focused on real-life health-care issues and strong visual images are used to stimulate lively discussion and debate. Each description includes the learning objectives of each exercise, basic equipment and resources, and learning outcomes.

Vocational training and beyond--listening to voices from a void

This paper is written from the viewpoint of a doctor who has recently undergone general practice vocational training, and has first-hand experience of some of the opportunities, difficulties, and uncertainties facing doctors at this stage of their careers. The literature on vocational training and the issues concerning young doctors are explored in the light of concerns that recruitment into general practice is falling, that registrars may feel lost in a 'void' at the end of training, and that the 'new world' of post-training work brings problems for many new general practitioners (GPs). Instead of a traditional partnership, one of the authors (RB) chose a salaried, educationally oriented introduction to inner-city general practice. Some innovative, educational schemes, which are aiming to improve the appeal of general practice, are discussed.

Impact of Hurricane Luis on the health services of Antigua and Barbuda

Antigua and Barbuda, located in the Caribbean, was one of the countries most affected by Hurricane Luis in 1995. Electricity, water supply and health facilities were disrupted for several weeks. Inadequate criteria at the design stages, unsound structural design, and lack of maintenance of building components, are some of the reasons that damage was so severe. The main hospitals and 6 health facilities were destroyed and flooded and most of the medical staff had to cope with their own damaged houses. Although the knowledge and materials are available to reduce the losses caused by hurricanes, building codes are not reinforced by laws and preventive maintenance to protect health care facilities from natural hazard damage is not usually budgeted for. The additional cost of making a single or two-storey health facility almost invulnerable to future catastrophe in a hurricane is only 2% in initial capital cost and becomes negligible when spread over the life of a building. The effort of UN International Decade for Natural Disasters (IDNDR) directed towards disaster mitigation should be increased over the remainder of the decade to ensure that standards are respected and building codes are mandatory.

Acute myelomonocytic leukaemia following atypical congenital rubella

The child of a woman immunised against rubella presented at 5 months with developmental delay and recurrent infection; she was shown to have congenital rubella. At 15 months she developed acute myelomonocytic leukaemia (AMML). Rubella is difficult to diagnose after immunisation. AMML has not been previously described in association with congenital rubella, as far as is known.

Socioeconomic factors and cancer incidence among blacks and whites

Findings from previous studies suggest that differences in socioeconomic status may be responsible for some, if not all, of the elevated incidence of cancer among blacks as compared with whites. Using incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, we tested this hypothesis by correlating black and white cancer incidence rates in three US metropolitan areas between 1978 and 1982 with data from the 1980 census on socioeconomic status within individual census tracts. The study analyzed data on the incidence of cancer at all sites combined (greater than 100 cancer sites) and at seven major sites separately. As in other studies, income and educational levels served as surrogates for socioeconomic status. The present study also used census-tract data on population density as a surrogate factor. Each of these measures of socioeconomic status was analyzed independently. Before correlation with census-tract data, age-adjusted data on cancer incidence showed statistically significant elevated risks among blacks for cancer at all sites combined and at four of the seven separate sites; whites showed an elevated risk for cancer at two sites. Cancer at only one site, the colon, showed no significant association with race. When age-adjusted incidence data were correlated with socioeconomic status, the comparative black-white risks changed: Whites showed an elevated risk of cancer at all sites combined and at three of the seven separate sites; blacks maintained their elevated risk at three sites. These findings suggest that the disproportionate distribution of blacks at lower socioeconomic levels accounts for much of the excess cancer burden among blacks. They also suggest that for both blacks and whites unidentified racial factors, which may be either cultural or genetic and which are not closely linked to socioeconomic status, may play a role in the incidence of some cancers.

Black-white differences in cancer prevention knowledge and behavior

Data from the 1987 National Health Interview Survey Cancer Control Supplement were used to estimate multivariate logistic regression models of diet change, mammography utilization, stool blood test utilization, and smoking. Predictor variables included race, sex, age, income, dietary concerns, and four knowledge-related variables: education and three measures of cancer prevention knowledge. When knowledge variables were included in the models, race was not a significant predictor of behavior, with one exception: among women, Blacks were found to smoke less than Whites.

Current status of prostate cancer in North American black males

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program is used to examine the most recent data available to draw inferences about black and white males in the United States with prostate cancer. Findings include a continuing rise in the incidence of prostate cancer which, as of 1985 SEER data, is 50% higher in the black male population than in white males. With the exception of minor fluctuations over the last 17 years, the mortality rate for black males demonstrates an upward trend. Combining all stages and ages, the survival rate for black males is 10% poorer than for white males. These data provide a glimpse into the problem of prostatic carcinoma in the United States today. To develop preventive strategies and cancer control interventions, a fuller understanding of the nature of the disease and its biologic course is necessary. Epidemiologic questions concerning socioeconomic status among and within racial groups, lifestyles, and behaviors that affect health seeking and diagnosis and treatment of prostatic cancer must be answered. By examining SEER data for prostatic cancer, we update the current status of this disease in North American blacks and infer possible directions for future epidemiologic surveys and cancer control intervention research.

Firearm-related fatalities: an epidemiologic assessment of violent death

This study examines 1970-78 South Carolina firearm fatalities utilizing vital record data. During this period, 5,808 firearm deaths, classified as accident, homicide, suicide, or undetermined, were reported with an average annual fatality rate of 23.35 deaths per 100,000 estimated population. Firearm fatalities in South Carolina were the sixth leading cause of death in 1975 and accounted for 2.9 per cent of all deaths to residents. A significant period decline in the firearm fatality rate was observed and was attributed mainly to decreases in the non-White rate. In 1978, the fatality rate for non-Whites (18.5) fell below the rate for Whites (19.1) for the first time in the years investigated. Firearm deaths represent a major community health problem and, as such, warrant attention and direct involvement by state and local health professionals.