Measurement of Electron-Neutrino Charged-Current Cross Sections on ^{127}I with the COHERENT NaIνE Detector

Using an 185-kg NaI[Tl] array, COHERENT has measured the inclusive electron-neutrino charged-current cross section on ^{127}I with pion decay-at-rest neutrinos produced by the Spallation Neutron Source at Oak Ridge National Laboratory. Iodine is one the heaviest targets for which low-energy (≤50  MeV) inelastic neutrino-nucleus processes have been measured, and this is the first measurement of its inclusive cross section. After a five-year detector exposure, COHERENT reports a flux-averaged cross section for electron neutrinos of 9.2_{-1.8}^{+2.1}×10^{-40}  cm^{2}. This corresponds to a value that is ∼41% lower than predicted using the MARLEY event generator with a measured Gamow-Teller strength distribution. In addition, the observed visible spectrum from charged-current scattering on ^{127}I has been measured between 10 and 55 MeV, and the exclusive zero-neutron and one-or-more-neutron emission cross sections are measured to be 5.2_{-3.1}^{+3.4}×10^{-40} and 2.2_{-0.5}^{+0.4}×10^{-40}  cm^{2}, respectively.

Push notifications for critical labs results: a pilot study in the intensive care unit (ICU)

Objective

We developed a push notification allowing for an electronic acknowledgment of critical lab results to providers in the intensive care unit.

Materials and Methods

This project was conducted over a 3-month period at a large academic safety net hospital. A push notification and acknowledgment system were created to comply with the existing critical results notification requirements. We monitored the number of acknowledged results, time to acknowledgment, and lab type.

Results

Prior to the push notification, lab services paged the provider. This resulted in many critical lab results relayed to the clinician beyond the expected 10-minute window. With the push notification workflow, we found that, during the 3-month period, 82, or 5.8%, of the 1414 results were acknowledged. This represented 82 less pages/calls lab services had to make.

Discussion

The push notification alert was easy to use and there was quicker results notification when acknowledged. There were limitations due to hand-offs for clinicians and some were not familiar with the mobile technology and the electronic acknowledgment.

Conclusions

Although the acknowledgment rate was low, every electronic acknowledgment saved lab service technicians an average of 10 minutes compared to the existing workflow. As familiarity with the technology and workflow increases, this novel form of communication has the potential to have significant cost savings for lab services, in addition to efficiency gains for lab, clinicians, and more timely care. The integration of health information technology and push notification of critical labs should be the focus of investigation for further future research.

First Probe of Sub-GeV Dark Matter beyond the Cosmological Expectation with the COHERENT CsI Detector at the SNS

The COHERENT Collaboration searched for scalar dark matter particles produced at the Spallation Neutron Source with masses between 1 and 220  MeV/c^{2} using a CsI[Na] scintillation detector sensitive to nuclear recoils above 9  keV_{nr}. No evidence for dark matter is found and we thus place limits on allowed parameter space. With this low-threshold detector, we are sensitive to coherent elastic scattering between dark matter and nuclei. The cross section for this process is orders of magnitude higher than for other processes historically used for accelerator-based direct-detection searches so that our small, 14.6 kg detector significantly improves on past constraints. At peak sensitivity, we reject the flux consistent with the cosmologically observed dark-matter concentration for all coupling constants α_{D}<0.64, assuming a scalar dark-matter particle. We also calculate the sensitivity of future COHERENT detectors to dark-matter signals which will ambitiously test multiple dark-matter spin scenarios.

Transposon Mutagenesis Reveals RBMS3 Silencing as a Promoter of Malignant Progression of BRAFV600E-Driven Lung Tumorigenesis

Mutationally activated BRAF is detected in approximately 7% of human lung adenocarcinomas, with BRAFT1799A serving as a predictive biomarker for treatment of patients with FDA-approved inhibitors of BRAFV600E oncoprotein signaling. In genetically engineered mouse (GEM) models, expression of BRAFV600E in the lung epithelium initiates growth of benign lung tumors that, without additional genetic alterations, rarely progress to malignant lung adenocarcinoma. To identify genes that cooperate with BRAFV600E for malignant progression, we used Sleeping Beauty-mediated transposon mutagenesis, which dramatically accelerated the emergence of lethal lung cancers. Among the genes identified was Rbms3, which encodes an RNA-binding protein previously implicated as a putative tumor suppressor. Silencing of RBMS3 via CRISPR/Cas9 gene editing promoted growth of BRAFV600E lung organoids and promoted development of malignant lung cancers with a distinct micropapillary architecture in BRAFV600E and EGFRL858R GEM models. BRAFV600E/RBMS3Null lung tumors displayed elevated expression of Ctnnb1, Ccnd1, Axin2, Lgr5, and c-Myc mRNAs, suggesting that RBMS3 silencing elevates signaling through the WNT/β-catenin signaling axis. Although RBMS3 silencing rendered BRAFV600E-driven lung tumors resistant to the effects of dabrafenib plus trametinib, the tumors were sensitive to inhibition of porcupine, an acyltransferase of WNT ligands necessary for their secretion. Analysis of The Cancer Genome Atlas patient samples revealed that chromosome 3p24, which encompasses RBMS3, is frequently lost in non-small cell lung cancer and correlates with poor prognosis. Collectively, these data reveal the role of RBMS3 as a lung cancer suppressor and suggest that RBMS3 silencing may contribute to malignant NSCLC progression.

SIGNIFICANCE

Loss of RBMS3 cooperates with BRAFV600E to induce lung tumorigenesis, providing a deeper understanding of the molecular mechanisms underlying mutant BRAF-driven lung cancer and potential strategies to more effectively target this disease.

Measurement of the Coherent Elastic Neutrino-Nucleus Scattering Cross Section on CsI by COHERENT

We measured the cross section of coherent elastic neutrino-nucleus scattering (CEvNS) using a CsI[Na] scintillating crystal in a high flux of neutrinos produced at the Spallation Neutron Source at Oak Ridge National Laboratory. New data collected before detector decommissioning have more than doubled the dataset since the first observation of CEvNS, achieved with this detector. Systematic uncertainties have also been reduced with an updated quenching model, allowing for improved precision. With these analysis improvements, the COHERENT Collaboration determined the cross section to be (165_{-25}^{+30})×10^{-40}  cm^{2}, consistent with the standard model, giving the most precise measurement of CEvNS yet. The timing structure of the neutrino beam has been exploited to compare the CEvNS cross section from scattering of different neutrino flavors. This result places leading constraints on neutrino nonstandard interactions while testing lepton flavor universality and measures the weak mixing angle as sin^{2}θ_{W}=0.220_{-0.026}^{+0.028} at Q^{2}≈(50  MeV)^{2}.

230 Acute Bowel Obstruction - Are We in The Loop?

Aim

Acute bowel obstruction (ABO) is a common surgical emergency associated with high mortality and morbidity. The aim of this audit is to compare the quality of local management of ABO against recommendations set by the NCEPOD.

Method

A prospective audit of all patients presented with ABO over 8 weeks from February 2020 at a tertiary centre. Data was collected from electronic records.

Results

34 patients were reviewed with a mean age of 69.8 years. 24 presented with small bowel obstruction and 10 with large bowel obstruction. 25 (73.5%) patients had a CT with IV contrast with a median time to scan of 5 hours. 25 (73.5%) patients were reviewed by consultants within 14 hours and 5/7 high-risk cases were discussed within an hour. Adequate pain control was achieved in 26 (76.5%) cases. All patients had BMI recorded and 29 (85.3%) had MUST score documented. 16/25 (64.0%) patients aged above 64 had their frailty score assessed and 11/25 (44.0%) received geriatrician input. 32 (94.1%) patients had their treatment plan discussed with them and family was informed in 19 (55.9%) cases. 19 (55.9%) patients underwent emergency operation and there was a delay in access to surgery in 7/19 (36.8%) cases. Morbidity and mortality risk was calculated in 3/19 (15.8%) cases.

Conclusions

This audit has highlighted numerous positive management measures but also the need for improved radiological resources, better emergency capacity planning and risk assessment. There needs to be a focus on predicting outcomes, especially in the elderly and setting limitations and expectations before surgery.

First Measurement of Coherent Elastic Neutrino-Nucleus Scattering on Argon

We report the first measurement of coherent elastic neutrino-nucleus scattering (CEvNS) on argon using a liquid argon detector at the Oak Ridge National Laboratory Spallation Neutron Source. Two independent analyses prefer CEvNS over the background-only null hypothesis with greater than 3σ significance. The measured cross section, averaged over the incident neutrino flux, is (2.2±0.7)×10^{-39}  cm^{2}-consistent with the standard model prediction. The neutron-number dependence of this result, together with that from our previous measurement on CsI, confirms the existence of the CEvNS process and provides improved constraints on nonstandard neutrino interactions.

Abstract B092: Epstein-Barr virus prevalence in classical Hodgkin lymphoma tumors by race/ethnicity in a multiethnic U.S. population

Background Classical Hodgkin lymphoma (cHL) is one of the most common cancers among adolescents and young adults (AYA). Incidence rates vary by demographic factors, with the highest incidence in whites of high SES. Malignant Hodgkin Reed-Sternberg (HRS) cells comprise a small percentage of the tumor (about 1%), with the remainder composed of various immune cells (tumor microenvironment, TME). The TME in cHL predicts survival and response to treatment in NHW, but has not been examined in diverse populations. We implemented a study to examine the TME and survival by race/ethnicity and SES in a multiethnic, multicenter set of 1,536 U.S. cHL cases. We conducted an initial analysis of factors associated with EBV status in tumors. Methods FFPE tumor blocks for 649 cases diagnosed from 1996-2016 were identified to date. Diagnosis and histological subtype was confirmed by pathology review for 554. Tissue microarrays were constructed with two 2 mm cores from each case with 29 cases on each array. EBER was assessed using in situ hybridization and scored as negative, positive in HRS cells or positive in the surrounding normal infiltrate. Demographic and clinical information, including the anatomic site of the biopsy, subtype, race/ethnicity (Hispanic, African American [AA], Asian, Native American, NHW), age at diagnosis and gender was collected. Multiple logistic regression was conducted to assess the relationship between age at diagnosis, race/ethnicity, gender, subtype and EBV tumor status. Results Race data was available at this time for 549 cases including 153 NHW, 235 Hispanics, 110 AAs, 36 Asians, 2 Native Americans and 13 with unknown race. 260 (47%) were female. EBV prevalence was available for 393 cases, with 316 nodular sclerosis (NS), 52 mixed cellularity (MC), 8 lymphocyte depleted (LD), 3 lymphocyte rich (LR), and 14 not otherwise specified (NOS). Age at diagnosis ranged from 5-87 years of age, with 189 (48.09%) in AYA (15-35 y). EBV+ by histology was 12.5%% for LD, 33% for LR, 47% for MC, 25% for NS, and 29% for NOS. Histologic subtype was a statically significant predictor of EBV tumor status (p=.0007), even after adjusting for age, sex, and race/ethnicity (p=.0085). Among NS cases, EBV+ was similar across racial/ethnic groups. However, there was a much higher prevalence of EBV+ in AA (73%) compared to NHW and Hispanic (36-42%) MC cases. HIV/AIDS status was available for 40% of the AA cases but none were positive. There was no correlation between year of diagnosis and the presence of EBV in tumors (r=0.05, p=0.42), thus block storage time did not affect the results. Conclusions This is the largest study of the Hodgkin lymphoma TME in a racially and ethnically diverse population. In an initial analysis, histologic subtype was the strongest predictor of positive EBV tumor status. Unlike previous reports, EBV-positive tumors were not more common among non-whites, except for AA MC cases. We expect to confirm these results in a larger sample as more cases are accrued.

Citation Format: Rachel Bolanos, Amie Hwang, Jose Aparicio, Chun Chao, Naba Qurashi, Christopher Flowers, Sheeja Pullarkat, David Conti, Sophia Wang, Karen Mann, Leon Bernal-Mizrachi, Joo Song, Christian Steidl, Imran Siddiqi, Wendy Cozen. Epstein-Barr virus prevalence in classical Hodgkin lymphoma tumors by race/ethnicity in a multiethnic U.S. population [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B092.

Comorbidity, family history and personality traits in pathological gamblers compared with healthy controls

Background

While DSM-5 classified pathological gambling as an addictive disorder, there is debate as to whether ICD-11 should follow suit. The debate hinges on scientific evidence such as neurobiological findings, family history of psychiatric disorders, psychiatric comorbidity, and personality variables.

Methods

In the “Baden-Württemberg Study of Pathological Gambling”, we compared a group of 515 male pathological gamblers receiving treatment with 269 matched healthy controls. We studied differences in sociodemographic characteristics, gambling-related variables, psychiatric comorbidity (lifetime), family history of psychiatric conditions, as well as personality traits such as impulsivity (Barratt Impulsiveness Scale), sensation seeking (Zuckerman's Sensation Seeking Scale) and the NEO-FFI big five. Personality traits were validated in an age- and ethnicity-matched subsample of “pure” gamblers without any psychiatric comorbidity (including nicotine dependence). Data were analyzed using two-sample t-tests, Chi2 analyses, Fisher's exact test and Pearson correlation analysis, as appropriate. Bonferroni correction was applied to correct for multiple comparisons.

Results

Only 1% of the gamblers had been diagnosed with an impulse control disorder other than gambling (ICD-10). Notably, 88% of the gamblers in our sample had a comorbid diagnosis of substance dependence. The highest axis I comorbidity rate was for nicotine dependence (80%), followed by alcohol dependence (28%). Early age of first gambling experience was correlated with gambling severity. Compared to first-degree relatives of controls, first-degree relatives of pathological gamblers were more likely to suffer from alcohol dependence (27.0% vs. 7.4%), pathological gambling (8.3% vs. 0.7%) and suicide attempts (2.7% vs. 0.4%). Significant group differences were observed for the NEO-FFI factors neuroticism, agreeableness and conscientiousness. Gamblers were also more impulsive than controls, but did not differ from controls in terms of sensation seeking.

Conclusions

Our findings support classifying pathological gambling as a behavioural addiction in the ICD-11. This decision will have a significant impact on the approaches available for prevention (e.g. age limits) and treatment.

Sex-Based Diverse Plaque Microbiota in Children with Severe Caries

Severe early childhood caries (S-ECC) is a multifactorial disease that can lead to suffering and reduced oral health-related quality of life in young children. The bacterial and fungal composition of dental plaque and how children's sex is associated with S-ECC are largely unknown. In this study, V4-16S rRNA and ITS1 rRNA gene amplicon sequencing was used to compare the plaque bacteriome and mycobiome of children <72 mo of age: 40 with S-ECC (15 males, 25 females) and 40 caries-free (19 males, 21 females). Health- and nutrition-related questionnaire data were also investigated. This study aimed to analyze potential sex-based differences in the supragingival plaque microbiota of young children with S-ECC and those caries-free. Behavioral and nutritional habit differences were observed between children with S-ECC and those caries-free and between male and female children. Overall, higher levels of Veillonella dispar, Streptococcus mutans, and other bacterial species were found in the S-ECC group as compared with caries-free controls (P < 0.05). A significant difference in the abundance of Neisseria was observed between males and females with S-ECC (P < .05). Fungal taxonomic analysis showed significantly higher levels of Candida dubliniensis in the plaque of children with S-ECC as compared with those caries-free (P < 0.05), but no differences were observed with Candida albicans (P > 0.05). Significant differences in the relative abundance of Mycosphaerella, Cyberlindnera, and Trichosporon fungal species were also observed between the caries-free and S-ECC groups (P < 0.05). Machine learning analysis revealed the most important bacterial and fungal species for classifying S-ECC versus caries-free. Different patterns of crosstalk between microbial species were observed between male and female children. Our work demonstrates that plaque microbiota and sex may be important determinants for S-ECC and could be factors to consider for inclusion in caries risk assessment tools.

Abstract 5053: Epstein-Barr virus prevalence in classical Hodgkin lymphoma tumors is explained by histologic subtype, not race/ethnicity in a multiethnic US population

Epstein-Barr virus (EBV) is present in a varying proportion of classical Hodgkin lymphoma (cHL) tumors reportedly associated with age, sex, race/ethnicity and histologic subtype. As part of a study to examine the tumor microenvironment and survival in a multiethnic set of US cHL cases, we examined the distribution of EBV expression in tumor blocks from a subset of 269 of the available cases. We confirmed cHL diagnosis and histological subtype in H&E sections of FFPE tumor blocks of excisions and core biopsies from cases provided by Southern California Kaiser, Winship Cancer Center at Emory University, City of Hope National Medical Center, Grady Memorial Hosiptal, University of California Los Angeles and University of Southern California hospitals diagnosed from 1996-2016. Immunostain results were available for most cases. Tissue microarrays were constructed with two 2 mm cores from each case with 29 cases on each array. EBER was assessed using in situhybridization and scored as negative, positive in HRS cells or positive in the surrounding normal infiltrate. Demographic and clinical information, including the biopsy anatomic site, subtype, race/ethnicity (Hispanic, African American, Asian, non-Hispanic white), age at diagnosis and gender. Multiple logistic regression was conducted to assess the relationship between age, race/ethnicity, gender, subtype and EBV tumor status. Race/ethnicity data was available at this time for 237 cases. Of these, 186 were nodular sclerosis (NS), 53 were mixed cellularity (MC), 8 were lymphocyte depleted (LD), 3 were lymphocyte rich (LR), and 10 were not otherwise specified (NOS). Fifty-seven cases were African American, 48 were non-Hispanic white, 115 were Hispanic, 16 were Asian and one was other race. 106 were female (42%). Age at diagnosis ranged from 5-84 years, with 118 (50%) in the adolescent/young adult (AYA) range (15-35). EBV prevalence in HRS cells by subtype was 0% for LD, 47% for MC, 33% for LR, 23% for NS and 50% for NOS. When restricted to the two most common subtypes, NS and MC, histologic subtype alone was a statistically significant predictor of EBV tumor status (p=.0008) and when adjusting for age, sex, site and race/ethnicity (p=.0011). In NS cases, EBV HRS cell positivity was highest in non-Hispanic whites (31%), followed by Hispanics (23%) and African Americans (18%). Among MC cases, it was very high among African Americans (80%) compared to Hispanics and non-Hispanic whites (33-39%). The patterns were similar when restricted to the AYA age group. 6.5%, 4% and 20% of EBV-negative NS, MC and NOS cases, respectively, had EBV present in non-malignant lymphocytes but not in HRS cells. Histologic subtype was the strongest predictor of EBV HRS cell positivity in this set of multiethnic cHL patients. Unlike previous reports, EBV-positive tumors were not more common among non-whites, except for African American MC cases.

Citation Format: Rachel Bolanos, Amie Hwang, Chun Chao, Christopher Flowers, Sheeja Pullarkat, Jose Aparicio, Sophia Wang, Karen Mann, Leon Bernal-Mizrachi, Joo Song, Christian Steidl, Christine Lee, Wendy Cozen, Iran Siddiqi. Epstein-Barr virus prevalence in classical Hodgkin lymphoma tumors is explained by histologic subtype, not race/ethnicity in a multiethnic US population [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5053.

Caregiver Intention To Restart Vaccinations After Childhood Cancer Treatment

Timely vaccination after childhood cancer treatment is vital for protecting against vaccine-preventable diseases during survivorship. However, caregiver intention for restarting vaccinations, such as getting catch-up or booster vaccines, after cancer treatment is unknown. Methods: We surveyed primary caregivers ages 18 or older with a child who had completed cancer treatment in the prior 3–24 months (N = 129; participation rate = 60.3%). Participants were asked about demographics, their child's vaccination status, and healthcare factors (e.g., provider recommendations, barriers). We examined the influence of whether the oncology care team recommended catch-up or booster vaccines on caregiver intention to restart vaccines using multivariable generalized linear models. Vaccine barriers were examined by intention in chi- square tests. Results: Caregivers were primarily aged 30–49 years (82.0%), mothers (81.2%), college graduates (44.8%), married (89.1%), and Non-Hispanic (90.3%). In total, 67% of caregivers intended to restart vaccines for their child and 49.6% reported that they had a discussion with the cancer care team about catch-up or booster vaccines. Caregivers who discussed vaccines with their child's cancer care team were much more likely to report intention to restart vaccination (Relative Risk (RR) = 1.82, 95% CI 1.37–2.45). The most common barrier to restarting vaccines after cancer was not knowing which vaccines to get, which was common across both groups (intend to restart = 31% vs. did not intend = 40.5%, P = 0.29). Of caregivers, 93.1% who intended to restart vaccines felt vaccines were safe compared to 79.5% of those who did not (P = 0.02). Conclusions: Caregivers of childhood cancer survivors need guidance for restarting vaccinations after cancer treatment, including information on safety and which vaccines their child needs. Provider recommendations positively influence caregiver's intention to restart vaccines. Clinical guidelines are needed to support providers in making tailored vaccination recommendations after cancer treatment.

The R2C2 Model in Residency Education: How Does It Foster Coaching and Promote Feedback Use?

PURPOSE

The authors previously developed and tested a reflective model for facilitating performance feedback for practice improvement, the R2C2 model. It consists of four phases: relationship building, exploring reactions, exploring content, and coaching. This research studied the use and effectiveness of the model across different residency programs and the factors that influenced its effectiveness and use.

METHOD

From July 2014-October 2016, case study methodology was used to study R2C2 model use and the influence of context on use within and across five cases. Five residency programs (family medicine, psychiatry, internal medicine, surgery, and anesthesia) from three countries (Canada, the United States, and the Netherlands) were recruited. Data collection included audiotaped site assessment interviews, feedback sessions, and debriefing interviews with residents and supervisors, and completed learning change plans (LCPs). Content, thematic, template, and cross-case analysis were conducted.

RESULTS

An average of nine resident-supervisor dyads per site were recruited. The R2C2 feedback model, used with an LCP, was reported to be effective in engaging residents in a reflective, goal-oriented discussion about performance data, supporting coaching, and enabling collaborative development of a change plan. Use varied across cases, influenced by six general factors: supervisor characteristics, resident characteristics, qualities of the resident-supervisor relationship, assessment approaches, program culture and context, and supports provided by the authors.

CONCLUSIONS

The R2C2 model was reported to be effective in fostering a productive, reflective feedback conversation focused on resident development and in facilitating collaborative development of a change plan. Factors contributing to successful use were identified.

A mixed methods investigation of an online intervention to facilitate student midwives' engagement in effective conversations about weight-related behaviour change with pregnant women

OBJECTIVE

(1) To identify whether an online training intervention could increase midwifery students' knowledge of behaviour change techniques (BCTs) and intentions to use them in practice. (2) To identify students' views and current experiences of talking to women about weight-related behaviour change.

DESIGN

Mixed methods study involving pre- and post-training assessments, and qualitative interviews with midwifery students.

SETTING

Online training course delivered at a University in the North of England, UK.

PARTICIPANTS

Midwifery students in the third year of their undergraduate degree during 2015-2016.

INTERVENTION

Online training focused on equipping students with knowledge of theoretically-informed BCTs, and the skills to use them opportunistically in existing practice settings.

MEASUREMENTS

Likelihood of discussing obesity with women was assessed via a 12-item, 7-point Likert scale assessing students' attitudes, subjective norms, perceived behavioural control, and intentions. A 14-item checklist was used to assess BCT knowledge whereby students selected recognised BCTs (of 7 correct, 7 false). Students' views and experiences of current practice was explored through in-depth, semi-structured one-on-one interviews with a member of the research team.

FINDINGS

Students' subjective norms, perceived behavioural control, and knowledge of BCTs increased post-training but intention and attitudes did not. Interviews revealed three themes accounting for students experiences and views of behaviour change practice: (1) 'How training fits with current encounters with maternal obesity in midwifery training' (2) 'TEnT PEGS prepares students for practice', and (3) 'Value of tailored training'.

KEY CONCLUSIONS

Online BCT training can improve the midwifery students' confidence, knowledge and beliefs that this is part of their role. They also reported finding the training helpful in better preparing them for this challenging element of their routine practice.

IMPLICATIONS FOR PRACTICE

Online BCT training can be used to prepare undergraduate midwifery students for practice.

Ergebnisse der Radiojod-Behandlung von Patienten mit immunogener und nicht-immunogener Hyperthyreose bei Anwendung unterschiedlicher Herddosen

The aim of this study was to check the efficacy of radioiodine (131I) therapy (RIT) in a large number of patients (n = 506) suffering from immunogenic or non-immunogenic hyperthyroidism (Graves’ disease, Plummer’s disease). Since there is no causal cure for immunogenic hyperthyroidism RIT provides, like all other modalities, only a moderate rate of success which is clearly dose-related. Applying 60 Gy, normal thyroid function can be achieved in only 54% of the cases. A dose of 150 Gy succeeds in 86% of the cases. The solitary decompensated autonomous adenoma (DAA) can be eliminated surgically as well as by RIT with a high degree of success (95%). Contrary to surgery, RIT does not have any noticeable early or late morbidity. The high rate of success of RIT in patients with DAA could be confirmed in two groups with different follow-up periods (16 and 65 months). As expected, the rate of hypothyroidism increased from 11 % in the early group to 23% in the late group. Multinodular autonomous adenomas can be eliminated successfully using RIT as well. The concept to apply a dose of 400 Gy to the total functional autonomous tissue as determined by ultrasound yields better results (95%) than 150 Gy to the whole thyroid gland as measured by ultrasound (88%). The rate of hypothyroidism as shown by these results (up to a maximum of 62% after RIT of Graves’ disease using 150 Gy) is the lesser evil compared to remaining or recurrent hyperthyroidism since these patients can be treated with thyroid hormones without problems.

Highly Sensitive Determination of TSH in the Follow-Up of TSH-Suppressive Therapy of Patients with Differentiated Thyroid Cancer

Basal and TRH-stimulated TSH levels were determined in 72 patients with differentiated thyroid cancer on hormonal treatment, using a highly sensitive immunoradiometric assay (IRMAclon, Henning). 43 patients were under treatment with levothyroxine (T4), 29 patients with triiodothyronine (T3). In 33/43 patients (77%) under T4- and in 18/29 patients (62%) under T3-treatment basal TSH levels were below 0.1 mU/l and levels stimulated with 200 µg TRH i.v. were below 0.5 mU/l. 3 patients showed a significant response (to above 0.5 mU/l) in the TRH test despite basal values of less than 0.1 mU/l. In 2 patients with elevated basal TSH levels (0.23 and 0.60 mU/l, resp.) in the IRMAclon, total suppression of TSH secretion was suggested by a failure of TSH to rise after TRH. By retesting these samples in an own TSH IRMA, basal and stimulated TSH values were below 0.1 mU/l. In conclusion, basal and TRH-stimulated TSH levels are well correlated in most patients with thyroid cancer under hormonal treatment. However, in some cases (5/72) determination of basal TSH could not clearly define the degree of thyrotropic suppression. Thus, TRH testing is still necessary to establish definitely complete TSH suppression in patients with thyroid carcinoma under suppressive treatment.

Schilddrüsen-Hormon-Resistenz: unterschiedlicher klinischer Ausprägungsgrad bei fünf Patienten

Ziel: Erhöhte freie Schilddrüsenhormon-Konzentrationen bei nicht sup-primiertem TSH sind das biochemische Kennzeichen der Schilddrüsenhormon-Resistenz (RTH = Resistance to Thyroid Hormones). Bei der RTH liegt ein Rezeptordefekt in der ß-Untereinheit des Schilddrüsen-Hormon-Rezeptors vor. In der vorliegenden Arbeit wird über den unterschiedlichen klinischen und biochemischen Verlauf von fünf Patienten mit RTH berichtet. Methoden: Im Verlauf der letzten Jahre wurde der klinische Verlauf sowie die schilddrüsenspezifischen Parameter von fünf Patienten mit RTH untersucht. Ebenfalls erfolgte eine sonografische Untersuchung der Schilddrüse sowie die Bestimmung des Technetium-Uptakes unter Normal- und unter Suppressionsbedingungen. Die individuellen Exons des Schilddrüsen-Hormonrezeptor-ß-Gens wurden aus der Leukocyten-DNA mittels PCR amplifiziert und sequenziert. Ergebnisse: Bei allen Patienten zeigte sich eine Punktmutation in der T3-bindenden Domäne des Schilddrüsenhormonrezeptors. Bei zwei unserer Patienten handelt es sich um Spontanmutationen; bei drei der Patienten ist die RTH familiär bedingt. Drei von fünf Patienten hatten sich vor Diagnosestellung ein bzw. mehrmals einer Schilddrüsenoperation oder einer Radiojodtherapie wegen einer Struma bzw. wegen einer »therapierefraktären« Hyperthyreose unterzogen. Eine Patientin entwickelte zusätzlich eine Hyperthyreose vom Typ M. Basedow und mußte sich einer dritten Schilddrüsenoperation unterziehen. Beim sechs Jahre jüngeren Bruder besteht neben der RTH noch eine Hashimoto Thyreoiditis. Schlußfolgerung: Bei Patienten mit erhöhten freien Schilddrüsenhormonparametern und inadäquat erhöhten bzw. normalem TSH muß immer eine RTH in Erwägung gezogen werden. Der klinische Ausprägungsgrad der RTH ist äußerst variabel. Auch sollten bei Patienten mit RTH Schilddrüsenantikörperbestimmungen durchgeführt werden, um das Auftreten einer autoimmunen Schilddrüsenerkrankung nicht zu übersehen.

Prognostic value of c-erbB-2 expression in papillary thyroid carcinoma

Aims: c-erbB-2 overexpression has been shown to be a potential marker of aggressive biological behaviour in a varity of tumours, whereas its role played in thyroid papillary thyroid carcinoma (PTC) remains unclear. Objective of the study is to determine whether c-erbB-2 overexpression correlates with the clinical course. Methods: We have studied 32 PTC by a two-step immunocytochemical staining procedure for paraffin-embedded specimens (DAKO Hercep- Test). Semiquantitative evaluations were performed, based on the intensity of immunostaining and the percentage of tumor cells. Results: 34% (11/32) of the PTC showed a membranous overexpression of the HER2/neu oncoprotein. Correlating the pathological and clinical data revealed that 81% (9/11) c-erbB-2 positive patients and only 33% (7/21) c-erbB-2 negative patients developed a tumor recurrence or a progression (p = 0.02 in Fisher’s exact test). 3/11 c-erbB-2 positive patients died from PTC whereas all (21/21) c-erbB-2 negative patients are still alive (p=0.03). Conclusions: Our results strongly suggest that c-erbB-2 oncoprotein overexpression is related to the clinical course of PTC.

A Constructive Reframing of Student Roles and Systems Learning in Medical Education Using a Communities of Practice Lens

Health systems are in the midst of a transformation that is being driven by a variety of forces. This has important implications for medical educators because clinical practice environments play a key role in learning and professional development, and evolving health systems are beginning to demand that providers have "systems-ready" knowledge, attitudes, and skills. Such implications provide a clear mandate for medical schools to modify their goals and prepare physicians to practice flexibly within teams and effectively contribute to the improvement of health care delivery. In this context, the concepts of value-added medical education, authentic student roles, and health systems science are emerging as increasingly important. In this Article, the authors use a lens informed by communities of practice theory to explore these three concepts, examining the implications that the communities of practice theory has in the constructive reframing of educational practices-particularly common student roles and experiences-and charting future directions for medical education that better align with the needs of the health care system. The authors apply several key features of the communities of practice theory to current experiential roles for students, then propose a new approach to students' clinical experiences-value-added clinical systems learning roles-that provides students with opportunities to make meaningful contributions to patient care while learning health systems science at the patient and population level. Finally, the authors discuss implications for professional role formation and anticipated challenges to the design and implementation of value-added clinical systems learning roles.

The invisible work of distributed medical education: exploring the contributions of audiovisual professionals, administrative professionals and faculty teachers

Distributed medical education (DME) is becoming increasingly prevalent. Much of the published literature on DME has focused on the experiences of learners in distributed programs; however, our empirical work leads us to believe that DME changes the context significantly, not only for learners, but also for other important members of the educational community including audiovisual professionals, administrative professionals and faculty teachers. Based on a three-year ethnographic study, we provide a detailed account of how alliances between various workers involved in DME develop to produce and deliver an undergraduate medical curriculum across geographically separate campuses. We explore the question 'What is the work involved in the delivery of a DME program?' and cast a critical gaze on the essential but invisible, and therefore potentially unrecognized and underappreciated, contributions of AV professionals, administrative professionals, and faculty teachers. Our goal is to make visible the complexity of DME, including the essential contributions of these workers. The study was theoretically framed in sociomateriality and conceptually framed in Star and Strauss' notion of articulation work.

R2C2 in Action: Testing an Evidence-Based Model to Facilitate Feedback and Coaching in Residency

BACKGROUND

Feedback is increasingly seen as a collaborative conversation between supervisors and learners, where learners are actively and reflectively engaged with feedback and use it to improve. Based on this, and through earlier research, we developed an evidence- and theory-informed, 4-phase model for facilitating feedback and practice improvement-the R2C2 model (relationship, reaction, content, coaching).

OBJECTIVE

Our goal was to explore the utility and acceptability of the R2C2 model in residency education, specifically for engaging residents in their feedback and in using it to improve, as well as the factors influencing its use.

METHODS

This qualitative study used the principles of design research. We recruited residents and their supervisors in 2 programs, internal medicine and pediatrics. We prepared supervisors to use the R2C2 model during their regular midrotation and/or end-of-rotation feedback sessions with participating residents to discuss their progress and assessment reports. We conducted debriefing interviews with supervisors and residents after each session. We analyzed transcripts as a team using template and content analysis.

RESULTS

Of 61 residents, 7 residents (11%) participated with their supervisors (n = 5). Schedules and sensitivity to feedback prevented broader enrollment. Supervisors found the structured R2C2 format useful. Residents and supervisors reported that the coaching phase was novel and helpful, and that the R2C2 model engaged both groups in collaborative, reflective, goal-oriented feedback discussions.

CONCLUSIONS

Participants found that using the R2C2 model enabled meaningful feedback conversations, identification of goals for improvement, and development of strategies to meet those goals.

"It's Just Not the Culture": A Qualitative Study Exploring Residents' Perceptions of the Impact of Institutional Culture on Feedback

Phenomenon: Competency-based medical education requires ongoing performance-based feedback for professional growth. In several studies, medical trainees report that the quality of faculty feedback is inadequate. Sociocultural barriers to feedback exchanges are further amplified in graduate and postgraduate medical education settings, where trainees serve as frontline providers of patient care. Factors that affect institutional feedback culture, enhance feedback seeking, acceptance, and bidirectional feedback warrant further exploration in these settings.

APPROACH

Using a constructivist grounded theory approach, we sought to examine residents' perspectives on institutional factors that affect the quality of feedback, factors that influence receptivity to feedback, and quality and impact of faculty feedback. Four focus group discussions were conducted, with two investigators present at each. One facilitated the discussion, and the other observed the interactions and took field notes. We audiotaped and transcribed the discussions, and performed a thematic analysis. Measures to ensure rigor included thick descriptions, independent coding by two investigators, and attention to reflexivity.

FINDINGS

We identified five key themes, dominated by resident perceptions regarding the influence of institutional feedback culture. The theme labels are taken from direct participant quotes: (a) the cultural norm lacks clear expectations and messages around feedback, (b) the prevailing culture of niceness does not facilitate honest feedback, (c) bidirectional feedback is not part of the culture, (d) faculty-resident relationships impact credibility and receptivity to feedback, and (e) there is a need to establish a culture of longitudinal professional growth. Insights: Institutional culture could play a key role in influencing the quality, credibility, and acceptability of feedback. A polite culture promotes a positive learning environment but can be a barrier to honest feedback. Feedback initiatives focusing solely on techniques of feedback giving may not enhance meaningful feedback. Further research on factors that promote feedback seeking, receptivity to constructive feedback, and bidirectional feedback would provide valuable insights.

Internet Addiction and the Virtual Self-image

Background

Internet gaming disorder appears to be associated with self-concept deficits and increased identification with one's avatar. For increased social network use, the few existing studies suggest striatal-related positive social feedback as an underlying factor. Furthermore, few study findings indicate that internet addicts generally have problems in emotional inhibitory control processing.

Methods

Pathological and addicted internet gamers as well as social network users were compared with healthy controls regarding psychometric and neurobiological measures of self-concept-related characteristics, avatar identification and emotional inhibitory control processing.

Results and conclusion

Psychometric results indicated that both subgroups showed higher self-concept deficits compared to healthy controls. Neurobiologically, different brain activation patterns were observed in the subgroups during self-knowledge retrieval and inhibition of emotional stimuli. Furthermore, addicted internet gamers showed a higher identification with the own avatar, mirrored in an increased left angular gyrus activation, a region functionally associated with identification processing and feelings of empathy.

These findings provide a starting point for the deduction of specific psychotherapeutic treatment approaches for addicted internet gamers and social network users.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Adolescent interviewing skills: effect of feedback

BACKGROUND

Communicating with adolescent patients can be challenging. Our study assessed the effect of structured feedback following a standardised patient (SP) encounter on postgraduate year-1 (PGY1) residents' adolescent-specific communication skills. Communicating with adolescent patients can be challenging METHODS: A two-group, prospective, double-blind randomised control study design was employed. Measures were taken before and after the intervention. PGY1 residents conducted a 30-minute interview with an SP adolescent-mother pair, who then individually scored the resident's performance using the validated Structured Communication Adolescent Guide (SCAG). PGY1s were randomised to receive either structured feedback following the interview (feedback group) or no feedback (no feedback group). All residents completed a second interview 4-6 weeks later. Scores were analysed using unpaired t-tests.

RESULTS

Thirty-eight residents completed both interviews. The mean total-item and mean global scores for the first interview did not differ significantly between the feedback (n = 21) and no-feedback group (n = 17). The mean total-item scores for the feedback group [first interview: 34.19 ± 10.19 (adolescent); 36.33 ± 9.77 (mother)] improved significantly for the second interview [45.17 ± 6.22 (adolescent); 44.71 ± 6.72 (mother); p = 0.002 and 0.003, respectively]. The mean global scores also improved significantly from the first interview [27.00 ± 6.49 (adolescent); 27.47 ± 6.50 (mother)] to the second interview [34.05 ± 3.30 (adolescent); 31.19 ± 3.85 (mother); p = 0.001 and 0.03, respectively]. No significant improvement in the mean total-item or mean global rating was observed in the no feedback group.

CONCLUSIONS

Structured feedback following a single adolescent and mother SP encounter resulted in significant improvement in the adolescent-specific communication skills of PGY1s in performing an adolescent interview.

The 'bother' of obstructed defecation

OBJECTIVE

To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment.

METHODS

All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings.

RESULTS

Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001).

CONCLUSIONS

VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Twelve tips for applying the science of learning to health professions education

Findings from the science of learning have clear implications for those responsible for teaching and curricular design. However, this data has been historically siloed from educators in practice, including those in health professions education. In this article, we aim to bring practical tips from the science of learning to health professions educators. We have chosen to organize the tips into six themes, highlighting strategies for 1) improving the processing of information, 2) promoting effortful learning for greater retention of knowledge over time, 3) applying learned information to new and varied contexts, 4) promoting the development of expertise, 5) harnessing the power of emotion for learning, and 6) teaching and learning in social contexts. We conclude with the importance of attending to metacognition in our learners and ourselves. Health professions education can be strengthened by incorporating these evidence-based techniques.

Neurobiological correlates of internet gaming disorder: Similarities to pathological gambling

The number of massively multiplayer online games (MMOs) is on the rise worldwide along with the fascination that they inspire. Problems occur when the use of MMOs becomes excessive at the expense of other life domains. Although not yet formally included as disorder in common diagnostic systems, internet gaming disorder (IGD) is considered a "condition for further study" in section III of the DSM-5. The current review aims to provide an overview of cognitive and neurobiological data currently available on IGD, with a particular focus on impulsivity, compulsivity, and sensitivity to reward and punishment. Additionally, we also compare these findings on IGD with data from studies on pathological gambling (PG)-so far the only condition officially classified as a behavioral addiction in the DSM-5. Multiple similarities have been observed in the neurobiology of IGD and PG, as measured by alterations in brain function and behavior. Both patients with IGD and those with PG exhibited decreased loss sensitivity; enhanced reactivity to gaming and gambling cues, respectively; enhanced impulsive choice behavior; aberrant reward-based learning; and no changes in cognitive flexibility. In conclusion, the evidence base on the neurobiology of gaming and gambling disorders is beginning to illuminate the similarities between the two. However, as only a few studies have addressed the neurobiological basis of IGD, and some of these studies suffer from significant limitations, more research is required before IGD's inclusion as a second behavioral addiction in the next versions of the ICD and DSM can be justified.

Coming in From the Cold-Physician Professional Development as Deepening Participation in the Healthcare Community

This Conversation Starters article presents a selected research abstract from the 2016 Association of American Medical Colleges Southern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the pilot study. These thoughts probe the concept of patient "ownership" and suggest an alternative way of conceptualizing physicians' total dedication to patient care.

The clinical utility of genetic testing of tissues from pregnancy losses

OBJECTIVE

To map the current testing being undertaken following pregnancy loss across the UK and to examine the clinical utility in terms of identifying a cause for the loss and in identifying couples at risk of an unbalanced liveborn child.

DESIGN

Retrospective audit.

SETTING

UK, for the year 2014.

POPULATION

An audit of 6465 referrals for genetic testing of tissue samples following pregnancy loss.

METHODS

Data were obtained by questionnaire from 15 UK regional genetics laboratories.

MAIN OUTCOME MEASURES

Data were analysed with respect to gestational age, the presence of identified fetal anomalies, methodologies used, abnormality rates and the presence of a parental balanced rearrangement.

RESULTS

Of 6465 referrals a genetic cause was identified in 22% of cases (before 12 weeks' gestation, in 47%; at 12-24 weeks, in 14%; after 24 weeks, in 6%). In 0.4% of cases a balanced parental rearrangement was identified where there was a risk of an affected liveborn child in a future pregnancy. Eighty percent of genetic imbalances identified were aneuploidy or triploidy and could be identified by quantitative fluorescence polymerase chain reaction alone. There was significant variation across the UK in acceptance criteria, testing strategies and thus level of resolution of testing.

CONCLUSIONS

Genetic testing of tissues following pregnancy loss identifies a probable cause of fetal demise in 22% of cases, but it is of low clinical utility in identifying couples at risk of a future unbalanced liveborn child. A comprehensive multidisciplinary review is needed to develop proposals for an affordable and equitable service.

TWEETABLE ABSTRACT

UK audit of genetic testing of fetal loss shows variation in access to and resolution of analysis.

A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide No. 40

BACKGROUND

This review, which focused on faculty development initiatives designed to improve teaching effectiveness, synthesized findings related to intervention types, study characteristics, individual and organizational outcomes, key features, and community building.

METHODS

This review included 111 studies (between 2002 and 2012) that met the review criteria.

FINDINGS

Overall satisfaction with faculty development programs was high. Participants reported increased confidence, enthusiasm, and awareness of effective educational practices. Gains in knowledge and skills, and self-reported changes in teaching behaviors, were frequently noted. Observed behavior changes included enhanced teaching practices, new educational initiatives, new leadership positions, and increased academic output. Organizational changes were infrequently explored. Key features included evidence-informed educational design, relevant content, experiential learning, feedback and reflection, educational projects, intentional community building, longitudinal program design, and institutional support.

CONCLUSION

This review holds implications for practice and research. Moving forward, we should build on current success, broaden the focus beyond individual teaching effectiveness, develop programs that extend over time, promote workplace learning, foster community development, and secure institutional support. We should also embed studies in a theoretical framework, conduct more qualitative and mixed methods studies, assess behavioral and organizational change, evaluate transfer to practice, analyse key features, and explore the role of faculty development within the larger organizational context.

Residents as teachers: Near peer learning in clinical work settings: AMEE Guide No. 106

This AMEE Guide provides a framework to guide medical educators engaged in the design and implementation of "Resident as Teacher" programs. The suggested approaches are based on established models of program development: the Program Logic model to guide program design, the Dundee three-circle model to inform a systematic approach to planning educational content and the Kirkpatrick pyramid, which forms the backbone of program evaluation. The Guide provides an overview of Resident as Teacher curricula, their benefits and impact, from existing literature supplemented by insights from the authors' own experiences, all of whom are engaged in teaching initiatives at their own institutions. A conceptual description of the Program Logic model is provided, a model that highlights an outcomes-based curricular design. Examples of activities under each step of this model are described, which would allow educational leaders to structure their own program based on the scope, context, institutional needs and resources available. Emphasis is placed on a modular curricular format to not only enhance the teaching skills of residents, but also enable development of future career educators, scholars and leaders. Application of the Dundee three-circle model is illustrated to allow for a flexible curricular design that can cater to varying levels of educational needs and interests. In addition, practical advice is provided on robust assessment of outcomes, both assessment of participants and program evaluation. Finally, the authors highlight the need for congruence between the formal and hidden curriculum through explicit recognition of the value of teaching by institutions, support for development of teaching programs, encouragement of evidence-based approach to education and rewards for all levels of teachers.

Skills for Interviewing Adolescent Patients: Sustainability of Structured Feedback in Undergraduate Education on Performance in Residency

BACKGROUND

Effective adolescent (10 to 19 years) interviewing by physicians is an essential skill that many trainees can find challenging.

OBJECTIVE

We assessed whether structured adolescent interviewing using standardized patients (SPs) and feedback in undergraduate medical education (UME) has a sustained effect on residents' skills.

METHODS

Postgraduate year (PGY) 1 residents conducted interviews with a SP adolescent-mother pair. The SPs independently scored each PGY-1 interview using the structured communication adolescent guide (SCAG). Unpaired t tests were conducted comparing "Total-Item" and "Global" scores of PGY-1s who received structured SP adolescent interviewing with feedback in UME ("structured training" group) to those who had not ("no structured training" group).

RESULTS

PGY-1s in the structured training group (n = 23) received significantly higher mean Total-Item scores from both the SP adolescent (40.78 ± 7.04 and 32.41 ± 10.12, respectively; P = .001) and the SP mother (40.48 ± 7.90 and 33.34 ± 10.90, respectively; P = .01) than those without structured training (n = 29). Statistically significant results favoring PGY-1s with prior training were also seen with the SP adolescent and mother total Global SCAG scores.

CONCLUSIONS

Structured training in adolescent interviewing with SPs and feedback in UME appears to have a sustained effect on residents' adolescent interviewing skills. PGY-1s will interview adolescents and may benefit from structured adolescent SP interviewing with feedback, especially individuals who did not have this experience during their medical school training.

The Effect of Early Thyroidectomy on the Course of Active Graves' Orbitopathy (GO): A Retrospective Case Study

The aim of the work was to investigate the effect of early thyroidectomy on the course of active Graves' orbitopathy (GO) in patients with low probability of remission [high TSH receptor antibody (TRAb) serum levels, severe GO] compared to that of continued therapy with antithyroid drugs. Two cohorts were evaluated retrospectively (total n=92 patients with active GO, CAS≥4). Forty-six patients underwent early thyroidectomy (Tx-group) 6±2 months after initiation of antithyroid drug (ATD) therapy, while ATD was continued for another 6±2 months in the ATD-group (n=46). These controls were consecutively chosen from a database and matched to the Tx-group. GO was evaluated (activity, severity, TRAb) at baseline and at 6 month follow-up. At baseline, both cohorts were virtually identical as to disease severity, activity and duration, as well as prior anti-inflammatory treatment, age, gender, and smoking behavior. At 6 month follow-up, NOSPECS severity score was significantly decreased within each group, but did not differ between both groups. However, significantly more patients of the Tx-group presented with inactive GO (89.1 vs. 67.4%, * p=0.02), and mean CAS score was significantly lower in Tx-group (2.1) than in ADT-group (2.8; * p=0.02) at the end of follow-up. TRAb levels declined in both groups (Tx-group: from 18.6 to 5.2 vs. ATD-group: 12.8-3.2 IU/l, p0=0.07, p6months=0.32). Residual GO activity was lower in Tx-group, associated with a higher rate of inactivation of GO. This allows an earlier initiation of ophthalmosurgical rehabilitation in patients with severe GO, which may positively influence quality of life of the patients.

Cardiology grand rounds: effect of videoconferencing on educational value

We studied four cardiology grand rounds transmitted by videoconference from a tertiary care centre to four other hospitals in eastern Canada. We collected data with evaluation questionnaires and by video recording participants at the receiving-site and the presentation they received from the presenting site. Receiving-site participants ( n = 20) rated their satisfaction with all domains significantly lower than did presenting-site participants ( n = 49). The greatest difference in ratings was in the ability to see slides (receiving sites 2.6/5, presenting site 4.6/5). Review of video recordings revealed that slides showing material copied from print sources was difficult to read at receiving sites. While 56% of discussion time was devoted to questions from receiving sites, participants there rated their ability to participate in discussion lower than those at the presenting site (3.9/5 vs 4.4/5). This may be because some parts of the discussion from the presenting site were not transmitted. Receiving-site participants rated the educational value of the rounds lower than their presenting-site colleagues (3.9/5 vs 4.4/5) but answered a similar percentage of knowledge questions correctly (85 vs 89%).

Trastuzumab-targeted gene delivery to Her2-overexpressing breast cancer cells

We describe a novel gene delivery system that specifically targets human epidermal growth factor receptor 2 (Her2)-overexpressing breast cancer cells. The targeting complexes consist of a PEGylated polylysine core that is bound to DNA molecules coding for either green fluorescent protein or shrimp luciferase. The complex is disulfide linked to the monoclonal antibody trastuzumab and to a pore-forming protein, Listeriolysin O (LLO). Trastuzumab is responsible for specific targeting of Her2 receptors and uptake of the gene delivery complex into endosomes of recipient cells, whereas LLO ensures that the DNA molecules are capable of transit from the endosomes into the cytoplasm. Omission of either trastuzumab or LLO from the nanocomplexes results in minimal gene product in targeted cells. Treatment of isogeneic MCF7 and MCF7/Her18 cell lines, differing only in number of Her2 receptors, with the complete gene delivery system results in a 30-fold greater expression of luciferase activity in the Her2-overexpressing MCF7/Her18 cells. Our nanocomplexes are small (150–250 nm), stable to storage, nontoxic and generic in make-up such that any plasmid DNA or antibody specific for cell-surface receptors can be coupled to the PEGylated polylysine core.

Introducing medical educators to qualitative study design: Twelve tips from inception to completion

Many research questions posed by medical educators could be answered more effectively by the application of carefully selected qualitative research design than traditional quantitative research methods. Indeed, in many cases using mixed methods research would expand the scope of a study and yield meaningful qualitative data in addition to quantitative data. Qualitative research seeks to understand people's experiences, the meanings they assign to those experiences, the psychosocial aspects of and language used in interpersonal interactions, and the factors that influence perspectives and interactions. This understanding is vital in exploring learning and teaching styles, learners' experiences and perceptions, implementing and studying the impact of educational interventions and faculty development. This article aims to advance medical educators' understanding and application of qualitative research principles in educational scholarship by summarising and consolidating the fundamental principles of research in medical education described in recent AMEE guides. The 12 tips below offer a systematic, yet practical approach to designing a qualitative research study, particularly targeting educators new to this arena.

Can alcohol-dependent patients really reduce their alcohol consumption over time?

Introduction

Treatment of alcohol dependent patients is moderately successful but it only reaches about 10% of the population in need. A new harm reduction strategy aims at abstinence in the long run but claims to benefit patients already early on by reducing their alcohol consumption.

Objectives

A brief outline of the debate on abstinence versus controlled drinking will be followed reporting several RCTs striving for reduced drinking in alcohol dependent patients.

Aims

The participant will find guidance whether and how to treat patients following this new approach.

Results

Studies testing behavioural treatments and counselling (MATCH, UKATT) indicate that a reduction over time is possible. Using nalmefene (a mu and delta opioid antagonist and a partial agonist) RCTs with more than 2500 patients were performed showing a benefit over placebo. On this basis the EMA approved this drug for the reduction of alcohol consumption in alcohol dependent patients. Other compounds such as naltrexone showed similar effects in smaller trials but are not approved for reduction. More studies testing further compounds are underway.

Conclusions

This new approach has the potential to lower the barriers which to date prevent many patients from accepting treatment for their alcohol problems. Two research questions warrant further study: (1) does the reduction in alcohol consumption translate into health and other benefits, and (2) are there specific subgroups of patients who benefit more than others. Preliminary answers will be given in the lecture.

Disclosure of interest

The author has not supplied his declaration of competing interest.