Effectiveness of an online module: climate-change and sustainability in clinical practice.

BACKGROUND: Climate change has significant implications for health, yet healthcare provision itself contributes significant greenhouse gas emission. Medical students need to be prepared to address impacts of the changing environment and fulfil a key role in climate mitigation. Here we evaluate the effectiveness of an online module on climate-change and sustainability in clinical practice designed to achieve learning objectives adapted from previously established sustainable healthcare priority learning outcomes. METHODS: A multi-media, online module was developed, and 3rd and 4th year medical students at Brighton and Sussex Medical School were invited to enrol. Students completed pre- and post-module questionnaires consisting of Likert scale and white space answer questions. Quantitative and qualitative analysis of responses was performed. RESULTS: Forty students enrolled and 33 students completed the module (83% completion rate). There was a significant increase in reported understanding of key concepts related to climate change and sustainability in clinical practice (p < 0.001), with proportion of students indicating good or excellent understanding increasing from between 2 - 21% students to between 91 - 97% students. The majority (97%) of students completed the module within 90 min. All students reported the module was relevant to their training. Thematic analysis of white space responses found students commonly reported they wanted access to more resources related to health and healthcare sustainability, as well as further guidance on how to make practical steps towards reducing the environmental impact within a clinical setting. CONCLUSION: This is the first study to evaluate learner outcomes of an online module in the field of sustainable health and healthcare. Our results suggest that completion of the module was associated with significant improvement in self-assessed knowledge of key concepts in climate health and sustainability. We hope this approach is followed elsewhere to prepare healthcare staff for impacts of climate change and to support improving the environmental sustainability of healthcare delivery. TRIAL REGISTRATION: Study registered with Brighton and Sussex Medical School Research Governance and Ethics Committee (BSMS RGEC). Reference: ER/BSMS3576/8, Date: 4/3/2020.

Surgical Treatment of Hyperparathyroidism After Kidney Transplant.

Chronic renal impairment is often associated with complex bone disorders. Improvement of secondary hyperparathyroidism (HPT) is expected after kidney transplant (KT) if the glomerular filtration rate is normalized. PATIENTS AND METHODS: There were 888 KTs performed between 1996 and 2017 at our department. A total of 558 general patients have been operated on for HPT during the same period. The 2 populations had a common part: out of the 558, a total of 69 (12.4%) were in end-stage renal failure when operated on because of secondary HPT. That also means that 7.8% of all KTs were associated with HPT. Retrospective, single-center analysis was performed using the patients' medical records. The aim of our study was to analyze the results of parathyroidectomies after KT. RESULTS: Parathyroid surgery was performed on 19 patients (2.14%) because of HPT after KT. The applied surgical technique was total parathyroidectomy with autotransplant in 6 cases, subtotal parathyroidectomy in 3 cases, and selective parathyroidectomy in 10 cases. In all cases, histology revealed benign disease. Complications were observed in 10 cases (52%); there were 6 cases of postoperative hypocalcaemia (31.58%), 1 case of transient laryngeal recurrent nerve paresis (5.26%), and 6 cases of recurrent HPT (31.58%). SUMMARY: The first step of HPT management is calcimimetic drug treatment. It is essential to prevent possible complications with regular laboratory monitoring. If the proper conservative therapy is refractory or severe in complications, surgery should be chosen. If the patient is already waiting for a KT, it is worth performing the parathyroid surgery before KT. Close collaboration with endocrinologists and nephrologists is needed to achieve successful therapy.

Combined prognostic value of absolute lymphocyte/monocyte ratio in peripheral blood and interim PET/CT results in Hodgkin lymphoma.

Decreased absolute lymphocyte/monocyte ratio (LMR) in peripheral blood has been reported as an unfavorable prognostic marker in Hodgkin lymphoma. We aimed to investigate whether combining LMR and interim PET/CT scan result (PET2) confers stronger prognostic value than PET2 alone. 121 HL patients were investigated. LMR was calculated from a blood sample taken at the time of diagnosis. PET2 was carried out after the second chemotherapy cycle. Survival was calculated using the Kaplan-Meier method and significance was determined by log-rank test. Effect of variants on survival results was examined using univariate and multivariate analyses. Best LMR cut-off value was determined by receiver operating characteristic (ROC) curve. Best LMR cut-off value was 2.11 in the case of our patients (LMR > 2.11: favorable, LMR ≤ 2.11: unfavorable). Overall and progression-free survivals (OS/PFS) were significantly worse both in lower LMR (≤ 2.11) (OS: P = 0.041, PFS: P = 0.044) and PET2 positive groups (OS: P < 0.001, PFS: P < 0.001). In PET2 positive patient group (n = 32) the low LMR result meant a significantly worse OS (0.030) and PFS (0.001). Both LMR and PET2 proved to be independent prognostic factors on multivariate analysis, and strengthened each other's effect.

Prognostic value of interim and restaging PET/CT in Hodgkin lymphoma. Results of the CHEAP (Chemotherapy Effectiveness Assessment by PET/CT) study - long term observation.

Very few studies have determined the prognostic value of interim and restaging PET/CT in patients with Hodgkin lymphoma using current standard of care therapy outside clinical trials. We analyzed the effect of the results of interim and restaging PET/CT on the survival (overall- and relapse-free) in patients who received standard first-line treatment based on the stage of disease and risk factors. We investigated the differences between the relapse and non-relapse groups based on the clinical pathological characteristics of patients who had positive interim PET/CT results.Between January 1, 2007 and December 31, 2011, the staging, interim and restaging PET/CT scans of patients with Hodgkin lymphoma were analyzed. The Deauville criteria were used for the evaluation of interim PET/CT scans. One hundred and thirteen Hodgkin lymphoma patients underwent staging, interim and restaging PET/CT scans. None of the therapy was modified based on the interim PET/CT results. The median follow-up time was 43.5 months. A total of 62 early stage patients and 51 advanced stage patients were identified. The five-year overall survival rates were 93.4% in the interim PET negative group and 58% in the interim PET positive group (p<0.001). The five-year relapse-free survival rates for the negative and positive groups were 92.7% and 40.8%, respectively (p<0.001). The negative predictive value was 100% in the early stage group and 82.35% in the advanced stage group. By comparison, the positive predictive values were 53.8% and 58.8%, respectively, in these two groups. In the interim PET positive group, patients over 40 years of age had a significantly higher probability of relapse (p=0.057).The routine clinical use of interim PET/CT is highly recommended based on our investigation. However, patients with positive interim PET/CT results required frequent additional evaluations.

Profile of the oral healthcare team in countries with emerging economies.

Health is a critical dimension of human well-being and flourishing, and oral health is an integral component of health: one is not healthy without oral health. Significant barriers exist to ensuring the world's people receive basic healthcare, including oral healthcare. Amongst these are poverty, ignorance, inadequate financial resources and lack of adequate numbers of educated and trained (oral) healthcare workers. Emerging economies are encouraged to develop a national strategic plan for oral health. International organizations have developed goals for oral health that can be referenced and adapted by emerging economies as they seek to formulate specific objectives for their countries. Demographic data that assess the nature and extent of oral diseases in a country are essential to sound planning and the development of an oral healthcare system that is relevant, effective and economically viable. Prevention should be emphasized and priority consideration be given to oral healthcare for children. The types and numbers of members of the oral healthcare team (workforce) will vary from country to country depending on the system developed. Potential members of the workforce include: generalist dentists, specialist dentists, dental therapists, dental hygienists, denturists, expanded function dental assistants (dental nurses) and community oral health workers/aides. Competences for dentists, and other members of the team, should be developed to ensure quality care and developed economies should cooperate with emerging economies. The development, by more advanced economies, of digital, virtual curricula, which could be used by emerging economies for educating and training members of the oral healthcare team, should be an important initiative. The International Federation of Dental Educators and Associations (IFDEA) should lead in such an effort.

Predictors of syphilis seroreactivity and prevalence of HIV among street recruited injection drug users in Los Angeles County, 1994-6.

OBJECTIVES: To describe HIV prevalence and the association between syphilis incidence and sexual and drug injection risk behaviours in a cohort of street recruited injecting drug users (IDUs) in Los Angeles County, between 1994 and 1996. METHODS: During the study period, 513 street recruited African-American and Latino IDUs were screened for syphilis and antibodies to HIV. Subjects were administered a risk behaviour survey at baseline and followed up at 6 month intervals for 18 months with repeated interviews and serological screening. Rate ratios were used to examine associations between syphilis incidence and demographic characteristics and risk behaviours. A proportional hazard model was used to identify predictors of syphilis incidence independent of demographic characteristics. RESULTS: 74% of the sample were male, 70% African-American, 30% Latino; and the median age was 43 years. Overall baseline serological prevalence of HIV was 2.5% and of syphilis 5.7%. None of the participants were co-infected for HIV and syphilis at baseline or at any of the 6 month follow ups. Among 390 eligible IDUs retained for analysis of incidence data, the overall syphilis incidence was 26.0 per 1000 person years. Higher syphilis incidence was found for women compared with men (RR = 2.70; 95% CI 1.60, 4.55), and for those 44 years of age or younger compared with those 45 years of age and older (RR = 2.26; 95% CI 1.25, 4.08). African-Americans were more likely to be syphilis incident cases when compared with Latinos, although the difference did not reach statistical significance (RR = 1.27; 95% CI 0.72, 2.23). In bivariate analysis, risk behaviours significantly associated with higher syphilis incidence included injection of cocaine, "speedball" and heroin, "crack" smoking, recency of first injection event, backloading of syringes, injecting with others, exchanging drugs or money for sex, multiple sex partners, and non-heterosexual sexual preference. Variables that significantly predicted syphilis infection at follow up in the multivariate analysis included multiple sex partners (RR = 7.8; 95% CI 2.4, 25.0), exchanging money for sex (RR = 3.0; 95% CI 0.9, 9.6), and recent initiation to injection drug use (RR = 4.6; 95% CI 1.1, 18.8). CONCLUSION: Syphilis transmission among IDUs in Los Angeles County remains a serious public health concern, particularly among IDUs who engage in trading of sex for money or drugs. Although low, the prevalence of HIV observed in this study constitutes a serious concern because of the potential for expanded HIV transmission in this susceptible population of IDUs with high syphilis incidence. Enhanced case finding screening efforts and prevention of transmission of sexually transmitted infections should specifically target hard to reach IDUs and their sexual partners.

A Pixel-Array Detector for Time-Resolved X-ray Diffraction.

An integrating pixel-array detector for recording time-resolved X-ray diffraction measurements on microsecond timescales has been designed and tested as a 4 x 4 pixel prototype. Operational characteristics and radiation tolerance are discussed. A 100 x 92 array with 151.2 micro m square pixels is currently under construction.

Undergraduate training in the European Union. Convergence or divergence?

A survey of dental schools in the European Union was carried out for two main reasons. Firstly to promote the exchange of information in respect of curriculum objectives in the different countries and secondly to ascertain the differences in the interpretation of the 1978 EU sectoral directives for dental education and training. Out of 127 schools, only 30 responded, yet the information provided is of considerable importance. It demonstrates wide divergence in the interpretation of the 1978 Directives and methods of assessment of clinical competence. There is a considerable difference throughout Europe in hours devoted to the various subjects included in the Dental Directives. There is little evidence of convergence in methods of assessment or quality assurance. The survey demonstrates the difference in resources, levels of staff, availability of clinical training places, output in research and patient treatments throughout the European Union. The results question the effectiveness of the 1978 Dental Directives in promoting convergence of standards. As there is free movement of dentists throughout the European Union, it is concluded that a different approach may be necessary to ensure that all European Union dental graduates achieve comparable standards in their education and training.

High-resolution macromolecular structure determination using CCD detectors and synchrotron radiation.

BACKGROUND: Synchrotron radiation sources have made impressive contributions to macromolecular crystallography. The delay in development of appropriate X-ray detectors has, however, been a significant limitation to their efficient use. New technologies, based on charge-coupled devices (CCDs), provide capabilities for faster, more accurate, automated data collection. RESULTS: A CCD-based X-ray detector has been developed for use in macromolecular crystallography and has been in operation for about one and a half years at the Cornell High Energy Synchrotron Source. It has been used for a variety of crystallographic projects, including a number of high-resolution structural studies. The statistical quality of the data, the detector's ease and efficiency of use, and the growing number of structural results illustrate the practical utility of this new detector system. CONCLUSIONS: The new detector has enhanced capabilities for measuring diffraction patterns from crystals of macromolecules, especially at high resolution, when the X-ray intensities are weak. The survey of results described here ranges from virus crystallography to weakly diffracting small-molecule structure determination and demonstrates the potential of CCD detectors when combined with synchrotron radiation sources.

[Investigations of the left ventricular dynamics in stable-angina pectoris (AP)]. / Explorarea dinamicii ventriculare stîngi în angina pectorala stabile.

The investigations were carried out in 78 patients with stable AP without myocardiaI infarction in their case history and in 30 controls all distributed in three series: I = 37 patients with AP and marked alterations of ventricular repolarization (ST depression ≥ 52 mm and T negative waves ≥ 2 mm); II = 41 patients with AP and normal ECG and III = 30 controls, clinically and ECG normal, of similar age with the patients in the I and II series. The investigations of the left ventricular systole periods also rendered evident in the patients with AP important alterations of ventricular repolarization (Ist series): prolonged preejection period (PEP) due to the izovolumetric contraction time (IVCT), shortening of the ejection time (LVET) and decrease of PEP/LVET ratio as well as the significant increase of S(IV)/S(I) ratio. Although slightly shortened in this series, the electromechanic systole (QS(II)) does not present statistically significant alterations, the prolonged PEP being partially counter-balaced by the shortened LVET. The most sensitive index seems to be the PEP/LVET ratio. The alterations' of the left ventricular systole periods become evident late in the course of the disease, when significant ischemic lesions are present this the method has no value in determining an early diagnosis. On the other hand this type of investigation is an useful quantitative method for estimating the functional state of the cardiac muscle in the patients with the diagnosis of AP (stage diagnosis of AP) and subsequent evolution (repeated records).

The progress of developmentally delayed pre-school children in a home-training scheme.

The present study compared the rates of development of a group of 35 pre-school children in a home-training scheme. The children entered the service at different ages and suffered from different disabilities. The families received weekly visiting from a home advisor, who was specially trained to develop skills in the parents to help their children. Those who developed most rapidly were the group of environmentally deprived children. The non-specific developmentally delayed and Down's syndrome children progressed well during the study period. The children who suffered from cerebral palsy and those with visual handicaps developed at a very slow rate, despite the training that they were receiving. This finding may reflect the severity of their handicaps but also it suggests that the needs of these particular groups should be further examined. The age of entry to the scheme did not seem to be an important variable. The individual variability within each specified group was wide.