Local Physicians Research Articles

Decitabine Plus Cytarabine for Induction of Remission in Newly Diagnosed Elderly AML or High Risk MDS Patients

Introduction:Acute myeloid leukemia (AML) primarily affects older adults. Treating these patients requires balancing risk of toxicity with risk of ineffective therapy. Here we examine the ability of decitabine combined with cytarabine (DecitAC) to strike such a balance. Our objectives were to 1) examine the likelihood DecitAC would improve 6-month survival probability from historical 60% (poor risk)-65% (good risk) in older patients treated with azacitidine + gemtuzumab on SWOG study - S0703 (Nand S et al Blood. 2013;122(20);3432-3439) to 80% in patients age ≥60 with newly diagnosed AML or high risk MDS (10-19% blasts); 2) determine response rate in this population; and 3) evaluate the effect of cytarabine dose escalation in patients who had a response short of CR after the first 2 cycles of the combination.Patients and Methods:In addition to age ≥ 60, patients needed a treatment related mortality (TRM) score <22.9 corresponding to <25% chance of death within 28 days of beginning 7+3 or high dose cytarabine-containing induction (Walter et al. JCO 2011). Prior use of azacitidine, lenalidomide, or decitabine, but not more intense therapy, was permitted. Doses were: decitabine 20mg/m2 once daily days 1 through 10, and cytarabine 100mg/m2once daily days 1 through 7. Two courses were planned to be given 28-35 days apart, regardless of blood counts. Bone marrow evaluation was planned after DecitAC course 2. The protocol allowed for cytarabine dose escalation after course to 1gm/m2 daily x 5 days for patients with ≥ 20% blasts by flow cytometry and if non-hematologic toxicities were < grade 3. If blasts were 5-19% by flow after two cycles, the doctor would choose between the original dose of cytarabine or the dose escalated dose. For patients that had ≥ grade 3 non-hematologic toxicities, the number of DecitAC dosed days were shortened if <5% blasts by flow after 2 cycles, or the patient was taken off study if marrow had ≥5% blasts by flow. Treatment was given outpatient or inpatient and patients were often managed by their referring physicians.Results:12 newly diagnosed patients (10 AML, 2 MDS) were treated on protocol at our academic center. 18 others (16 AML, 2 MDS) were treated off study because of higher TRM scores or by community oncologists, with chart review on an IRB approved protocol. TRM scores ranged from 0.5 - 61 with a median of 10. Ages ranged from 46-92 with a median of 73. Fourteen of the 26 AML patients had an antecedent hematological disorder. Two AML patients had ELN favorable risk disease, 12 had intermediate, and 12 adverse.DecitAC produced CR in 14/30 patients (47%; 95% CI 28-65%), CRi was seen in 7 other patients. No patients died within the first 28 days (95% CI 0-11%, i.e. up to 3 patients) contrasted with 5 expected deaths based on TRM score. Dose escalation of cytarabine to 1 gm/m2 on course 3 was conducted in 2 patients (TRM scores 14.2 and 9.8), each of whom died on this couse.Median survival in the 30 patients was 8 months and is 19 months in the 9 patients still alive as of August 2016. At 6 months survival probability was 57% in this group considered poor risk by definition in the comparison group vs. 60% in the controls. Results were not affected by whether patients were managed here or by their local physicians. Grade 3 adverse events included infections, diarrhea, hepatic dysfunction, and others, as expected with other regimens treating newly diagnosed AML and MDS patients.Conclusion:DecitAC resulted in a CR+Cri rate of 21/30 (70%) caused less TRM than expected. Whether this reflects the general decline in TRM or a specific effect of DecitAC is unknown. DecitAC can be given equally well in the community as at an academic center. However pending multivariate analysis it does not appear to improve survival relative to that seen previously. DisclosuresBecker:GlycoMimetics: Research Funding.

Predictors of long term survival after surgical resection in carcinoma gall bladder

Background-Carcinoma of the gallbladder is known to be associated with a dismal prognosis, with majority of patients presenting at late stages. Controversies still exist regarding the optimal management and the extent of surgery. Methods-This study was done at a tertiary hospital in an endemic region for cancer gallbladder (north Indian Gangetic belt). All patients operated for cancer gallbladder between January 2006 and January 2011 were included, with details of clinical presentation, survival analysis and identification of prognostic factors. Results- Of the total 252 patients of carcinoma gall bladder identified during the study period, 71 patients were explored surgically. Curative resection was achieved in 27 patients with 10 long term survivors (disease free interval >3years). Nodal status, TNM stage and bilirubin levels affect survival. Majority of patients presented late in the course of disease (Mean of 44 days from the onset of symptoms). Conclusion-Majority patients with carcinoma gallbladder in our region have advanced unresectable disease. Bilirubin levels at presentation predict resectability. Nodal involvement implies a worse prognosis; however the extent of lymphadenectomy to be done is still debatable. Community screening programs and sensitization of local physicians for early referral can improve survival in endemic areas.

Leveraging Telehealth to Bring Volunteer Physicians Into Underserved Communities.

Many disadvantaged communities lack sufficient numbers of local primary care and specialty physicians. Yet tens of thousands of physicians, in particular those who are retired or semiretired, desire meaningful volunteer opportunities. Multiple programs have begun to use telehealth to bridge the gap between volunteer physicians and underserved patients. In this brief, we describe programs that are using this model and discuss the promise and pitfalls. Physician volunteers in these programs report that the work can be fulfilling and exciting, a cutting-edge yet convenient way to remain engaged and contribute. Given the projected shortfall of physicians in the United States, recruiting retired and semiretired physicians to provide care through telehealth increases the total supply of active physicians and the capacity of the existing workforce. However, programs typically use volunteers in a limited capacity because of uncertainty about the level and duration of commitment. Acknowledging this reality, most programs only use volunteer physicians for curbside consults rather than fully integrating them into longitudinal patient care. The part-time availability of volunteers may also be difficult to incorporate into the workflow of busy safety net clinics. As more physicians volunteer in a growing number of telehealth programs, the dual benefits of enriching the professional lives of volunteers and improving care for underserved communities will make further development of these programs worthwhile.

Late Effects Following Treatment of Hodgkin Lymphoma During Childhood and Adolescence. Results of the Hodgkin Lymphoma Late Effects Research Project.

Survival rates have been excellent in patients treated for Hodgkin lymphoma (HL) during childhood and adolescence. Unfortunately, severe treatment related late effects have been observed. It was therefore an important aim of the cooperative pediatric HL therapy studies in Germany to reduce the number of late effects without jeopardizing the excellent treatment results. Progress and relapses of HL were analyzed to obtain important information for the future salvage therapy. All late effects were documented and their etiologies analyzed. Information obtained from bacterial infections and late deaths following splenectomy were used to inform patients at risk and their local physicians about necessary preventive measurements. Procarbazine was recognized as major gonadotoxic agent in boys and eliminated successively from the treatment regimens. Parenthood was normal in female patients when compared to the German female population documenting normal ovarian function except in patients with pelvic radiation. Radiation was the most important risk factor for thyroid diseases, cardiac late effects and subsequent malignant neoplasms, especially thyroid and breast cancer. A special screening program was initiated for women with chest radiotherapy, since they had a high risk of breast cancer already at a young age. The results of the HL Late Effects Research Project are important for the aftercare of patients and for the design of future HL treatment regimens.

Socio-demographic and reproductive determinants of cervical neoplasia in seven sub-Sahara African countries.

Since most human papilloma virus (HPV) infections regress without any intervention, HPV is a necessary but may not be a solely sufficient cause of cervical intraepithelial neoplasia (CIN) and cervical cancer. Hence, the influence of cofactors on progression from cervical HPV infection to high-grade CIN and invasive cervical cancer has been a subject of intensive research. We assessed the effect of socio-demographic and sexual reproductive factors on the prevalence of invasive cervical cancer and CIN diagnosed in cross-sectional cervical cancer screening projects carried out in seven sites of different sub-Saharan countries. Between January 2000 and August 2007, healthy women aged 25-59 who participated in the screening projects were interviewed for socio-demographic, reproductive, and behavioral characteristics, investigated for disease confirmation with colposcopy, and had biopsies directed from colposcopically abnormal areas by trained local physicians. Odds ratios (ORs) and their 95% confidence intervals (CIs) from logistic regression analyses were used to assess the effect of women characteristics on CIN 1, CIN 2-3, CIN 3, and invasive cancer outcome measures. Among 47,361 women screened and investigated for disease confirmation, CIN 1 was diagnosed in 1,069 (2.3%), CIN 2 in 517 (1.1%), CIN 3 in 175 (0.5%), and invasive cancer in 485 (1.0%). The site-specific prevalence of CIN 2-3 lesions ranged from 0.3 to 5.1% and from 0.2 to 1.9% for invasive cancers. Risk factors for CIN 2-3 were being widowed or separated versus currently married (OR 1.3, 95% CI 1.0-1.7 a); and having had at least four pregnancies versus zero or one pregnancy (OR at least 1.4-fold, 95% CI 1.1-1.8). Risk factors for invasive cancer were being widowed or separated versus currently married (OR 2.0, 95% CI 1.3-3.1); and having had at least three pregnancies versus zero or one pregnancy (OR at least 3.0-fold, 95% CI 2.1-4.2). Additionally, cervical cancer risk increased with increasing age, age at menarche, and age at marriage, while the risk decreased with increasing level of education and in those with some form of employment compared to housewives. The exposure of the exocervix and/or the increased levels of estrogen and progesterone for more prolonged periods during pregnancy in multiparous women and the vulnerability of widowed/separated women in society might result in increased risk of cervical neoplasia more so among women exposed to HPV infection. High parity probably explains the persistently high rates of cervical cancer in sub-Saharan Africa.

IMAGE cloud: medical image processing as a service for regional healthcare in a hybrid cloud environment

To handle the emergence of the regional healthcare ecosystem, physicians and surgeons in various departments and healthcare institutions must process medical images securely, conveniently, and efficiently, and must integrate them with electronic medical records (EMRs). In this manuscript, we propose a software as a service (SaaS) cloud called the iMAGE cloud. A three-layer hybrid cloud was created to provide medical image processing services in the smart city of Wuxi, China, in April 2015. In the first step, medical images and EMR data were received and integrated via the hybrid regional healthcare network. Then, traditional and advanced image processing functions were proposed and computed in a unified manner in the high-performance cloud units. Finally, the image processing results were delivered to regional users using the virtual desktop infrastructure (VDI) technology. Security infrastructure was also taken into consideration. Integrated information query and many advanced medical image processing functions-such as coronary extraction, pulmonary reconstruction, vascular extraction, intelligent detection of pulmonary nodules, image fusion, and 3D printing-were available to local physicians and surgeons in various departments and healthcare institutions. Implementation results indicate that the iMAGE cloud can provide convenient, efficient, compatible, and secure medical image processing services in regional healthcare networks. The iMAGE cloud has been proven to be valuable in applications in the regional healthcare system, and it could have a promising future in the healthcare system worldwide.

Perspectives on International Urological Volunteerism: A Survey of IVUmed Resident Scholar Alumni

IntroductionThe primary intentions of international surgical programs are to directly benefit those receiving medical care, educate local physicians and staff, and improve care delivery models. IVUmed, a nonprofit organization dedicated to providing urological care to resource poor areas of the world, provides scholarship opportunities for urology trainees. We assessed the motivations and barriers of IVUmed traveling resident scholars regarding continuing international surgical work after completion of the program. MethodsAn Internet based survey was sent to all previous IVUmed resident scholars assessing potential factors associated with repeat international service. Logistic regression was used to examine the association between survey responses and the likelihood of repeating an international service trip after completion of training. ResultsOf 196 IVUmed resident scholar participants 100 (51%) responded to the survey. Of the 69 attending surgeons 17 (25%) had repeated an international service trip. Altruism (100%), personal fulfillment (99%) and practicing in a resource limited setting (94%) were the most frequently cited motivating factors for repeat participation, while lack of time (96%) was the most commonly reported barrier. Respondents in private practice were less likely to participate in a subsequent trip compared to those in an academic setting (OR 0.16, CI 0.03–0.80, p = 0.03). No other factors were associated with the likelihood of repeating an international service trip. ConclusionsAmong urologists who participated in a funded international scholarship program during residency repeat participation during the subsequent 7 years was modest. Private practitioners were less likely to repeat international service compared to academic urologists.

Simulation for training in resource-restricted countries: using a scalable temporal bone surgical simulator.

Simulation for training in resource-restricted countries: using a scalable temporal bone surgical simulator.

Perspectives on global health amongst obstetrician gynecologists: A national survey

ObjectiveTo characterize contemporary attitudes toward global health amongst board-certified obstetricians-gynecologists (Ob-Gyns) in the US.MethodsA questionnaire was mailed to members of the American College of Obstetricians and Gynecologists. Respondents were stratified by interest and experience in global health and group differences were reported.ResultsA total of 202 of 400 (50.5%) surveys were completed; and 67.3% (n = 136) of respondents expressed an interest in global health while 25.2% (n = 51) had experience providing healthcare abroad. Personal safety was the primary concern of respondents (88 of 185, 47.6%), with 44.5% (57 of 128) identifying 2 weeks as an optimal period of time to spend abroad. The majority (113 of 186, 60.8%) cited hosting of local physicians in the US as the most valuable service to developing a nation’s healthcare provision.ConclusionDespite high interest in global health, willingness to spend significant time abroad was limited. Concerns surrounding personal safety dovetailed with the belief that training local physicians in the US provides the most valuable service to international efforts. These attitudes and concerns suggest novel solutions will be required to increase involvement of Ob-Gyns in global women’s health.

INTEGRATION OF COMMUNITY SETUP IN PHARMACEUTICAL CARE: CURRENT CHALLENGES, PERCEPTION, FACTS AND OPPORTUNITIES IN PAKISTAN

&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;A qualitative, cross-sectional survey-based study was conducted to evaluate the integration of community setup in pharmaceutical care with respect to current challenges, awareness/perception of individuals from various walks of life, related facts and opportunities which are contextual to local settings in Karachi, Pakistan.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This cross-sectional, a qualitative study, was conducted between May–November 2015. A questionnaire was designed using 15 close ended and 5 open-ended questions. And validated using correlation of spearman coefficient and Cronbach’s α value (α = 0.916 and &lt;em&gt;p&lt;/em&gt; = 0.941). Local residents, pharmacist, medical practitioners, and pharmacy technicians were selected as study participants. Informed consents of all respondents were obtained prior to the participation.&lt;strong&gt; &lt;/strong&gt;SPSS 20.0 was utilized and results were calculated with respect to percentages of responses and mean scores. Chi-square test was used to analyze the problems associated in effective implementation and integration of community pharmacy practices in Pakistan. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Rate of response in the various cohort were in the order of 76%, 94%, 71% and 83% for local residents, pharmacist, physicians and pharmacy technicians respectively. Community pharmacy knowledge and beliefs mean scores were correspondingly found to be 1.971.83, 1.457.44, 2.842.10 and 2.385.54 for doctors, pharmacist, residents and technicians respectively.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;A significant difference in the level of perception was observed amongst the professionals and local resident’s cohort, which necessitates the effective and better execution of community residents counseling and more stringent implementation of health care facilities at the community level to improve the medication and health outcomes of related inhabitants.&lt;/p&gt;

Malawian impressions of expatriate physicians: A qualitative study.

In many low-income countries, including Malawi, expatriate physicians serve diverse roles in clinical care, education, mentorship, and research. A significant proportion of physicians from high-income countries have global health experience. Despite the well-known benefits of global health experiences for expatriates, little is known about local physician and trainee impressions of their expatriate counterparts. The objective of this study was to explore University of Malawi College of Medicine (COM) physicians' and trainees' impressions of expatriate physicians. We conducted a cross-sectional qualitative study using semi-structured interviews with COM medical students, interns, registrars, and faculty. Through open coding, we developed a codebook that we applied to interview transcripts and used thematic analysis to identify major themes. We interviewed 46 participants from across the continuum of medical education at two teaching hospitals in Malawi. Participants discussed themes within the following domains: perceived benefits of expatriate physicians in Malawi, perceived challenges, past contributions, and perceived roles that expatriate physicians should play going forward. Malawian faculty and trainees appreciated the approachability, perspectives, and contribution to education that expatriates have provided, though at times some have been perceived as aggressive, unable to relate to patients and trainees, deficient at adapting to the setting, and self-serving. Potential roles that Malawian physicians and trainees feel expatriates should serve include education, training, capacity building, and facilitating exchange opportunities for local physicians and trainees. This study highlights the perceived benefits and challenges that physicians and trainees at the COM have experienced with their expatriate counterparts, and suggests roles that expatriates should play while abroad. These findings can be used to help inform existing global health guidelines, assist with the establishment of host institution expectations for global health programmes, and guide individual expatriate physicians who hope to optimise their roles abroad.

Sleep time and pattern of adult individuals in primary care in an Asian urbanized community: A cross-sectional study.

Sleep norms vary between individuals, being affected by personal, communal, and socioeconomic factors. Individuals with sleep time which deviate from the population norm are at risks of adverse mental, cardiovascular, and metabolic health. Sleep-related issues are common agenda for consultation in primary care. This study aimed to determine the sleep time, pattern, and behavior of multiethnic Asian individuals who attended public primary care clinics in an urban metropolitan city-state.Standardized questionnaires were assistant-administered to adult Asian individuals who visited 2 local public primary care clinics in north-eastern and southern regions of Singapore. The questionnaire included questions on demographic characteristics, self-reported sleep time, patterns, and behavior and those originated from the American National Sleep Foundation Sleep Diary. The data were collated, audited, rectified, and anonymized before being analyzed by the biostatistician. Individuals with 7 h sleep time or longer were deemed getting adequate sleep. Chi-squared or Fisher exact test was used to test the association between the demographic and behavioral variables and sleep time. Next, regression analysis was performed to identify key factors associated with their sleep time.A total of 350 individuals were recruited, with higher proportion of those of Chinese ethnicity reporting adequate sleep. Almost half (48.1%) of those who slept <7 h on weekdays tended to sleep ≥7 h on weekends. More individuals who reported no difficulty falling asleep, had regular sleep hours and awakening time, tended to sleep adequately. Those who slept with children, studied, read leisurely, used computer or laptops in their bedrooms, drank caffeinated beverages or smoked had inadequate sleep. Those who perceived sufficient sleep and considered 8 h as adequate sleep time had weekday and weekend sleep adequacy.Sleep time varied according to ethnicity, employment status, personal behavior, and perception of sleep sufficiency. Awareness of sleep time and pattern allows the local physicians to contextualize the discussion of sleep adequacy with their patients during consultation, which is a prerequisite to resolve their sleep-related issues.

A Case of Sudden Death in Decameron IV.6: Aortic Dissection or Atrial Myxoma?

Giovanni Boccaccio's Decameron contains a novella that details the sudden death of a young man called Gabriotto, including a portrayal of the discomfort that the protagonist experienced and a rudimentary autopsy performed by local physicians. The intriguing description of symptoms and pathologies has made it possible to read a 7-century-old case through the modern clinical lens. Thanks to the medical and philological analysis of the text-despite the vast difference between modern and medieval medicine-2 hypothetical diagnoses have emerged: either an aortic dissection or an atrial myxoma.

Using pharmacy quality measures in Medicaid drug utilization review programs

Drug–drug interactions (DDIs) are a significant cause for adverse drug events (ADEs). DDIs are often predictable and preventable, but their prevention and management require systematic service development. Most DDI studies focus on interaction rates in hospitalized patients. Less is known of DDIs in outpatients, particularly how community pharmacists could contribute to DDI management by applying their surveillance systems for identifying high-risk medications.The study was related to the implementation of the first online DDI surveillance system in Finnish community pharmacies. The goal was to demonstrate how community pharmacies can utilize their prospective surveillance system 1) for identifying high risk medications causing potential DDIs in outpatients, 2) for collaborative service development with local physicians, and 3) for academic risk management research purposes.All DDI alerts given by the online surveillance system were collected during a one-month period in 16 out of 17 University Pharmacy outlets in Finland, covering approximately 10% of the national outpatient prescription volume. The surveillance system was based on the FASS database, which categorizes DDIs into four classes (A–D) according to their clinical significance.Potential drug–drug DDIs were analyzed for 276,891 dispensed community pharmacy prescriptions. Potential DDIs were associated with 10.8%, or 31,110 of these prescriptions. Clinically significant interaction alerts categorized as FASS classes D (most severe, should be avoided) and C (clinically significant but controllable) were associated with 0.5% and 7.0% of the prescriptions, respectively.Methotrexate and warfarin had the highest risk of causing potentially serious (class D) interactions. These interaction alerts were most frequently between methotrexate and NSAIDs and warfarin and NSAIDs. In general, NSAIDs were the most commonly interacting drugs in this study.This study demonstrates that community pharmacies can actively contribute to DDI risk management and systematically use their surveillance systems for identifying patients having clinically significant DDIs. The findings also indicate that the majority of potentially serious interactions in outpatients involve a limited number of drugs, particularly NSAIDs, warfarin and methotrexate. Further research should focus on community pharmacists' involvement in DDI risk management in collaboration with local health care providers.

Childhood Injuries in Singapore: Can Local Physicians and the Healthcare System Do More to Confront This Public Health Concern?

Childhood injury is one of the leading causes of death globally. Singapore is no exception to this tragic fact, with childhood injuries accounting up to 37% of Emergency Department visits. Hence, it is important to understand the epidemiology and risk factors of childhood injuries locally. A search for relevant articles published from 1996–2016 was performed on PubMed, Cochrane Library and Google Scholar using keywords relating to childhood injury in Singapore. The epidemiology, mechanisms of injury, risk factors and recommended prevention strategies of unintentional childhood injuries were reviewed and described. Epidemiological studies have shown that childhood injury is a common, preventable and significant public health concern in Singapore. Home injuries and falls are responsible for majority of the injuries. Injuries related to childcare products, playground and road traffic accidents are also important causes. Healthcare professionals and legislators play an important role in raising awareness and reducing the incidence of childhood injuries in Singapore. For example, despite legislative requirements for many years, the low usage of child restraint seats in Singapore is worrisome. Thus, greater efforts in public health education in understanding childhood injuries, coupled with more research studies to evaluate the effectiveness and deficiencies of current prevention strategies will be necessary.

Blending Western Biomedicine with Local Healing Practices.

Western allopathic physicians working internationally might encounter allopathic colleagues who endorse local healing practices that are not scientifically supported and, hence, might pose harm to patients. Respect for the autonomy of local physicians and patients thus can conflict with the ethical principles of beneficence and nonmaleficence. In such a situation, it is advisable for Western allopathic physicians to communicate their concerns to local colleagues as equal partners. Making an effort to understand local meanings associated with a traditional therapy demonstrates one's respect for local cultural ideas and practices, even if one disagrees with that therapy, and is crucial to tailoring messages about clinical practice change. A realistic approach to cross-cultural clinical practice change seeks to reduce, rather than eliminate, harm.

An economic evaluation of the costs of training a medical scribe to work in Emergency Medicine

ObjectiveTo undertake a cost analysis of training medical scribes in an ED.MethodsThis was a pilot, observational, single-centre study at Cabrini ED, Melbourne, Australia, studying the costs of initiating a scribe...

USING A QUALITATIVE RESEARCH FRAMEWORK TO ANALYZE MEDICAL TOURISM IN CROATIA

ABSTRACT Twenty years after Croatia's civil war and two years after its admission into the European Union, the Croatian medical industry is seeking to increase revenues needed to support its national healthcare system. The purpose of this study is to identify current trends and opportunities in the medical tourism industry, and to explore the possibility of an expanded medical tourism industry in the country of Croatia from the perspective of medical physicians practicing in Croatia. A semi-structured interview format was utilized to allow local medical physicians employed by a public hospital to freely discuss their impressions and opinions regarding the strengths of Croatian health care and possible opportunities in the area of medical tourism. Overall, while this study's participants possess a positive attitude toward development of a Croatian medical tourism industry Croatia's post-Communism environment presents unique challenges for the implementation and growth of the medical tourism industry. This paper concludes with suggestions for Croatian policy makers. Keywords medical tourism, qualitative methodology, tourism development, Croatia

P205 Management of STI outbreaks. What can we learn from each other? A qualitative study in the UK

Background/introduction When outbreaks of sexually transmitted infections (STIs) are identified, effective management in a timely manner is essential for bringing the outbreak under control. Challenges to achieving this may vary, needing different approaches. Aim(s)/objectives To review the management of outbreaks contrasting by setting and sexual orientation in order to inform responsive guidance. Methods We interviewed clinicians and public health professionals who had recently been involved in identifying and managing STI outbreaks in the United Kingdom. Transcripts were analysed using thematic analysis. Results Ten outbreaks were reviewed. The combination of public health teams’ wider outbreak expertise and clinic staff’s knowledge of the local population was essential when developing management strategies. Partner notification, mainly by health advisers, was very achievable in smaller heterosexual outbreaks but proved challenging in MSM focussed outbreaks where use of mobile apps or anonymous sex was common. Publicity campaigns via social media platforms and third sector organisations were employed although quantifying their impact was difficult. Education of local physicians resulted in syphilis referrals to sexual health services via ophthalmology, gastroenterology, oral and maxillofacial surgery and general practice. Enhanced surveillance enabled venue identification but was time consuming for clinic staff. In gonorrhoea outbreaks, the use of dual NAAT testing as part of the chlamydia screening programme enabled case finding. Discussion/conclusion Traditional management strategies remain important but as the use of social media increases, novel strategies for managing outbreaks are needed. Education of other professionals is essential to maximise case finding.

Physicians' knowledge on the work-related chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) may be induced by the work environment conditions. According to the estimates, 10-20% of all COPD cases are associated with occupational exposure to dusts and irritant gases. However, in 2014, only 11 cases of work-related COPD were recognized in Poland. The aim of the study was to analyze the reasons for the low incidence of work-related COPD in the context of pulmonologists' knowledge about occupational risk factors and procedures on reporting suspected occupational diseases. A survey included 94 pulmonologists randomly selected out of 225 specialists registered at the Local Physicians Chamber in Łódź. The study was performed anonymously with the use of original questionnaire. More than a half of the surveyed pulmonologists identified environmental risk factors for COPD correctly, while only 23.4% properly identified the main occupational risk factors as the cause of COPD. Only 58.5% of the pulmonologists always asked their patients suffering from COPD about their job/profession and 60.6% of them did not have any knowledge about procedures on reporting suspected occupational diseases. The physicians rarely ask patients suffering from COPD about their job/profession and the relationship between their ailments and occupational exposure. What is more, they do not know legal regulations on proper referral of a patient with a suspected case of occupational disease. The results of the study clearly indicate that there is an urgent need for increasing pulmonologists' knowledge on work-related COPD. Med Pr 2016;67(3):375-384.