What do senior genitourinary medicine physicians think of the future of the speciality? A national survey.

Genitourinary Medicine (GUM) is a specialty that has undergone significant change over the past decade. Multiple factors have contributed to this including changes in service models and commissioning landscapes, health service leadership, medical education and changes in the spectrum of our clinical work. The Joint Specialist Committee for GUM at the Royal College of Physicians (RCP) conducted a national survey in December 2019 - January 2020 to understand the changing scope of work for GUM consultants. The survey indicated an increase in clinical complexity alongside a decline in registrar recruitment, staff shortages and service fragmentation. Funding cuts have impacted many services and the majority of consultants feel a return to an NHS commissioning model would be preferable. Despite the many challenges, GUM physicians consider the specialty 'unique, dynamic, friendly and open-minded'. It is clear that senior doctors value the wider clinical, academic and educational opportunities within the specialty.

Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study.

OBJECTIVES: To quantify post-colonoscopy colorectal cancer (PCCRC) rates in England by using recent World Endoscopy Organisation guidelines, compare incidence among colonoscopy providers, and explore associated factors that could benefit from quality improvement initiatives. DESIGN: Population based cohort study. SETTING: National Health Service in England between 2005 and 2013. POPULATION: All people undergoing colonoscopy and subsequently diagnosed as having colorectal cancer up to three years after their investigation (PCCRC-3yr). MAIN OUTCOME MEASURES: National trends in incidence of PCCRC (within 6-36 months of colonoscopy), univariable and multivariable analyses to explore factors associated with occurrence, and funnel plots to measure variation among providers. RESULTS: The overall unadjusted PCCRC-3yr rate was 7.4% (9317/126 152), which decreased from 9.0% in 2005 to 6.5% in 2013 (P<0.01). Rates were lower for colonoscopies performed under the NHS bowel cancer screening programme (593/16 640, 3.6%), while they were higher for those conducted by non-NHS providers (187/2009, 9.3%). Rates were higher in women, in older age groups, and in people with inflammatory bowel disease or diverticular disease, in those with higher comorbidity scores, and in people with previous cancers. Substantial variation in rates among colonoscopy providers remained after adjustment for case mix. CONCLUSIONS: Wide variation exists in PCCRC-3yr rates across NHS colonoscopy providers in England. The lowest incidence was seen in colonoscopies performed under the NHS bowel cancer screening programme. Quality improvement initiatives are needed to address this variation in rates and prevent colorectal cancer by enabling earlier diagnosis, removing premalignant polyps, and therefore improving outcomes.

Display glass for low-loss and high-density optical interconnects in electro-optical circuit boards with eight optical layers.

Parallel optical interconnects on-board level requires low propagation loss in wavelength range between 850 and 1550 nm to be compatible with datacom and telecom optical engines. For highest integration density tight waveguide bends and a scalable number of optical layers should be manufacturable for 2D interfaces to optical fiber array connectors and photonic assembly I/O's. We developed a glass waveguide panel process for double-sided processing of commercial available display glass by applying a two-step thermal ion-exchange process for low-loss multi-mode graded-index waveguides. Multiple glass waveguide panels can be embedded between electrical layers. The generic concept enables fabrication of high-density integration (HDI) electro-optical circuit boards (EOCB) with high number of optical and electrical layers. Waveguides with high NA of 0.3 for low bend losses could be achieved in glass with propagation loss of 0.05 dB/cm for all key wavelengths. Four of those glass waveguide panels were embedded in an EOCB demonstrator with size of 280 x 233 mm² providing eight optical layers with 96 channels in an area of 2.8 x 1.5 mm². To the best of our knowledge it's the highest number of layers that has ever been demonstrated for an EOCB.

Hepatology outpatient service provision in secondary care: a study of liver disease incidence and resource costs.

This paper discusses the annual incidence of liver disease and resource costs in providing a hepatology service for all new outpatient referrals to a secondary care setting. In a retrospective study, we found that 200 patients (1 in 1,000 of the West Suffolk population) with a mean age of 52 years were referred per year. One-third of patients had cirrhosis (almost half due to alcohol). Annual incidence (per 100,000 population) were as follows: non-alcoholic fatty liver disease (29: of which 23.5 non-cirrhotic and 5.5 cirrhotic), hepatitis C (25), hepatitis B (3), alcohol-related cirrhosis (12.5), primary biliary cirrhosis (3.5), autoimmune hepatitis (3), primary sclerosing cholangitis (2), haemochromatosis (2), hepatocellular carcinoma (1.5) and oesophageal variceal haemorrhage (6.5). Using national indicative tariffs, the total annual hepatology budget was 130K pounds (58K pounds for resources and 72K pounds for clinic attendances). The greatest resource expenditure was on endoscopy (almost half for oesophageal varices) and radiological imaging (one-third of the total budget). These findings will help inform commissioners in hepatology service funding.

Living with primary ciliary dyskinesia: a prospective qualitative study of knowledge sharing, symptom concealment, embarrassment, mistrust, and stigma.

BACKGROUND: Primary ciliary dyskinesia (PCD) is a chronic respiratory disease for which there is little psycho-social research and no qualitative studies of individuals living with the condition. A questionnaire-based survey in 2003 found evidence of stigmatisation in some individuals with PCD. Although the questionnaire had face and construct validity, stigmatisation was not cross-validated against interviews. The present study had the twin aims of carrying out a qualitative study of the adult patients living with PCD, and using a structured design to validate the questionnaire measure of stigma. METHODS: Interviews were carried out with six pairs of individuals with PCD, matched for sex, situs, and age, one with a high stigma score in 2003 and the other with a low stigma score. Depth-qualitative interviews were conducted by one author to explore themes surrounding the psycho-social impact of PCD using a grounded theory analysis. The interviewer was blind to the stigma scores of participants, and after the qualitative analysis was completed, the interviewer made an assessment of which member of each pair seemed the more stigmatised, after which the code was broken. RESULTS: Interviews revealed a number of themes, including other people's knowledge of PCD, the sharing of knowledge about PCD, the concealment of symptoms of PCD, embarrassment at symptoms, changes of behaviour in response to PCD, mistrust of medical care, in particular in relation to problems in diagnosis, a mistrust of general practitioners who were seen as poorly informed, and the importance of expert care at tertiary referral centres. Although stigmatisation as such was rarely mentioned directly by respondents, when the interviewer's judgement on level of stigmatisation was correlated with stigma scores from 2003, it was found that the more stigmatised member had been correctly identified in all six pairs (p = .016). CONCLUSION: Our results suggest that some people with PCD feel isolated through mistrust in medicine, and lack of knowledge surrounding PCD. Many responses to PCD can be explained in terms of stigmatisation, and in particular felt stigma. The correlation between questionnaire used several years previously, and the interviewer's judgements of stigmatisation suggest that the stigma questionnaire had both predictive validity and long-term stability. As in other chronic conditions, stigmatisation occurs only in some individuals with PCD, and the present study explores the basis of stigmatisation, and validate the questionnaire as a measure of difference in stigma.

Evolution of hepatitis B virus during primary infection in humans: transient generation of cytotoxic T-cell mutants.

BACKGROUND & AIMS: Acute hepatitis B is a highly dynamic human viral infection during which the hepatitis B virus can generate many genetic variants. METHODS: We analyzed the evolution of the hepatitis B virus genome in sequential serum samples from a unique cohort of patients with acute infection acquired from a single source. RESULTS: We showed that most mutations were nonsynonymous, that genetic diversity was greatest at the peak of viremia, and that patients who resolved their infection ("resolvers") showed a significantly higher level of diversity in the core, surface, and polymerase genes compared with those who progressed to chronic infection. Overall, the core gene showed the greatest genetic diversity. In resolvers who possessed an HLA-A*0201 haplotype, the emergence of mutants in the immunodominant HLA-A*0201-restricted core 18-27 epitope was observed. Functional studies showed that these mutants were less able to stimulate interferon-gamma release from core 18-27 specific CD8 + T-cell lines. However, they appeared only as a transient low-abundance species and were rapidly displaced by wild-type sequences before resolution of infection, and their overall significance is uncertain. CONCLUSIONS: Overall, genetic evolution of the hepatitis B virus differs at early time points between patients who experience acute resolving hepatitis B and those who progress to chronicity. These observations suggest that the rapid development of broadly reactive host immune responses leads to clearance of hepatitis B virus, even in the presence of possible CD8+ T-cell immune escape variants.