Dementia syndromes are under-diagnosed and under-treated in primary care. Earlier recognition of and response to dementia syndrome is likely to enhance the quality of life of people with dementia, ...but general practitioners consistently report limited skills and confidence in diagnosis and management of this condition. Changing clinical practice is difficult, and the challenge for those seeking change it is to find ways of working with the grain of professional knowledge and practice. Assessment of educational needs in a practice has the potential to accommodate variations in individual understanding and competence, learning preferences and skill mix. Educational prescriptions identify questions that need to be answered in order to address a clinical problem. This paper reports the development of an educational needs assessment tool to guide tailored educational interventions designed to enhance early diagnosis and management of dementia in primary care, in the Evidence Based Interventions in Dementia in the Community - Early Diagnosis trial.
A multidisciplinary team, including a lay researcher, used an iterative technology development approach to create an educational needs assessment tool, from which educational prescriptions could be written. Workplace learning was tailored to each practice using the educational prescription, and the method was field-tested in five pilot practices.
The educational prescriptions appeared acceptable and useful in volunteer practices. The time commitment (no more than four hours, spread out at the practice's discretion) appeared manageable. The pilot group of practices prioritised diagnosis, assessment of carers' needs, quality markers for dementia care in general practice, and the implications of the Mental Capacity Act (2005) for their clinical practice. The content of the educational needs assessment tool seemed to be comprehensive, in that no new topics were identified by practices in the field trial.
The educational needs assessment tool took into account practitioners' knowledge of the local health and social care systems, reflected the complexity of the diagnostic and care processes for people with dementia, and acknowledged the complexity of the disease process itself.
Objective
Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the ...attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms.
Design
A qualitative study using in-depth interviews and thematic analysis.
Setting
Three hospitals in the North Thames area.
Participants
Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology.
Main outcome measure
Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients.
Results
There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor’s level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care.
Conclusions
Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.
The SPARC Toroidal Field Model Coil Program Hartwig, Zachary S.; Vieira, Rui F.; Dunn, Darby ...
IEEE transactions on applied superconductivity,
03/2024, Letnik:
34, Številka:
2
Journal Article
Recenzirano
Odprti dostop
The SPARC Toroidal Field Model Coil (TFMC) Program was a three-year effort between 2018 and 2021 that developed novel rare earth barium copper oxide (REBCO) superconductor technologies and then ...successfully utilized these technologies to design, build, and test a first-in-class, high-field (∼20 T), representative-scale (∼3 m) superconducting toroidal field (TF) coil. The program was executed jointly by the MIT Plasma Science and Fusion Center (PSFC) and Commonwealth Fusion Systems (CFS) as a technology enabler of the superconducting high-field pathway to fusion energy, and, in particular, as a risk retirement program for the no insulation (NI) TF magnet in the SPARC net-energy fusion tokamak. The TFMC achieved its programmatic goal of experimentally demonstrating a large-scale high-field REBCO magnet, achieving 20.1 T peak field-on-conductor with 40.5 kA of terminal current, 815 kN/m of Lorentz loading on the REBCO stacks, and almost 1 GPa of mechanical stress accommodated by the structural case. Fifteen internal demountable pancake-to-pancake joints operated in the 0.5 to 2.0 nΩ range at 20 K and in magnetic fields up to 12 T. The dc and ac electromagnetic performance of the magnet predicted by new advances in high-fidelity computational models was confirmed in two test campaigns while the parallel, single-pass, pressure-vessel style coolant scheme capable of large heat removal was validated. In the test facility, a feeder system composed of REBCO current leads and cables was experimentally qualified up to 50 kA, and a liquid-free cryocooler-based helium cryogenic system provided 600 W of cooling power at 20 K with mass flow rates up to 70 g/s at a maximum design pressure of 2 MPa for the test campaigns. Finally, the feasibility of using passive, self-protection against a quench in a fusion-scale NI TF coil was experimentally assessed. While the TFMC was intentionally not optimized for quench resiliency-and suffered localized thermal damage in response to an intentional open-circuit quench at 31.5 kA terminal current-the extensive data and validated models that it produced represent a critical step towards this important objective.
ABSTRACT
Tissue remodeling is a characteristic of many solid tumor malignancies including melanoma. By virtue of tumor lymphatic transport, remodeling pathways active within the local tumor ...microenvironment have the potential to be operational within lymph nodes (LNs) draining the tumor interstitium. Here, we show that lymphatic drainage from murine B16 melanomas in syngeneic, immune‐competent C57B1/6 mice is associated with LN enlargement as well as nonuniform increases in bulk tissue elasticity and viscoelasticity, as measured by the response of whole LNs to compression. These remodeling responses, which quickly manifest in tumor‐draining lymph nodes (TDLNs) after tumor inoculation and before apparent metastasis, were accompanied by changes in matrix composition, including up to 3‐fold increases in the abundance of soluble collagen and hyaluronic acid. Intranodal pressures were also significantly increased in TDLNs (+1 cmH2O) relative to both non‐tumor‐draining LNs (‐1 cmH2O) and LNs from naive animals (‐1 to 2 cmH2O). These data suggest that the reorganization of matrix structure, composition, and fluid microenvironment within LNs associated with tumor lymphatic drainage parallels remodeling seen in primary malignancies and has the potential to regulate the adhesion, proliferation, and signaling function of LN‐resident cells involved in directing melanoma disease progression.—Rohner, N. A., McClain, J., Tuell, S. L., Warner, A., Smith, B., Yun, Y., Mohan, A., Sushnitha, M., Thomas, S. N. Lymph node biophysical remodeling is associated with melanoma lymphatic drainage. FASEB J. 29, 4512‐4522 (2015). www.fasebj.org
Cardiovascular disease is the leading cause of death in cancer survivors. The short‐term and long‐term cardiotoxic effects of targeted chemotherapeutics is not well known. PP242, a dual inhibitor to ...mammalian target of rapamycin (mTOR) complex 1 (mTORC1) and 2 (mTORC2), is a targeted therapy in clinical trials for various malignancies including bladder, ovarian and gastric cancer. mTORC1 inhibition has been associated with heart failure, while mTORC2 inhibition has been considered cardioprotective. We hypothesized that PP242 leads to enhancedcontractile response to phenylephrine (PE), and impaired Acetylcholine (ACh)‐induced relaxation. We studied the effects of PP242 on the contractility and relaxation of aortic rings and mesenteric resistance arteries (MRA) of male Wistar rats (12–15 weeks old, n=4) and spontaneously hypertensive rats (SHR) (15–18 weeks old, n=6) on a wire myograph. Vessel segments were exposed to PP242 (500nM) for one‐hour incubation. Normotensive aortic rings exposed to PP242 showed a decreased contractile response to PE (LogEC50±SEM, Ctrl:−7.617±0.178 vs Drug: −7.292±0.129) and increased relaxation to ACh (LogEC50±SEM, Ctrl:−6.917±0.164 vs Drug: −7.588±0.164). SHR aortic rings exposed to PP242 (LogEC50±SEM, Ctrl:−7.606±0.129 vs Drug: −7.124±0.118) showed decreased contractility but no difference in ACh‐induced relaxation. No differences were observed in normotensive MRA. SHR MRA showed decreased PE‐induced contraction (LogEC50±SEM, Ctrl:−5.402±0.060 vs Drug:‐−5.322±0.065) and increased ACh‐induced relaxation (LogEC50±SEM, Ctrl:−7.992±0.117 vs Drug:−8.139±0.092). Our data suggest that dual inhibition of mTORC1 and mTORC2 with PP242 may provide a cardioprotective effect by limiting vasoconstriction and may be a good therapeutic agent for hypertensive cancer patients. However, long term treatments with this targeted therapy need to be evaluated for vascular dysfunction induction, as the hypocontractile effect could contribute to failure of the cardiovascular system, which could be associated with cardiotoxicity.
Support or Funding Information
NIH P01 HL134604 (RCW), k99GM11888 (CFW)
This is from the Experimental Biology 2019 Meeting. There is no full text article associated with this published in The FASEB Journal.
Abstract only While targeted chemotherapeutics have improved cancer clinical outcomes, many of these agents have the drawback of cardiovascular complications. It has been established that the mTOR ...complexes have a pivotal role in many types of cancer, promoting cell growth, proliferation, and survival. Inhibitors of this pathway such as first generation Everolimus, and second generation PP242, have inhibited cancer cell proliferation and cancer progression. When compared with other target chemotherapeutics such as VEGF and tyrosine kinase inhibitors, first generation mTOR inhibitors have demonstrated decreased incidence of cardiovascular complications, however the specific vascular effects of mTOR inhibitors have not been investigated. Therefore, Everolimus, an inhibitor of mTORC1, and PP242, an inhibitor of mTORC1 and mTORC2, were evaluated for their effects on vascular reactivity of rat aorta. Previous studies have demonstrated that mTORC2 displayed cardioprotective effects. Therefore, we hypothesize that Everolimus, which does not inhibit mTORC2, will have a decreased contractile response to Phenylephrine (PE) and increased Acetylcholine (Ach)-induced relaxation. On the contrary, since PP242 inhibits mTORC2, we hypothesize that PP242 will increase contractile response to PE, and will decrease ACh-induced relaxation. Concentration response curves to PE (1nM - 30μM), and Ach (1nM - 30μM) were conducted in isolated aortic rings from male normotensive Wistar rats (12-15 weeks old) on a pin myograph ex vivo after 1 hour of incubation with each drug. Aortic rings treated with 31 μM of Everolimus showed decreased sensitivity to PE (LogEC 50 = -7.322 ±0.078 vs. treated: -6.578 ± 0.1116 p<0.05). No differences were observed in the contractile responses to PE for Everolimus (0.1 nM) or PP242 (245 nM) (p>0.05). Similarly, no differences were observed in the endothelium-dependent relaxation response to Ach for all three treatments. These results suggest that Everolimus may be a good therapeutic choice for cancer patients also suffering from cardiovascular dysfunction.
On a sunny and warm Saturday at the end of April 1982, twelve women donned shirts emblazoned with the name Coalition for a Feminist Sexuality and Against Sadomasochism to picket a conference and pass ...out flyers explaining the reason for their protest.¹ Given the success of such grassroots feminist activism to date, this scene was not unusual; the fact that the group was protesting another group of feminists, however, was surprising. The Coalition had gathered to confront “The Scholar and the Feminist IX” conference at Barnard College in New York City, a venerable feminist conference that brought together academics and
The SPARC Toroidal Field Model Coil (TFMC) is the first large-scale (∼3 m), high-field (∼20 T) superconducting fusion magnet based on Rare Earth Yttrium Barium Copper Oxide (REBCO). Weighing 10,058 ...kg and utilizing 270 km of REBCO, the TFMC is a non-insulated, stack-in-plate style superconducting magnet. It has three main components: (1) the winding pack; (2) the structural case; and (3) the case extensions, or plena. The winding pack is composed of sixteen single pancakes with two termination plates top and bottom. The pancakes are Nitronic 40 radial plates machined with spiral channels on one side for the REBCO tape stack and single-pass channels on the opposite side for supercritical helium coolant. After assembly, each pancake undergoes a vacuum-pressure impregnation solder process to provide good mechanical protection of the REBCO tape stack and efficient thermal and electrical connectivity within each pancake. The pancakes are bolted along the inner and outer perimeter to provide mechanical and thermal connectivity while inter-pancake joints provide low resistance current transfer between pancakes. The top and bottom termination plates facilitate electrical connection to a superconducting feeder system. Embedded throughout the winding pack are 211 voltage taps, 34 temperature sensors, 34 helium flow monitors, 4 Hall probes, and 4 resistive surface heaters. The winding pack is contained within a structural case, a "trough and lid" style design composed of two Nitronic 50 forgings machined to shape and bolted together. The case reacts the large electromechanical stresses approaching 1 GPa during operation and serves as a pressure vessel that enables 20 bar supercritical helium flow that cools the winding pack and case. Two case extensions are attached to the case with unique high-pressure feedthroughs to provide winding pack access for current, cooling, and instrumentation, completing the magnet assembly.
ObjectivesMedically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and ...significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training.DesignMixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop.SettingNineteen foundation schools in England, Wales and Northern IrelandParticipantsQuestionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors.ResultsThe 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2–3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor–patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients’ symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options.ConclusionsThere is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.
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