Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.The guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia.The literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented.Family meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined. Palliative care is expected to be holistic and multidisciplinary; it is provided to both the patient and their family . EffectiHowever despite the promotion of family meetings as an essential tool for information sharing and goal clarification in specialist palliative care settings, it has been reported that sparse evidence exists to demonstrate the process for training staff to conduct or participate in them . It has We set out to develop practice guidelines for conducting family meetings within the context of the specialist palliative care setting, based on the best available evidence and complemented by consensus based expert opinion. For the purposes of these guidelines we define a specialist palliative care setting as a health care environment or service that specifically focuses on the care of patients with an advanced incurable disease and their family. An evaluation of the effectiveness of these guidelines in clinical practice will be reported separately.Key questions guiding the development of the guidelines were: (a) How should family meetings be convened and structured? (b) What content is essential? and (c) Who should attend and lead them?Development of the guidelines was based on the following three methods: (1) A literature search using MEDLINE (1995 – 2007), CINAHL (1995 – 2007), and PsycINFO (1995–2007) databases. The principal search terms used either singly or in combination, were: family, carers, case, conference, meeting, hospice and palliative care. Key palliative care textbooks (eg ) and theData from the expert panel and focus groups were audiotaped and transcribed verbatim. These data were then content analysed in accordance with the structured questions set by the research team.The literature search revealed only three published articles in peer reviewed journals specifically related to family meetings in the specialist palliative care setting ,3,7. DueOne palliative care related article acknowledged that most health professionals do not receive sufficient training to conduct family meetings . The autThe opinion based family meeting guidelines for health professionals advocated suitable planning and an overt purpose in order to conduct an effective meeting. Other key recommendations included giving consideration to who should attend, a meeting place that ensures privacy and a method for disseminating outcomes of the meeting.Similar recommendations on how to conduct a family meeting exist in the aged care setting . While tA practice model for nurses working with families has been developed . It inclThe conduct of family meetings has also been described in the context of training medical practitioners . Two relOur review identified several studies that explored family meetings within the context of the intensive care unit (ICU) -20. EvenA study involving qualitative analysis of 51 family conferences across four ICUs in the USA and a survey of 169 family members regarding their satisfaction with communication found that increasing the frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction. These sLilly and colleagues examined the effectiveness of a proactive patient and family centred communication strategy within the ICU . The intA study conducted in France aimed to measure the amount of time physicians in ICU spent with patients' families by examining contact over a 24 hour period with 951 patients . The medA cross sectional study involving audiotaping family meetings in the ICU concluded that family satisfaction with communication was increased when they were given ample opportunity to voice their concerns, rather than just listening to the medical staff . LautretIn summary, from our review of the literature, while family meetings are promoted as a common and valuable tool within the context of specialist palliative care there is limited evidence related to how they should be conducted and indeed whether they are valuable, most evidence being extrapolated from other settings. Furthermore, despite the apparent support for family meetings, there is limited evidence from the literature that explores ways of preparing or educating health professionals to conduct them . While tThe conceptual foundation for the family meeting guidelines for palliative care was derived initially by the research team from the available literature and then with input from the expert panel. Research team and panel members drew upon their knowledge of various conceptual and theoretical models which appeared to be applicable to underpinning the guidelines. The final conceptual foundation was informed by: (1) The transactional model of stress and coping, (2) Single session therapy, (3) Family consultation model and (4) Therapeutic communication principles. A brief overview of each is now provided.The diversity of responses related to end-of-life issues from patient and family carers can be understood from a psychological perspective based on a transactional model of coping in which cognitive appraisals are made to determine the possible impact of a potentially stressful event -23. The The psychologist, Moshe Talmon is most often associated with the development of Single Session Therapy which he articulated in his texts in the early 1990s in the United States . Talmon Over time the practice of Single Session Therapy has developed into an approach and set of techniques that emphasizes both the client and the therapist approaching their single session with an attitude of trying to make the most of each meeting (even if further sessions are needed). It also sees Single Session Therapy as part of a process that begins with initial contact and includes phone contact after the session with the client. An advantage of the single session method is that it has been used in combination with a range of counselling approaches with differing theoretical orientations.More recently, there have been attempts to integrate Single Session approaches, including the types of questions used, into existing work roles; for example, as part of intake or assessment processes in mental health settings. In other contexts it has been used to inform meeting practices with families, where ongoing treatment and contact occurs with an individual but where professional contact with their family may be occasional or episodic. Family meetings in palliative care typically occur only once . The tenets of single session therapy therefore seem relevant to the development of family meetings clinical guidelines. Although we contend that conducting a routine family meeting should not be considered as 'therapy', some principles of single session therapy appear applicable.Family Consultation is a model of family intervention that emerged in the mental health field in the United States in the late 1980s . It arosThe model assumes a position of family competence and seeks to cultivate a respectful and reciprocal relationship between health professionals and families . In pracGuidelines for therapeutic communication and psychosocial support for adults with cancer  offer stThe research team developed the initial draft of the clinical guidelines based on their clinical experience, the aforementioned literature review and the conceptual framework. The guidelines were then refined by an expert panel comprising: family therapist, social worker, psychologist, clinical nurse consultant, pastoral care consultant, consumer representative, and a palliative care medical consultant.After several iterations a penultimate version of the guidelines was presented at two focus groups for feedback to inform the final version of the guidelines. The first focus group consisted of multi-disciplinary team members from three metropolitan palliative care in-patient units. There were seven participants in this focus group. The health professionals represented the following disciplines: medicine (2); nursing (2); social work (1); occupational therapy (1); and pastoral care (1). The second focus group consisted of consultative palliative care service representatives from three major metropolitan hospitals. Eight participants contributed to this focus group including palliative care medical consultants (3); clinical nurses consultants (4); and social worker (1). Commensurate with the focus group questions (developed by the research team) the results were categorised in the following content areas: (a) description of current practice related to family meetings; (b) recommended core elements of family meetings and (c) feedback on the draft version of the family meeting clinical practice guidelines.A summary of the results is now outlined. In relation to current practice regarding family meetings it was reported that:• Meetings were typically offered based on need and not routinely;• Meetings were typically convened and chaired by a social worker;• The treating team usually determined who attended the meeting;• Formal training in conducting family meetings does not occur as part of general training;• Some units use a family meeting guide that they had developed internally;• The typical purpose of meetings was to find out what a family already knows about patient's prognosis and whether there are any gaps in knowledge;• Relevant health professionals generally try to meet before the meeting to clarify the goal of the meeting;• The social worker (who is commonly the chairperson) usually documents the outcomes of the meeting in the patient' medical record;• Documentation of the meeting discussion and outcome is not usually provided to the family;• Meetings are not formally evaluated as part of a quality improvement strategies.In relation to recommendations regarding core elements of family meetings it was reported that:• Good communication skills were considered essential;• A friendly and comfortable environment should be promoted;• Common goals and objectives should be established for the meeting;• Only key health professionals should be present at the meeting;• A designated chairperson is required for the meeting;• An agenda, specified aims and objectives should be confirmed at the start of the meeting;• The meeting should also be used as a forum to provide and gather information;• Allowing time at the beginning of the family meeting for introductions was considered essential.In relation to feedback regarding the draft version of the clinical guidelines for family meetings there was general consensus that the guidelines were applicable to the clinical setting and contained the aforementioned key elements. However the following points were considered important to be included in the guidelines:• Clarification of some terms throughout the protocol to reduce ambiguity was recommended;• Limiting the number to 'one or two' family members and/or friends was highlighted as a potential challenge in practice;• Ensuring that each discipline represented at the meeting has an opportunity to contribute was considered important;• Where pertinent and if possible (resources permitting), offer a family meeting via teleconference.The guidelines for conducting family meetings are outlined in Table • Family meetings can be a useful way to assist patients and family members to clarify goals of care, consider site of care options, and to share information. Ideally they provide a safe environment where issues and questions can be raised and appropriate strategies agreed upon.offer family meetings based on need.• Strategies to support family carers are a core component of palliative care; hence service providers have a responsibility to • Service providers should view family meetings as mutually beneficial. They are not only potentially valuable for patients and family carers; they may also provide a resource effective way to explain what the service can and cannot offer. Such meetings provide an opportunity to triage priority issues and a way to make referrals to other health professionals or other institutions early in the care planning phase.not be used as an opportunity for health care professionals to debate a patient's medical status; in this situation, a case conference should be convened prior to the family meeting.• Family meetings should • Family meetings should not be saved for 'crisis' situations. Instead, a preventative approach is advocated where issues are anticipated before they become major dilemmas. Hence a proactive rather than reactive approach to care is fostered.offered routinely on admission, and conducted at a pertinent time thereafter.• Ideally, family meetings are • Facilitators of family meetings require appropriate skills in group work, therapeutic communication and palliative care. We contend that the decision about who (i.e. which discipline) should convene and facilitate a family meeting is best determined on pragmatic grounds  and not based on hierarchical reasons (i.e. based on authority). Hence the multidisciplinary team should determine who conducts the family meeting and presumably this may change depending upon skills, knowledge of the family and resources.• Occasionally, family members may want to withhold details of the patient's prognosis from the patient; there may be incongruent wishes about the site of care; 'desire to die' statements may have been made by the patient; or there may be conflict within the family or difficulties regarding the transition from curative treatment to palliative care. In these circumstances we recommend the key resources and references to support therapeutic communication outlined in Table • Pre-planning for the actual meeting is imperative as outlined in Table • Suitable resources should be available to patients and family members who attend the meeting in order to complement the verbal information .Family meetings provide an ideal avenue to inform, deliberate, clarify and set goals for future care, based on discussions between health professionals and the patient and family. While there is consensus in the literature that family meetings are necessary and valuable, our study identified an absence of empirical evidence, within the context of specialist palliative care settings, to guide when they are required, who should attend, how they should be conducted and whether or not they are beneficial. Evidence from the intensive care context appears to offer the best guidance to date. While these data are important, caution is needed when considering their applicability to specialist palliative care settings where the population is somewhat different.The feedback from clinicians involved in the focus groups in this study also complemented other claims that most palliative care health professionals receive little or no preparation to conduct family meetings . Focus gThe clinical guidelines described herewith (based on a multidisciplinary research based approach) aim to assist health care professionals working in specialist palliative care to convene and conduct family meetings. Nonetheless, our study had several limitations and consequently more research is required. The clinical guidelines presented were in the most part based on expert opinion owing to the paucity of available research evidence. Accordingly, a formal evaluation of the benefits (or otherwise) of family meetings conducted using the guidelines is required. Furthermore, it would be advantageous to know whether the guidelines are applicable to other palliative care settings such as home care and aged care. Moreover, testing the utility of the guidelines in other countries is warranted. Our literature review included studies undertaken after 1995, hence there may have been evaluations of family meetings in palliative care conducted prior to this period. However, if so, the relevance of research findings almost 15 years on may be questionable. Evaluating strategies to prepare health care professionals to conduct family meetings would also be valuable .The essence of palliative care provision is effective communication amongst health professionals, patients and their family carers. Family meetings are one potential method of interaction that may facilitate optimal care planning and support and seem to be commonly used in palliative care. To our surprise however, according to our review, there have been no research studies within specialist palliative care settings that have examined: when meetings should be convened, how they should be conducted; who should attend and whether or not they are effective. It is intended that the clinical guidelines presented here will aid health care professionals to plan, conduct and evaluate family meetings. However, we recommend that the utility of these guidelines undergo additional examination.The authors declare that they have no competing interests.PH was the principal investigator for the study and was awarded a Postdoctoral Research Grant to undertake the project. He oversaw the grant application, management of the research project and was responsible for drafting the manuscript and preparing the final submission and responsible for coordinating feedback regarding reviewer and editorial queries. KQ was a chief investigator for the project and assisted with design, data collection, project oversight and provided input into the manuscript focusing on the literature review. BO'H was a consultant for the project focusing on the areas of single session therapy and assisted primarily with the conceptual framework and literature review sections of the manuscript. SA was a chief investigator for the project and helped conceptualise the study design and provided feedback on draft versions of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Attempts to identify particular aspects of psychosocial work conditions as predictors of sickness absence remain inconclusive. A global measure has previously been suggested to be an efficient way to measure psychosocial work conditions in questionnaires. This paper investigates whether satisfaction with specific aspects of psychosocial work conditions explains sickness absence beyond its association with a global measure of psychosocial work conditions.The participants were 13,437 employees from 698 public service workplaces in Aarhus County, Denmark. 33 items from a questionnaire fell in groupings around six aspects of psychosocial work conditions: skill discretion, professionalism, management, decision authority, workload and cooperation. A global measure rating satisfaction with psychosocial work conditions on a scale from 0 to 10 was also included in the questionnaire. Individual ratings were aggregated to workplace scores. Analysis of variance and multiple linear regression was used to compare the average number of days of yearly sickness absence with different levels of satisfaction with six aspects of psychosocial work conditions. The covariates included were gender, age, occupation, size of workplace, contact to hospital, civil status and children below 13 living at home.Dissatisfaction with each of the six aspects of psychosocial work conditions was associated with an increase in sickness absence. When all aspects were simultaneously included in the model, only skill discretion and professionalism were negatively associated with sickness absence. When a global measure of satisfaction with psychosocial work conditions was also included in the model none of the specific aspects showed a statistically significant association with sickness absence.Low global satisfaction with psychosocial work conditions is associated with increased levels of sickness absence. Including specific aspects of psychosocial work conditions in the model does not provide further information regarding the nature of this association. Many studies have attempted to establish the association between specific aspects of psychosocial work conditions and sickness absence. -10 Most In a previous study we examined the association between a global measure of psychosocial work conditions and sickness absence. We found a positive correlation between the level of satisfaction with psychosocial work conditions and the amount of sickness absence across different occupations and types of work places. A global measure is a parsimonious way of measuring psychosocial work conditions, assuming that the overall concept of psychosocial work conditions is conceived in a more homogenous way across heterogenous populations than separate aspects of psychosocial work conditions.The purpose of the present study was to investigate the relationship between specific aspects of psychosocial work conditions and sickness absence in a large sample of public services employees. Additionally it examines whether specific aspects of psychosocial work conditions explain sickness absence beyond the association found regarding the global measure. The study includes aspects of psychosocial work conditions evaluating professionalism and management that are not commonly included in studies regarding psychosocial work conditions.Two specific questions raised are i) do specific aspects of psychosocial work conditions function as independent predictors of sickness absence beyond a one-dimensional global measure of satisfaction with psychosocial work conditions? And ii) does the character of the association between psychosocial work conditions and sickness absence vary across different occupations?From April 2002 through April 2005 Aarhus County in Denmark conducted a general survey of the psychosocial work conditions among all employees, with the intent to use the results to improve psychosocial work conditions. . The surThe study population included 13,437 employees from 698 different workplaces in Aarhus County who received a questionnaire in one of the surveys  can be evaluated by a simple correlation matrix Table .Four of the scales were closer correlated than the others  with coefficients between 0.51 and 0.67. The same four aspects were also closer correlated to the global measure than skill discretion and workload. Workload and skill discretion were least correlated to the other aspects (Pearson's correlation coefficients between 0.29 and 0.50).The content validity was evaluated by two occupational psychologists. They were asked to place the original 40 items under headings with aspects commonly regarded as key aspects of psychosocial work conditions . The questionnaire was found to include measures of all of these aspects.th was chosen as the start date of measurement of sickness absence.Data regarding sickness absence were obtained from the salaries administrative system of the County of Aarhus. Reporting of sickness absence is compulsory and necessary to obtain wage reimbursement. The data are produced by each workplace and submitted to the administrative system each week. The data contain a record for each day of absence for every employee. Only the instances explicitly coded with illness as the reason for absence were included, thus excluding maternity leave and other reasons for absence. Data regarding sickness absence could only be linked to data regarding psychosocial work conditions at the workplace level, as the latter were not available at the individual level. The outcome measure was the number of days of sickness absence through one year for each employee. The number of spells of sickness absence was also examined. The distribution of spells was similar to the distribution of the number of days and the association to psychosocial work conditions was also similar. Choosing spells of sickness absence as our outcome measure would thus have lead to the same conclusions. The time period used was 6 months before and 6 months after the time of measurement of psychosocial work conditions. As only the month of measurement of satisfaction with psychosocial work conditions was known the 15The covariates included in the adjusted analyses were: gender ; age (continuous); occupation ; the size of the workplace unit ; marital status ; children ; and registered illness during the year of measurement of sickness absence .The responses to the items of each aspect were added using equal weights and scaled from 0 to 100. The global measure was also transformed to a 0 to 100 scale. The aggregated workplace unit scores from each of the 698 workplace-units were assigned to each employee for all of the aspects.The aggregate scores where divided into septiles. A low level of satisfaction was defined as the lowest septile, medium satisfaction as the 5 middle septiles and high satisfaction as the highest septile. The levels were defined to satisfy a trade off between the size of the groups and the magnitude of contrast between the groups. No absolute cut off point could be used across the 6 aspects as the distributions cover different spans of the 0 to 100-scale.Analyses were performed using the workplace unit scores on the 6 aspects of psychosocial work conditions as predictors of the individual number of days of sickness absence throughout a one-year period. In the first step of the analyses we compared the number of sickness absence days during a year for the three levels of satisfaction for each aspect and the global measure. Analysis of variance was used to test differences between mean values of sickness absence across the three levels of the scores. In a second step we used multiple linear regression to estimate the effect of a one-unit increase in the satisfaction with psychosocial work conditions on sickness absence.Estimates were calculated including the covariates with and without control for the other aspects in order to investigate how much the individual aspects contributed to prediction of sickness absence.The SAS 9.13 statistical package was used for all statistical analyses. Analysis of variance and multiple linear regression was performed using the MIXED procedure with the repeated option account for the workplace clustered nature of the data on satisfaction with psychosocial work conditions. All covariates were included in the model regardless of their contribution to the explanation of sickness absence variation. The distributions of the scores on the 6 aspects and of the global measure of psychosocial work conditions are presented in figure Distribution of 6 aspects and a global measure of psychosocial work conditionsTable The results from the first step of the analyses showed a statistically significant association between increasing satisfaction and decreasing sickness absence for all aspects except workload. For the 5 other components the decrease in sickness absence was statistically significant between the lowest and the medium level of satisfaction with psychosocial work conditions while the difference between the medium and the highest level was not statistically significant. Skill discretion, professionalism and decision authority were most closely associated with sickness absence. A 10 points increase in satisfaction with psychosocial work conditions on each of these 3 aspects was associated with a 1 – 1.5 days decrease in sickness absence per year.In the second step of the analyses, when all 6 aspects were included in the model only the skill discretion-aspect was statistically significantly associated with sickness absence ). The professionalism aspect had an equally high but not statistically significant regression coefficient ).In a third step we tested whether any of the aspects could independently predict sickness absence when a global measure of satisfaction with psychosocial work conditions was also included in the model. Only decision authority had a statistically significant, independent association with sickness absence ) and the effect was in the opposite direction than expected. Regression coefficients were positive (but non-significant) for all other aspects except skill discretion. The global measure was consistently negatively associated with sickness absence regardless of which of the 6 aspects were included in the model and it also had the strongest explanatory power in itself .The effect of poor satisfaction with psychosocial work conditions on sickness absence could not be further explained by including specific aspects of psychosocial work conditions in the model. The overall results from the model with all 6 aspects did not apply generally across all occupations included in the study. For some occupations other aspects than skill discretion or professionalism were closer associated with sickness absence. None of these associations were statistically significant when all 6 aspects were included in the model. For most occupations none of the aspects were associated with sickness absence (results not shown).We found that all aspects of psychosocial work conditions included in the study, except workload, were individually negatively associated with sickness absence. The amount of sickness absence was notably lower in the group with medium satisfaction with psychosocial work conditions than in the most dissatisfied group. When all aspects were included simultaneously in the model, skill discretion and professionalism showed the strongest association with sickness absence. The meaning of work, development opportunities and the deployment of personal and professional resources, which are inherent in the skill discretion aspect thus provide the best target for improving psychosocial work conditions in order to reduce sickness absence. Skill discretion was not highly correlated with the global measure, thus rendering an independent explanatory power on sickness absence possible.The negative association between professionalism and sickness absence (regression coefficient -0.11) was not statistically significant. Professionalism was more closely correlated to the global measure than skill discretion.When a global measure of psychosocial work conditions was included in the model, only one of the six aspects of psychosocial work conditions, namely decision authority, was associated with sickness absence. Surprisingly, an increase in decision authority was associated with increased sickness absence. The reason for this independent explanatory contribution could be that decision authority is not always contributing to enhance the psychosocial work conditions. Increased decision authority means increased responsibility and new ways of working can lead to a blurring of work and private life. The result could also be an artifact due to inclusion of overlapping variables in the analysis.Specific aspects of psychosocial work conditions have not explained sickness absence beyond its negative association with the global measure found in our previous study.Most previous studies have implicitly assumed that psychosocial work conditions can be divided into a number of clearly distinguishable aspects that can be consequently identified as latent variables across heterogeneous populations and thus measured with the use of generic questionnaires.Typically studies took offset in Karasek's demands, control (and support) model  or SiegrThe use of a global measure provides the opportunity to examine the explanatory power of specific aspects as compared to the global measure. This study suggested that psychosocial work conditions may be more of a one dimensional concept than previous studies have hypothesized, because the global measure explained more of the negative association between psychosocial work conditions and sickness absence than any of the aspects included in this study.If the specific aspects of psychosocial work conditions do not have any independent explanatory power when a global measure is included, then the aspects do not explain the association beyond the association found between sickness absence and the global measure.When only a limited number of items or aspects are included in a study, they could all account for the effect of the common latent aspect "psychosocial work conditions" and could lead to false conclusions. Furthermore, even when the association between a global measure of psychosocial work conditions and sickness absence is consistent across subpopulations, the combination of aspects of psychosocial work conditions responsible for this association may be different across subpopulations. The inconsistent results of earlier studies suggest that this indeed may be the case.Subpopulations are typically divided according to gender, occupation or type of institution. It also remains unclear whether specific dimensions of psychosocial work conditions are associated with sickness absence in the same manner across all of these subpopulations. Particular characteristics of the workplace amounting to a workplace "culture" may be more important for the association than e.g. different occupational categories.The strengths of this study are that it is based on a large and heterogeneous study sample and in the independent measurement of exposure and outcome. Our data on sickness absence are highly reliable, as the Danish legislation requires accurate registration for reimbursement of expenses. Equally the response rate in the surveys of psychosocial work conditions was high (81.0%). The validity of the 6 scales used in this study was evaluated through measurements of internal consistency, convergent, discriminant and content validity. On these criteria they performed adequately. The inclusion of the global measure of psychosocial work conditions allowed for further testing of the discriminant validity. However, the study also has some limitations: important predicting variables such as physical demands, shift wIndividual data regarding sickness absence could only be linked to workplace levels of psychosocial work conditions. This is both a limitation, possibly responsible for weakening the association found in the study but also a strength as the use of workplace unit scores may minimize the effect of individual characteristics not related to the workplace as the effect of these variables may be expected to be randomly distributed across workplaces in our study sample.Our design provides a better background to believe that our results represent an association truly related to satisfaction with psychosocial work conditions as it avoids the triviality trap of personal characteristics associated to both proneness to sickness absence and reporting of low satisfaction with psychosocial work conditions.We have earlier found a strong and consistent association between general satisfaction with psychosocial work conditions and sickness absence. The present study indicates that this association is not further explained by including measures of specific aspects of psychosocial work conditions as management, cooperation, skill discretion, professionalism, work load and decision authority.Instead it is a general dissatisfaction with psychosocial work conditions that is associated to sickness absence rather than a specific combination of different aspects of the psychosocial work conditions. No particular aspects can be identified as associated clearly to sickness absence neither in the total study population nor in occupational subgroups.A general recommendation for workplaces with poor psychosocial work conditions would be to focus particularly on the items and aspects with low scores in their own local survey results instead of pointing to specific aspects as being generally associated to sickness absence across all subpopulations. It can also be recommended to focus particularly on workplaces with low satisfaction with psychosocial work conditions because the difference in amount of sickness absence is most notable between the groups of workplaces with low and medium levels of satisfaction.Across large and heterogenous populations associations between psychosocial work conditions and sickness absence we find it appropriate to use a single global question as a screening to spot workplaces with particular problems regarding psychosocial work conditions. In a forthcoming study concerning interventions to improve psychosocial work conditions we argue, that only at workplaces with poor psychosocial work conditions (the lowest septile) there is an effect on sickness absence of intervening to improve psychosocial work conditions. At the workplaces spotted through the screening it will make sense to make a more detailed survey of psychosocial work conditions to clarify the aspects of psychosocial work conditions most in need for improvement and as indicators for measurement of the effect of subsequent interventions.The authors declare that they have no competing interests.TM was the main author of the manuscript and has contributed to all phases of it.  JW and JPB contributed substantially to the conception, design, analysis and interpretation of data and the drafting and revision of the manuscript.  EA and NW contributed substantially to the analysis and interpretation of data and to the revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Characteristics of 13,437 participants.Click here for fileSix aspects of psychosocial work conditions and the items used to measure them .Click here for file


Sentinel lymph node (SLN) detection and biopsy is gaining popularity in the treatment of Head and Neck cancer. Various methods in this regard have been described, each with their respective advantages and disadvantages. The aim of this paper was to evaluate the potential application of Indocyanin Green (ICG) in the mapping and detection of sentinel lymph nodes (SLN) in cancers of the head and neck.Patients with oropharyngeal cancer and N0 neck who were scheduled for primary tumor ablation as well as a neck dissection were selected. One milliliter of Indocyanin green was injected around the tumor and the sentinel node detection was performed by aiming the infra red video camera on the cervical area. When no detection was possible transcutaneously, a cervical incision was made, a sub-platysmal flap raised and further detection was done to visualize the fluorescing lymph nodes.Detection of cervical SLN was only possible when 5 mm or less tissue covered the sentinel lymph node. Accurate and clear detection of the lymph drainage pattern and SLN was possible. There is some uptake in other tissues such as the submandibular gland which is easily distinguishable from lymphatic tissue.Indocyanin green fluorescence is a potential valuable potential tool in the detection of SLN in patients with oropharyngeal cancer which warrants further investigation. It is well known that poorer prognosis prevails in head and neck cancer patients that develop metastatic lymph nodes and even more so if there is evidence of extra capsular spread. This is one of the reasons why elective neck dissections are frequently performed even in patients with N0 necks .There are no clear and accurate guidelines regarding the decision to perform a neck dissection concurrent to the ablation of the primary tumor in the N0 neck. Clinical staging of the neck by manual examination is notoriously inaccurate, especially in patients with more voluminous necks. Radiological staging with either CT or MRI has improved the sensitivity for identifying nodal metastatic disease and has contributed to the upstaging of necks in a significant number of patients, resulting in a more accurate selection of patients requiring a neck dissection. With size alone as one of the more important criteria in this regard it has been shown that an important group of patients at risk for occult lymphatic metastasis may be missed ,3.The potential benefit of CT-PET in the pre operative evaluation of patients with a negative CT or MRI is still controversial and probably plays a bigger role in detecting second primary tumors and follow up ,5.Ultrasound with simultaneous fine needle aspiration cytology is probably the most accurate method to date in staging the neck, but requires skill and solid ultrasound and cytology knowledge to reach good levels of accuracy .Currently there is thus no accurate way of determining the presence of occult lymphatic metastasis for cancers of the head and neck. It is clear that the gold standard for detecting involved lymph nodes is accurate pathological analysis of the nodes. This is traditionally done in a retrospective manner by sending the neck dissection specimen for analysis. In the normal pathological processing there is a possibility to miss micro metastases as the specimens are not as accurately examined as with a sentinel node protocol. In such a protocol stepwise serial sectioning as well as immunohistochemistry will be able to find occult microscopic deposits that would be missed with routine pathology examinations .Many factors determine the propensity of a tumor to disseminate its cells to spread via the anatomical lymphatic system. Tumor cell motility as well as lymphatic vessel density is factors that may contribute to the enhanced spread along lymphatic pathways .The principle of sentinel lymph node (SLN) identification and biopsy is to identify the first station of drainage of a particular anatomical area in which the tumor lies ,10.SLN detection was first used in other anatomical areas like the breast and soon skin cancer as well as gastric cancers followed. In many centers SLN detection has become standard clinical practice.Benefits for the patients are the more selective removal of the first drainage lymph nodes from a particular anatomical site with lower morbidity and by closer histological examination of the nodes a higher detection rate of micro metastasis is possible.The anatomical basis of head and neck cancer nodal drainage has been well established and is in use on a daily basis . On thisSLN identification and biopsy has increased its role in detection of the first nodal drainage in an attempt to either limit surgical damage, or to more accurately stage the patient by more accurate examination of the sentinel node or nodes. Koch et al (1998) was the first to describe the use of technesium-99 m (99T cm) labeled sulfur colloid in the quest for accurate sentinel node biopsy .The use of lymphoscyntography with 99T cm colloid as well as a following SLN biopsy with possible concurrent blue dye injection can be regarded as the current gold standard with regards to identification of the SLN . With thThe use of ICG in the diagnosis of SLN in areas other than that of the head and neck region has well been described. Reports of its use in gastric, breast, lung as well as skin cancer are found in the literature with good success -22A total of 8 Patients with oropharyngeal head and neck cancer and N0 neck status and where resection of the primary tumor as well as a neck dissection was planned were used to evaluate the use of ICG in the identification of the sentinel lymph node. Only unilateral elective neck dissections were performed according to the clinical indication. In no way was the treatment of the patients altered or influenced by the additional use of ICG or sentinel node detection. Patient's informed consent was obtained before surgery.®ICG-Pulsion, Pulsion medical Systems AG, Germany)is supplied as a sterile, water-soluble powder dye  was then directed to the cervical area within 3-5 minutes and an attempt was made to identify the sentinel lymph node.  alone or in combination with methylene blue is probably the most widely used as it allows one to quantify the radioactivity picked up on the gamma probe and further to have a pre operative picture of the identified SLN. Injection of 99 mTcSC around the primary tumor site is performed at least 2 hours before or even the afternoon before surgery the next morning. The injection is reported to be painful as local anesthesia in the vicinity should be avoided. Another advantage is the possibility to perform a scintigraphy beforehand to identify and localize the SLN before surgery. This may be of great help where the SLN isolated in an unexpected area.Technesium 99 labelled sulfur colloid : Indocyanin Green; (SLN): Sentinel lymph node; (SNB): Sentinel Node Biopsy; (IHC): Immuno histochemistry.The authors declare that they have no competing interests.


Skin and soft tissue infections are increasingly prevalent clinical problems, and it is important for health care practitioners to be well trained in how to treat skin abscesses. A realistic model of abscess incision and drainage will allow trainees to learn and practice this basic physician procedure.We developed a realistic model of skin abscess formation to demonstrate the technique of incision and drainage for educational purposes. The creation of this model is described in detail in this report.This model has been successfully used to develop and disseminate a multimedia video production for teaching this medical procedure. Clinical faculty and resident physicians find this model to be a realistic method for demonstrating abscess incision and drainage.This manuscript provides a detailed description of our model of abscess incision and drainage for medical education. Clinical educators can incorporate this model into skills labs or demonstrations for teaching this basic procedure. Staphylococcus aureus infections.[Skin abscesses are commonly encountered clinical problems, and the incision and drainage of an abscess is a treatment that is often performed in both emergency and outpatient practice settings. The goal of this project was to develop a model of abscess incision and drainage for educating clinicians about this minor surgical procedure. The importance of educational models for this procedure is evident in the recent resurgence of skin infections and abscesses associated with community acquired methicillin-resistant fections.,2 While fections.-5Our abscess model was developed in the human anatomy lab at our medical school using a donated human cadaver. The use of fresh cadaveric specimens without traditional preservatives allowed manipulation of dermal structures in a life-like fashion. Areas of erythema on the skin were often already present but were also simulated by application of a lipstick moulage.Tapioca pudding was diluted 30% with water to simulate purulent material for the abscess contents. Tapioca pudding was the appropriate consistency and color with individual particles to accurately simulate purulent abscess contents. Initial attempts to create a subcutaneous abscess with this simulated purulent material were unsuccessful as intradermal or subcutaneous injections rapidly diffused under the skin and did not create localized collections to correctly simulate an abscess.A Word catheter  , was idein situ using subcutaneous tunneling from a distant incision site [see Figure This filled catheter was surgically implanted into the cadaveric skin The size and firmness of the abscess was varied by changing the amount of simulated purulent material that was injected into the catheter, and this created a realistic model ready for an incision and drainage procedure. Draping of the area allowed for concealment of the incision site and the terminal end of the Word catheter to enhance the realistic appearance of the model, and the model was then used to practice incision and drainage [see Figure Digital video and still photography was used to demonstrate appropriate techniques for the incision and drainage procedure [see Figure The effectiveness of this model as a realistic way to demonstrate key components of the incision and drainage procedure was evaluated by creating a multimedia video presentation using this model. This vidThis project developed a model for incision and drainage of skin abscesses to teach clinicians this important clinical procedure. This model is realistic, which is demonstrated by physician review and the use of this technique to create a peer-reviewed and published teaching video. TeachingWhile the realism of our model is evident in the video and still photographs that have been produced using these methods, use of tThe authors declare that they have no competing interests.All authors participated in the conception, design, and implementation of the abscess model. MTF drafted the manuscript and all authors participated in the writing and revising of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Bronchial dehiscence in lung transplantation is still a significant and threatening cause ofmorbidity, even if several progresses have been made in this field. In the present report wediscuss a case of incomplete dehiscence of the right bronchial anastomosis in a patient whounderwent sequential double lung transplantation for bronchiectasis. This complication hasbeen successfully treated with endobronchial stent positioning, with the aim to allow thehealing of the anastomosis around a rigid endobronchial support and to prevent the airwaystenosis. The usefulness of 3D spiral CT reconstruction of bronchial tree is also underlined,for its capacity to detect the dehiscence and to monitor the healing of this complication.


Clonogenic survival of HeLa, Chinese hamster and HaK cells after treatment with a range of cisplatin concentrations and exposure times was determined and cellular platinum concentrations were measured by PIXE. It was demonstrated that cisplatin cytotoxicity of the three cell lines varied considerably as a function of drug exposure dose. These differences are related to differential cellular drug uptake.


Numerous case-control studies have suggested a link between the oral contraceptive pill and liver cancer. The secular trends in liver cancer mortality rates for England and Wales from 1975 to 1992 were examined to determine whether an effect of the pill was apparent. Liver cancer mortality has remained constant in women in the age groups that have had major exposure to the pill.


The behaviour of the normal epidermis of mice on the first 5 days of exposure to a single application of carcinogens and cocarcinogens has been investigated by simple quantitative measurements of cell population, size of cells and thickness of the epidermis. Irritant substances and promoting agents both produce cellular hypertrophy but the respective responses can be distinguished by the much greater incidence of degenerate cells associated with irritant treatment. Urethane treatment is characterized by induction of a transient hypoplasia which is not in agreement with the level of cellular division. This response has also been demonstrated after treatment with mild carcinogens or low doses of potent carcinogens. Higher dose levels are followed by a reduction in the mitotic index after about 27 hours. The possibility of developing a preliminary screening test for carcinogenic substances is discussed in the light of these observations.


In confirmation of other studies it has been shown that antibody directed against the tumour specific transplantation-type antigens (TSTAs) cannot be detected in rats with a tumour growing intramuscularly but appears within a few days after excision of the tumour. Circulating antibody is found in the serum of rats with lymph node metastasis following excision of the primary. Absorption by the intramuscular tumour of circulating antibody does not account for the absence of antibody since the antibody levels in thoracic duct lymph in rats with tumours in the leg are also very low and rise rapidly after tumour excision. Antibody is released by the draining nodes directly into the lymph and must pass through the thoracic duct before entering the blood. Under these conditions low levels of antibody activity in lymph cannot be ascribed to absorption by the tumour.It is postulated that TSTA is released from the tumour into the lymph. Following injection of tumour cells into immunized rats the level of antibody falls and this is attributed to release of TSTA from the injected cells. The possible role of antigen release from tumours in determining the host reaction to the tumour is discussed.


A substance capable of inducing tumour cell aggregation, which is supposed to be a glycoprotein showing noncytotoxicity, was separated from rat ascites hepatoma cells and partially purified by chromatography. Adhesiveness of rat ascites hepatoma cells induced by this substance was characterized by gradual development of known binding structures during a period of 24 h after contact with the substance; simple apposition and intermediate junctions developed in the early stage, and desmosomes and focal tight junctions in the later stage. It was assumed that the substance might be involved in the development of such binding structures as a triggering mechanism of tumour cell adhesiveness.


Hydatid disease is caused by the larval stage of the cestode, Echinococcus granulosus. Man is the intermediate host in its life cycle. The most common organ involved is liver followed by lung. Although surgery remains the definitive treatment for symptomatic lesions, it is associated with considerable morbidity. Other less invasive treatment strategies as an adjunct to medical treatment that have been tried in various case series include percutaneous aspiration, instillation and reaspiration of scolicidal agents (PAIR), and thoracoscopic removal of cysts located subpleurally. Here we report the case of a 58 year old gentleman with hepatic and pleuropulmonary hydatid disease who was subjected to medical thoracoscopy and instillation of hypertonic saline (3%), followed by medical management with albendazole with which complete resolution of the pulmonary cysts was achieved. A 58 year old male working in Saudi Arabia in an aquarium shop for more than 15 years was referred to our institute with complaints of breathlessness and vague abdominal discomfort of 8 months duration with worsening dyspnea and cough with scanty mucoid expectoration 1 month prior to admission. At his workplace, he had contact with aquatic creatures in the shop in which he was working. There was also occasional exposure to cats which was imported for sale and distribution to nearby places. The patient denied any addictions and there were no significant past medical or surgical illness. At the time of admission he was comfortable at rest, vitals were stable and respiratory system examination revealed features of left sided hydropneumothorax. Examination of other systems was within normal limits. Complete blood count, random blood sugar, renal and liver function tests were all normal. Chest X-ray taken at the time of presentation  revealedMost of the case reports regarding hydatid lung disease published from India are from the northern states where it is relatively common. Similar case reports are scarce from southern regions. Also thoracoscopic instillation of scolicidal agents in the treatment is reported only in a few case series, although percutaneous aspiration, instillation and reaspiration (PAIR) is commonly employed for treating hepatic hydatid cysts. Sarai et al68The use of minimally invasive technique like medical thoracoscopy under conscious sedation in the management of pulmonary hydatid located in the subpleural region as well as those with pleural complications seems promising and needs to be promoted in those patients who refuse surgery or in whom surgery is contraindicated due to various reasons. However, it should be stated that the optimum management of asymptomatic cysts which are diffusely distributed in thorax (that are difficult to access by thoracoscopy) as well as in liver  remains controversial and poses challenge to the treating clinician. A trial of prolonged treatment with albendazole may be tried as in our case which could be fruitful in certain cases.


The effect of the anabolic steroids nandrolone decanoate and oxymetholone on the peripheral blood haemoglobin, total leucocyte and platelet counts was studied in a controlled trial in which patients received standardized chemotherapy for one form of malignant disease. The results indicate that these agents have no protective effect on bone marrow suppression during cytotoxic chemotherapy. It was observed that the time interval between the initial nadir total leucocyte count and the return to pre-treatment values in those patients receiving the anabolic steroids was significantly shorter than in the control group.


We present a tool for tracking coronary vessels in MRIscans of the human heart to aid in the screening of heartdiseases. The vessels are identified through a single click insideeach vessel present in a standard orthogonal view. The vesselidentification results from a series of computational stepsincluding eigenvalue analysis of the Hessian of the MRI imagefollowed by a level set-based extraction of the vessel centerline.All identified vessels are highlighted using a virtual contrastagent and displayed simultaneously in a spherical curvedreformation view. In cases of over segmentation, the vessel tracescan be shortened by a click on each vessel end point. Intermediateanalysis results of the vessel computation steps can be displayedas well. We successfully validated the tool on 40 MRI scansdemonstrating accuracy and significant time savings over manualvessel tracing.


Karyotyping and marker analysis of G- and C-banded metaphases from a metastatic bronchial carcinoma revealed a dominant stemline with five markers and four sidelines with additional markers. One to three minute bodies were noted in the majority of cells and these were classified as markers. On the basis of this analysis it was possible to postulate an evolutionary pathway within the tumour whereby the stemline was derived from existing sidelines.


These observations are relevant to current proposals for adjuvant immunotherapy of human malignant disease where conditions of minimal residual disease are not being fulfilled.Growth of syngeneic transplants of a 3-methylcholanthrene induced rat sarcoma was suppressed when tumour cells were injected in admixture with BCG. Rejection of these mixed inocula resulted in the suppression of growth of a simultaneous challenge with cells of the same tumour at a contralateral subcutaneous site and conditions for immunotherapy were evaluated with respect to the maximum tumour cell challenge rejected and the optimum time of treatment. These studies established that viable tumour cells were more effective than radiation attenuated cells for the immunizing stimulus. Also, the maximum tumour challenge totally rejected in this way was of the order of 10


Antisera to extracts of a variety of bronchogenic carcinoma were raised in rabbits and extensively absorbed with immunoadsorbents prepared with normal lung extracts cyanogen bromide linked to Sepharose 4B, and glutaraldehyde insolubilized normal lung extracts. The antisera were tested by immunodiffusion against a panel of extracts from a variety of bronchogenic carcinoma, foetal lung extracts and pools of normal lung extracts. The results indicate that two distinct antigenic components are associated with bronchogenic carcinoma; one which is present in a high percentage of the tumour extracts tested and appears to have partial identity with a foetal lung component, and one (or more) which is not foetal and appears to have higher cross-reactivity (but not exclusively) with tumours of the same pathological type. Attempts to detect either antibody or antigens relating to these components in the serum of patients with bronchogenic carcinoma by these techniques were unsuccessful. The foetal cross-reacting component was neither carcinoembryonic antigen and alpha1-foetoprotein.


The Proteomics Standards Initiative (PSI) aims to define community standards for data representation in proteomics and to facilitate data comparison, exchangeand verification. Initially the fields of protein–protein interactions (PPI) and massspectroscopy have been targeted and the inaugural meeting of the PSI addressed thequestions of data storage and exchange in both of these areas. The PPI group rapidlyreached consensus as to the minimum requirements for a data exchange model; anXML draft is now being produced. The mass spectroscopy group have achieved majoradvances in the definition of a required data model and working groups are currentlytaking these discussions further. A further meeting is planned in January 2003 toadvance both these projects.


Two hundred and ninety-nine oral leukoplakias were examined by exfoliative cytology; 83 of these lesions were biopsied because of clinical or previous histological features. Epithelial atypia was found in 16 of these biopsies, exfoliative cytology detecting epithelial atypia in only 6 of these cases. Thus exfoliative cytology used alone would have led to a false negative diagnosis in 10 out of 16 (62%) of the cases with epithelial atypia verified by histology. In addition, in no instance was exfoliative cytology responsible for the detection of an epithelial atypia that had been overlooked by consideration of clinical or previous histological features. Exfoliative cytology was successful in the detection of atypia only in those cases in which the surface of the lesion was either ulcerated or not keratinized; all keratinized lesions with atypia yielded negative cytology. The results of this study lead to the conclusion that exfoliative cytology is not to be recommended as a routine diagnostic or screening procedure for the detection of possibly pre-malignant features in oral leukoplakias.


Two cases of portal hypertension due to hydatid cysts of the liver are reported. In one of the patients,symptoms were secondary to obstruction of inferior vena cava and hepatic outflow tract. The other patientwas operated on with a diagnosis of extrahepatic presinusoidal portal hypertension caused by extrinsiccompression of the liver by an hydatid cyst. Although hydatidosis is a benign disease, it can produce seriouscomplications as in these reported cases. Therefore hydatidosis should be remembered amongst the causes ofportal hypertension in countries where the disease is endemic.


The effects of various chemotherapeutic agents on alpha-fetoprotein (AFP) secretion and growth of human hepatocellular carcinoma and hepatoblastoma cell lines were investigated in vitro. It was found that there was a high correlation between hepatoma cell number and AFP secretion after treatment and that the amount of AFP secreted per cell per 72 h was not affected with therapeutically achievable concentrations. These results suggest that serum AFP level in patients with hepatomas does not correlate with the size of whole tumour but with that of viable tumour mass, and that AFP-secreting capacity of tumour cells in the mass is kept unchanged after chemotherapy.


Exposure to the fibrous mineral erionite is known to induce mesothelioma in man and laboratory animals. Previous studies demonstrated the presence of a trypsin-like protease associated with tumour cells. This protease could be demonstrated by the use of fluorescent probes which located cells possessing this enzyme. We have employed this fluorescent probe technique to follow the early events in the lungs of rats exposed to erionite. The evidence presented shows that the mesothelial cells initially lack this enzyme but the enzyme can be detected within hours of exposure of the rat to erionite. The number of mesothelial cells possessing the enzyme steadily increased after a single exposure to the mineral until the animal finally died with a massive pleural tumour. This is the first study of such fluorescent probes in the early stages of tumour induction.


Healthy Schools programmes may assist schools in improving the oral health of children through advocating a common risk factor approach to health promotion and by more explicit consideration of oral health. The objectives of this study were to gain a broad contextual understanding of issues around the delivery of oral health promotion as part of Healthy Schools programmes and to investigate the barriers and drivers to the incorporation of oral health promoting activities in schools taking this holistic approach to health promotion.Semi-structured telephone interviews were carried out with coordinators of Healthy Schools programmes in the Northwest of England. Interview transcripts were coded using a framework derived from themes in the interview schedule.All 22 Healthy Schools coordinators participated and all reported some engagement of their Healthy Schools scheme with oral health promotion. The degree of this engagement depended on factors such as historical patterns of working, partnerships, resources and priorities. Primary schools were reported to have engaged more fully with both Healthy Schools programmes and aspects of oral health promotion than secondary schools. Participants identified healthy eating interventions as the most appropriate means to promote oral health in schools. Partners with expertise in oral health were key in supporting Healthy Schools programmes to promote oral health.Healthy Schools programmes are supporting the promotion of oral health although the extent to which this is happening is variable. Structures should be put in place to ensure that the engagement of Healthy Schools with oral health is fully supported. The World Health Organisation (WHO) advocates using Health Promoting Schools/Healthy Schools (terms used interchangeably in this paper) to promote general and oral health ,2. HealtWHO guidance on Health Promoting Schools has been translated into policy in many countries. In England, the National Healthy Schools Programme (NHSP) provides strategic leadership to local Healthy School programmes (LHSPs) by endorsing a whole-school approach focused on common risk factors (CRFs); risk factors such as diet, tobacco and exercise, which are shared by the major non-communicable diseases . CurrentThe NHSP requires schools to achieve 'Healthy School' status by addressing the CRFs through focusing on four strands :Personal, Social & Health Education • Healthy Eating• Physical Activity• Emotional Health & Wellbeing• Oral health is not discussed within the NHSP, although the English oral health strategy suggests that oral health should be promoted using the CRF approach within settings such as Healthy Schools . LHSPs mA recent study in Scotland reported an association between Healthy School status and twice-daily toothbrushing for some children attending Healthy Schools in deprived areas . The autA study in Brazil has also reported oral health benefits for children attending schools engaging with the Health Promoting Schools philosophy . Schoolshow the Healthy Schools programme translates into interventions influencing oral health. Therefore the research questions being addressed were:Whilst these studies point towards Healthy Schools having a positive impact on oral health, nothing is known about What are the areas of the Healthy Schools programme which might impact on oral health? To what extent are these areas pursued within Healthy Schools programmes in the North-West of England? What are the barriers and drivers to the incorporation of oral health promoting activities within Healthy Schools programmes?Approval to carry out the study was obtained from the Central Office for Research Ethics Committees (COREC) (06/MRE/63), the Department of Health and employers of participants.. Each region of the NHSP consists of several LHSPs that operate as partnerships between local education and health agencies. Coordinators of the 22 LHSPs in the North-West of England  were identified as key informants for this study. These individuals have responsibility for managing LHSPs and as such, were considered to have the potential to provide both strategic and practical insights for the current study.The English NHSP is organised into 9 regions. The North-West region incorporates 2 large conurbations and some rural areas. Parts of the North-West region are among the most deprived areas in England, others are among the most affluent A qualitative rather than quantitative study design was selected because of the lack of previously reported data in this field. Semi-structured interview rather than focus group methodology was selected because of the difficulty in arranging for the participants to gather in one place. Interviews can also assist respondents in speaking freely . The intOral health promoting activities suitable for incorporation into the NHSP were identified from a literature search, followed by consultation with a range of senior personnel working in the field of dental public health by means of a questionnaire. A panel with expertise in the field of oral health promotion (OHP) reviewed the activities identified and thus finalised the interview schedule Table .The schedule contained questions around three themes:A. The concept of promoting oral health as part of Healthy SchoolsB. The delivery of OHP in Healthy SchoolsC. Drivers for oral health to be promoted as part of Healthy SchoolsCoordinators of the 22 LHSPs in the Northwest of England were mailed to invite them to participate and to give them information about the study. Participants who did not reply were contacted by telephone and/or email to establish whether they were willing to take part. All 22 LHSP coordinators consented to participate in the study. Participants were assured that their responses would be anonomised. Interviews were audio-taped and transcribed.A coding framework based on the themes in the interview schedule was designed. Transcripts were examined manually to identify codes using thematic content analysis and a system of constant comparison ,14. ThisThis study referred to qualitative research review guidelines to ensure its quality . SystemaAll the respondents felt that it was appropriate to promote oral health within Healthy Schools. All respondents placed OHP within the Healthy Eating strand of the NHSP. Six respondents also recognised the appropriateness of locating OHP within other strands of the programme:(numbers in brackets after each quote refer to the participant)'it goes hand in hand with the Healthy Eating standard' (9)'It's also an important part of the emotional health and ... the sex and relationship education' (22)All respondents felt that oral and general health were linked. Three participants conceptualised oral health as an indicator of general health:'the health of the gums etc is an indicator in terms of heart disease' (11)Other respondents felt that there was no distinction between oral and general health for the purposes of promoting oral health within Healthy Schools. There was also recognition that oral health had historically been separated from general health, but that it should now be included as part of general health, and the Healthy School approach was therefore a positive thing in this context:'I think the key thing is ... the linkage. Oral health has sat on its own for so long' (9)Eight participants gave schools or school nurses the responsibility for OHP, others felt that the responsibility lay solely with specialist OHP teams or jointly between Healthy Schools teams, schools and OHP teams:'it's part of what schools teach young people' (10)'It's got to be a partnership thing' (12)Many respondents acknowledged the necessity for the involvement of personnel with specialist oral health expertise.This code categorised oral health promoting activities within the main strands of the NHSP.All participants reported that schools addressing healthy eating as part of their Healthy Schools work were expected to have a healthy eating policy and to be acting on that policy. Irrespective of engagement with Healthy Schools, all schools were expected to conform to minimum nutritional standards . There wFormal oral health education and education about alcohol and tobacco fall within the PSHE strand . Although participants did not tend to make unprompted links between tobacco and alcohol and oral health, once prompted they were aware of the relevance of targeting these areas to promoting oral health. Tobacco interventions were being directed through national legislation e.g. The Smoke-free (Premises and Enforcement) Regulations (2006), as well as through Healthy Schools. Healthy Schools programmes required schools to have policies covering tobacco, alcohol and drugs. School interventions and education around these topics were more variable with some participants reporting smoking cessation workers visiting schools. In other areas schools-based smoking cessation was viewed as being inappropriate because it was felt that smoking cessation should be instigated by an individual's desire to quit.Nine respondents recognised the relevance of oral health to this Healthy Schools strand:'there's a very nice project ... about the effect of your teeth on your whole face, and your own personality ... that's about self-esteem as well' (11)Respondents were asked about two aspects of physical activity that could prevent oro-facial trauma: the use of cycle helmets and sports mouthguards. Cycle helmets were commonly being promoted either directly by the LHSP, or by their partners. Sports mouthguards were less commonly promoted and one respondent raised concerns raised about the appropriateness of promoting mouthguard use:'because of the chance of choking' (16)This code related OHP activities to the five core features of a whole school approach.Participants were generally positive about oral health being taught within schools, with most expressing that it should be taught either within PSHE or science. Not all participants were aware of precisely what was taught in relation to oral health. Some respondents expressed concerns about timetabling constraints.The physical environment of the school has the potential to impact on oral health because of its links to health and safety, accident prevention and emotional health and wellbeing. The extent to which it was being considered differed between localities. Some areas considered the physical environment of their schools as an area for schools to address after they achieved 'Healthy School' status. Others conceptualised assessing the physical school environment either as a part of ensuring that schools were using the whole school approach or as linked to the emotional health and wellbeing strand of the NHSP.All the participants except one were unaware of schools in their area having specific oral health policies; it was generally felt to be more appropriate that references to oral health should be embedded within more general policies:'it's also explicit in in you know the whole school food policy which we've modelled for them ...erm which which sort goes through ... DMFT figures ... so its sets the context of ...why it is important about healthy eating' (18)Pupil participation may impact on oral health through promoting psychological health and wellbeing. In one area pupil participation was being used to promote oral health specifically:'we ... use some of the older children to be peer educators ... we've trained the children ...and they then have gone to work with some of the nursery children' (11)Involving parents and staff in Healthy School programmes is a vital part of the whole school approach. Parents were more commonly involved in OHP in the primary than the secondary sector:'we're ... trying to educate parents of primary school children ... we emphasize that a lot more ...than we do with secondary children' (10)This code described the resources, personnel and partners involved in the delivery of OHP.Personnel involved with OHP in Healthy Schools sometimes included individuals working as core members of local Healthy Schools teams. In the majority of areas personnel also included people working for partner agencies such as OHP teams, local sports partnership teams, school nurses and drug education teams. OHP teams are generally dental nurses, hygienists, and therapists trained in oral health education and employed by the local salaried dental service. Only one participant reported that the LHSP was not working in partnership with an OHP team. The role of local OHP teams varied considerably between areas:'the OH  team come in and run a programme ... supporting the curriculum ... they've done something in terms of leaflets on resetting teeth, if they've been knocked out they ... support the work right throughout all Key Stages' (16)'they do like puppet plays as well ...around the theme of OH' (4)In one area, the issue of expertise was addressed differently; the Healthy School team had recognised that they had more expertise about delivering interventions in schools than the local OHP team. They worked with the OHP team to ensure that OHP messages were provided in the most appropriate ways:'oral health were working ... quite independently of us .... they were too focused on oral health ... there was actually a jarring happening so that when Health Promoting Schools were going in as well ... it was beginning to be seen as a bit of a nanny state .... so what we decided to do was because we had more expertise about delivering in schools ... is to make the health messages education friendly ... we started working more closely with oral health ... one of their workers actually joined our team ' (22)OHP interventions were sometimes targeted to either the primary sector and/or to those schools with the worst dental health. One reason for targeting the primary sector related to lack of uptake by secondary schools although other areas targeted the primary sector because of the perceived importance of establishing healthy behaviours at a young age.This code described challenges identified in promoting oral health in Healthy Schools.This problem emerged in relation to schools being able to choose the extent to which they engaged with their local Healthy Schools programme or with OHP interventions:'all our schools are signed up, it doesn't necessarily mean they're doing anything' (2)Seven respondents discussed that lack of expertise was a challenge in delivering OHP:'we don't go into the secondaries ... we haven't got enough medical knowledge' (22)Many of the challenges in delivering OHP in Healthy Schools discussed by participants were logistical:'if you give them water in classes, they'll just mess about with it' (10)Participants noted that there was evidence of mixed messages occurring in schools, for example with unhealthy food being served at some school events.The problem of outside vendors (ice cream vans at the school gates etc) was common to several localities. There was evidence of work going on to address the issue in six areas, by involving vendors themselves, trading standards and/or environmental health. Participants expressed a wish for guidance on this issue.The low profile of oral health was discussed by twelve respondents as a potential barrier to promoting oral health in Healthy Schools. Interviewees cited the exclusion of oral health from National Healthy Schools guidance, although they did recognise that oral health may be promoted as part of the CRF approach, despite the lack of national guidance:'it's hard because there's no specific reference to it within Healthy Schools ... at the moment the focus is on Healthy Schools status' (2)'it's almost implicit in the healthy eating work that you do. I don't think it's perhaps given as high a priority as it might do' (18)There were also comments made relating to the low profile of oral health on the local agenda:'oral health hasn't been targeted as a priority this time' (2)Respondents were also unsure if schools would make the link between Healthy Schools and oral health and recognised that this may depend on circumstances within individual schools.Problems identified specific to the secondary sector included accessing parents, engaging schools and the tight curriculum.Seventeen participants considered that oral disease in their area was a problem:'we've got the worst OH erm data in the country' (8)A few respondents did not think that oral disease was a local problem or recognised that although local levels of oral disease were high, the problem had not been prioritised:'as far as I'm aware it isn't' (19) 'it hasn't been deemed to be (a priority), .... that's not saying that it isn't' (2) In some areas oral health was a local priority:'we've specifically said good practice is linked to dental health' (15)Respondents were unaware of the existence of any national strategies or directives that would support the promotion of oral health as part of Healthy Schools:'we've not got any sort of directives, not sort of nationally' (17)Historical ways of working emerged from the data as a way to explain how many local Healthy Schools programmes had come to be so involved with oral health:'we've always done it in this area' (17)Recent evidence of an association between periodontal disease and systemic diseases such as coronary heart disease and diabetes , has broWhen interpreting the data generated from evaluations of health promotion interventions it is difficult to disentangle the intervention being studied from other interventions . In the Care is necessary in extrapolating the results of this study to wider national and international contexts. However, there is no evidence that the North-West region is different from other English Healthy School regions, in the way in which its Healthy Schools programmes engage with OHP. Further, because local Healthy Schools programmes work within the NHSP framework  and towaResults showed that some Healthy Schools programmes were relying largely on the promotion of oral health through the CRF approach, whilst others were more explicit in promoting oral health. Explicit OHP tended to be related to historical ways of working, and often involved input from local OHP teams using dental personnel. In some areas OHP teams were offering specific schools-based interventions. In other areas, OHP teams were more involved in providing advocacy and training, roles which have been recommended for oral health experts working within general health promotion frameworks -25. The OHP was most often related to the healthy eating and PSHE strands of the NHSP. Whilst it is easy to envisage the positive impact of the promotion of healthy eating within the school on levels of dental caries, it is more difficult to see how Healthy Schools programmes might impact on levels of toothbrushing, as indeed they appear to . It is wlocal Healthy School coordinators seem to have made linkages between Healthy Schools and oral health, Healthy Schools policy makers at a national level have excluded oral health from guidance. National guidance on OHP in Healthy Schools would legitimise the promotion of oral health in Healthy Schools and secure its future against the threats identified by participants in this study. The authors suggest a national document based on the WHO publication on OHP in Health Promoting Schools [The integration of OHP within Healthy Schools programmes was occurring despite participants' lack of awareness of international and national guidance in relation to oral health ,8. Curre Schools . The autThe authors declare that they have no competing interests.ES designed the study, carried out the fieldwork and drafted the manuscript. CMP and RVH assisted in the design of the study and advised on the preparation of the manuscript. All the authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Journal of Experimental and Clinical Cancer Research although this article had been accepted and previously published by Cancer Biotherapy & Radiopharmaceuticals [Nucleosides, Nucleotides and Nucleic Acids [Journal of Experimental and Clinical Cancer Research. The authors are deeply sorry for any inconvenience this may have caused to the editorial staff and readers.The corresponding author submitted this article  to Journeuticals . The artic Acids . Since i


This is the first report of a case-control epidemiological study on lymphomas and leukaemias occurring in Yorkshire during 1979-84. This paper deals with the results of the Hodgkin's disease analysis comprising 248 cases and 489 controls. The results indicate support for previous work with respect to small family size and past history of infectious mononucleosis. Positive observations made in a previous pilot study are also confirmed and extended with respect to associations with certain chronic skin lesions, dental anaesthesia and familial factors. Negative associations are described with respect to X-ray exposures and cigarette smoking. It is proposed that these results fit into a general hypothesis that these conditions are the result of interaction between infectious agents and altered immunity in those persons genetically predisposed.


The risk of nodal metastasis is higher in women with bigger breast. It is not clear if this increase is due to the size of the breast (largely related to obesity) or is the result of larger tumour size at presentation (due to delayed diagnosis). It is hypothesised that women with large breasts are more likely to have node positive disease mainly attributable to their breast size.® computer programme.One hundred and twenty consecutive patients who underwent mastectomy during the year 2004 and 2005 for primary breast cancers in a large Teaching Hospital were included in the study. Patient's variable and tumour variable were collected and analysed by SPSSIt was found that big breasted women (those patients with mastectomy weight greater than 800 g) had a significantly greater tumour size than those with smaller breasts  but there was no significant difference in grade  or lymph node positivity  between the two groups. Although, the tumour size was significantly greater in those with lymph node metastases (p < 0.001) but mastectomy weight was not found to be significantly greater in those with lymph node metastases (p = 0.11). For patients with similar tumour sizes mastectomy weight was not significantly greater in those patients with lymph node metastases (p = 0.28).It is concluded that increased incidence of lymph node positivity at presentation big-breasted women is because of larger size of the primary tumour and not due to the size of the breast alone. The present literature on the large size of breast and the stage of breast cancer is controversial. The larger size of the breasts is more common in obesity which is associated with poor prognosis of breast cancer in both pre and postmenopausal women. It is aOne hundred and twenty primary breast cancers operated at a large Teaching Hospital were included in the study. These were consecutive patients who underwent mastectomy during the year 2004 and 2005. Patient's variable and tumour variable were collected and analysed by SPSS computer programme.Spearman correlation was used to measure association between continuous variables, the Mann Whitney test for the comparison of continuous variables between two groups and Kendall's tau-b statistic to analyse ordinal variables such as grade and lymph node positivity. Binary logistic regression analysis was used to determine whether, for patients with similar tumour sizes, mastectomy specimen weight was a significant predictor of the presence of lymph node metastases.A large breast was defined as a breast with mastectomy specimen weight of 800 grams or more. It was found that increasing weight of the mastectomy specimen was associated with increasing risk of large tumour . The tumour size was significantly greater  in those with mastectomy weight greater than 800 g  have larger tumours reported that patients with bigger breasts had larger tumours in both symptomatic and screen detected group . In a laIt is concluded that Increased lymph node positivity at presentation of breast cancer in big-breasted women is because of larger size of the primary tumour and not due to the size of the breast alone.ARC conceived the idea and coordinated the data collection and analyses, participated in all stages of the study and drafted the manuscript, CS collected the data and PN participated in the performed the statistical analysis. All authors read and approved the final manuscript.


The expectant management of high grade renal injuries in hemodynamically stable children has gained increasing acceptance amongst paediatric surgeons. However, patients with grade 1V injury with complete renal transection have been identified as a subgroup with a poor outcome that may benefit from early operative intervention.Interestingly, both internal and external drainage have been independently utilised as part of the expectant approach. The former is more widely practiced and was first suggested by Haas et al who used it successfully in 5 patients with grade 1V renal trauma. Yet to be clearly established in this context is the value and timing of external drainage, particularly, when used in combination with internal stenting.Described is a child with complete renal transaction who was successfully managed with a combination of internal and external drainage. A 5 year old Caucasian male patient was admitted to a tertiary paediatric surgical centre within 1 hour of coming off a quadbike, sustaining blunt trauma to the right chest and the right upper quadrant of abdomen. Initial assessment confirmed hypovolaemic shock which responded to aggressive resuscitation as well as a tender right flank with macroscopic haematuria. Once stabilised a Computarised Tomography (CT) scan and IVP were performed which confirmed contusion of the right lower lung, fracture of several overlying ribs and complete right renal fracture with distraction of upper and lower poles (Grade1V),  scan Fig The kidneys in children are proportionally larger and have much less perirenal fat and costal protection than in adults which predisposes them to injury after blunt abdominal trauma (10% of cases) . Prompt However the management of grade IV renal injury in children is controversial, particularly with regard to the management of urinary extravasation. Grade IV trauma is defined as parenchymal laceration extending through the corticomedullary junction and into the collecting system . This reGrade 1V renal injuries with complete fracture and separation of the poles but with intact blood supply constitutes a special group with a decreased likelihood of spontaneous resolution and where early intervention may be necessary [There is currently no consensus on the optimal timing of these interventions. However from the experience of this case where a policy of early aggressive management with a combination of internal and external drainage was successfully utilised would lead us to support this approach to improve renal salvage. It would appear that reconstitution of the distracted but viable renal poles into a solitary functioning unit is possible provided the urinoma is adequately managed. Successful drainage also ensured that there was no significant residual scarring on late DMSA scanning.The expectant management of isolated high grade renal injuries with complete fracture in the haemodynamically stable patient is evolving and both internal and percutaneous drainage are crucial to the success of this approach. It seems the advances in interventional radiology are facilitating a less invasive approach to the management of these significant injuries in the paediatric population. The experience of this case reinforces a strategy which is leading to kidney salvage with minimal complications and is advocated.Consent was obtained from both parents and the involved institutions for publication of the case report.The authors declare that they have no competing interests.CH prepared the manuscript, MH provided the clinical details of the case, AM managed the case and edited the paper.


The current guidelines of the European Resuscitation Council (ERC) for advanced cardiac life support recommend that endotracheal intubation "should be attempted only if the healthcare provider is properly trained and has adequate ongoing experience with the technique."  One woulWithout adequate skills, not only in intubation but also in the verification of tracheal tube position, following advanced life support guidelines may not be possible without considerable risks for the patients. When German HEMS physicians assessed the tube position in patients who were initially intubated by other emergency physicians, the percentage of oesophageal intubations 6.7%) was unacceptably high . Many of.7% was uWhile the new guidelines of the Scandinavian Society for Anaesthesiologists and Intensive care medicine (SSAI) for prehospital airway management continue to recommend intubation by anaesthesiologists to secure the airway in emergencies, the importance of personal experience and skill level is pointed out as critical, in addition to the fulfillment of formal qualifications . These nConsulting and lecturing fees from VBM and Ambu.


The serum ferritin concentration is increased in both acute myeloblastic leukaemia and Hodgkin's disease. In acute leukaemia the mean concentration is about ten times the normal level and is associated with a high concentration of transferrin-bound iron. In Hodgkin's disease abnormal ferritinaemia is associated with a low concentration of transferrin-bound iron and appears to result from a block of reticuloendothelial iron release. Increased concentrations of circulating ferritin have also been observed in a few cases of chronic leukaemia and myelomatosis.


In "Reframing School Dropout as a Public Health Issue" , FreudenIt is time to include school dropout rates  among the national health objectives for 2010  to the sUniform national measures of school readiness  should also be included among current national health objectives and tracked through No Child Left Behind. Such measures would underscore the relevance of children's emotional and cognitive health to academic achievement . It would also provide schools with baselines for assessing students' academic growth, beginning in kindergarten. Most importantly, it would offer a national benchmark for assessing progress toward the national goal of ensuring that every child starts elementary school with the necessary skills to succeed and eventually graduate from high school by age 18.To the list of recommendations cited by the authors  for reduEarly childhood interventions are critical to reducing school dropouts over the long term. These programs are highly cost effective  and may Read the author's reply


The object of this study was to measure some of the differences between normal squamous epithelial cells and cells from invasive squamous carcinoma of the uterine cervix. A total of 107 patients were studied; only those specimens which when assessed by a histopathologist were thought to show classic normal features or undoubted invasive carcinoma were included in the quantitative analysis. In addition, any specimens which at the electron microscope level, showed faulty sampling or preparation were discarded, leaving us with 16 carcinoma and 15 normal specimens for detailed study.The nuclei of tumour cells had a greater area than those of normal cells; histograms of the size distribution of nuclei showed a distinctly different pattern in the 2 groups. Tumour cells had fewer ribosomes in each cubic micron of cytoplasm than had the normal cells and showed a reduction in the amount of intercellular space; in addition, the malignant cells had a smaller surface density and fewer tonofibrils in their cytoplasm. Some tumour cells had a smaller percentage of cell membrane specialized as desmosomes than the corresponding normal cells but all tumour cells had desmosomes of shorter length than normal.Discriminatory analysis, carried out with the help of a computer, allowed all of these variables to be assessed with respect to each other in order to arrive at a numerical score for each specimen. When expressed graphically, these scores showed that the populations of normal and carcinomatous cells fell into 2 separate groups. The significance of these results is discussed.


The 'unopposed oestrogen hypothesis' for endometrial cancer maintains that risk is increased by exposure to endogenous or exogenous oestrogen that is not opposed simultaneously by a progestagen, and that this increased risk is due to the induced mitotic activity of the endometrial cells. Investigation of the mitotic rate during the menstrual cycle shows that increases in plasma oestrogen concentration above the relatively low levels of the early follicular phase do not produce any further increase in the mitotic rate of endometrial cells. A modification of the unopposed oestrogen hypothesis which includes this upper limit in the response of endometrial cells to oestrogen is consistent with the known dose-effect relationships between endometrial cancer risk and both oestrogen replacement therapy and postmenopausal obesity; it also suggests that the mechanism by which obesity increases risk in premenopausal women involves progesterone deficiency rather than oestrogen excess, and that the protective effect of cigarette smoking may be greater in postmenopausal than in premenopausal women. Detailed analysis of the age-incidence curve for endometrial cancer in the light of this hypothesis suggests that there will be lifelong effects of even short duration use of exogenous hormones. In particular, 5 years of combination-type oral contraceptive use is likely to reduce a woman's lifetime risk of endometrial cancer by some 60%; whereas 5 years of unopposed oestrogen replacement therapy is likely to increase her subsequent lifetime risk by at least 90%; and even 5 years of 'adequately' opposed therapy is likely to increase subsequent lifetime risk by at least 50%.