Dental diagnostics system (DDS)

November 11, 2015

Providing clear information for patient and provider.

Our medical colleagues have been capturing the causes of death for centuries using standardised diagnostic terms. The first international conference to revise the International Classification of Diseases (ICD) was convened in 1900. In 1948, the World Health Organisation (WHO) took responsibility for the now renamed International Classification of Diseases, Injuries, and Causes of Death with the sixth edition. The WHO expects to launch ICD-11 in 2020. Oral health diagnoses are classified in the early and current revisions of ICD. However, they are not granular enough and difficult to find throughout the ICD volumes. Additionally, the dental profession does not mandate documentation of a dental diagnosis as part of the billing process and consequently, diagnoses are not captured in a structured format. Hence, until recently dentistry did not capture why a tooth becomes non-vital or why it had to be extracted, much to the disadvantage of clinical dentistry, dental public health and dental quality improvement efforts.

Several attempts to address this problem have been made throughout the years, including the development of the Toronto codes in 1999 and the Systemised Nomenclature of Dentistry (SNODENT) by the American Dental Association (ADA). SNODENT, which is integrated into SNOMED, has proved largely ineffective as a chair-side terminology, not least because it is composed of more than 7,000 terms, is not widely available and is yet to be finalised.

To meet the need for a comprehensive yet concise set of dental diagnostic terms, a happy medium between ICD sparseness and SNODENT/SNOMED enormousness, an academic workgroup came together in 2009 to create and implement the EZCodes dental diagnostic terminology, later renamed Dental Diagnostic System (DDS). Key motivators included the dire need for the dental profession to enter a diagnosis in the patient record that is clear and can be used to inform both the provider and the patient. A standardised terminology can capture a granular diagnosis in the electronic health record (EHR) that then helps inform the providers of the specific treatment procedures appropriate for the chosen diagnoses. For the patient it will specify information why a certain procedure is being done, by providing detailed reasoning behind each procedure. From an educational perspective, it allows faculty to create a diagnostic-centered academic approach that will facilitate students to learn.

Led by Dr. Elsbeth Kalenderian from Harvard School of Dental Medicine, an academic workgroup developed the first diagnostic interface terminology specifically applicable to the field of dentistry. The Dental Diagnostic System (DDS) – formerly known as EZCodes, contains dental diagnostic terms at the granularity level required by practicing dentist’s chair-side. Developing the DDS terminology was an iterative process that began with the University of California, San Francisco School of Dentistry’s Toronto Z skeleton, as it was representative of dental clinical practice. The Z Codes were based on the original Toronto codes proposed earlier, but never widely adopted. This Z skeleton was then populated with concepts from the American Academy of Periodontology, the American Board of Endodontics, UCSF own Z codes and International Classification of Disease terms to ensure adequate concept orientation. The first version of the DDS diagnostic terminology was produced following two rounds of discussion with domain experts and subsequent review by the workgroup. This produced DDS-2010 with 1,158 terms in 13 categories and 78 sub-categories. Subsequent revisions produced a robust DDS terminology with DDS-2015 consisting of 1589 terms, in 17 categories and 107 sub-categories.

Members of the workgroup include Drs. Joel White, Muhammad Walji, Oluwabunmi Tokede, Maxim Lagerweij, and Rachel Ramoni. All are united by a common goal to improve dental research, education and patient care by creating a go-to terminology for clinical and public health research. There were several considerations for the workgroup members to take into account during the process of developing a terminology that should be easy to use in the clinic and be usable for research through secondary data analysis. First and foremost, the team must ensure that clinicians use the standardised terminology consistently and accurately. Hence the DDS research team completes ongoing validation and measuring of DDS utilisation.

The DDS aligns dentistry with medicine, in terms of establishing standard clinical practice. Enabling diagnoses to be clearly recorded after examination and providing care is important to facilitating communication between clinicians, patients, epidemiologists, researchers and students. While the standardisation of dental diagnostic terminologies is of obvious benefit to dentistry, it is important that additional consideration is given to how the terminology will be shared. Facilitating and encouraging its use is key to the DDS realising its potential. With that in mind, NIH/NIDCR is supporting the development of the DDS implementation toolkit, which will enable the terminology to be rolled out to non-academic dental institutions and general practitioners.

Eighteen dental institutions from the US, Canada and Europe use the DDS for patient care, teaching and research. Ten additional schools are slated to implement the DDS terminology within the next year. Incorporated within axiUm, Exan Corporation’s dental EHR, the DDS is available to almost every dental school in the US. Two other EHR vendors are revising their HER interface in order to effectively upload the DDS. This as a result of pressure from their users who are concerned about government mandates to document a diagnosis as part of Medicaid reimbursement requirements. The DDS has been shown to be useful and accurate, and its terms are routinely paired with dental procedures providing a treasure trove of usable data on dental diagnosis and treatment for appropriateness of care and outcome research.

The DDS is a crucial component of the BigMouth Dental Data Repository (which houses data from six institutions with nearly 2 million patients). Structured data entry is essential for developing effective electronic data repository systems and helping clinicians and researchers use them in a meaningful way. With the creation of the DDS, the team has made this possible.

Dr. Elsbeth Kalenderian

Chair – Dept. of Oral Health Policy and Epidemiology

Chief of Quality – Harvard Dental Center, Harvard School of Dental Medicine

Tel: 1 617 432 4375

ohpe@hsdm.harvard.edu

www.dentaldiagnosticsystem.org

Research opportunities in Acute Medicine

November 11, 2015

Dinesen L1, 2, Poots AJ1, Bell D1, 2. 1.NIHR CLAHRC NW London, Imperial College London 2.Dept. Acute Medicine, Chelsea and Westminster Hospital

What is Acute Medicine?

Acute medicine is the part of internal medicine concerned with the immediate and early specialist management of adult patients who present to, or from within, hospitals as urgencies or emergencies and traditionally this include the first 72 hours of care in a well-staffed and equipped Acute Medical Unit. As such, acute medicine and acute physicians manage a large number of patients per day with complex health needs across a broad range of illness severity.

Acute medicine has a growing academic base but research in acute care needs to increase and accelerate for two main reasons. The first is to ensure we design adaptive systems for health care delivery in an increasingly complex environment related to the increasing demand and advances in technological intervention and diagnostics. The second is to better understand and treat patients with complex needs who are increasingly exposed to a cocktail of medicines which can have interactions, some with significant harm ¹. Acute medicine has developed over the past 10 years owing to a complex interplay of factors; it is now established in several European countries and is developing in Singapore and Malaysia. As the demand for acute physicians grows it is imperative that we provide increased research opportunities for clinicians and non-clinicians, to ensure best medical practice. This means that major grant funders need to recognise the patient need for research in this area and pump prime grants and new academic posts. Translational research ² is recognised as an essential area for research and with Acute Medicine’ acting as the front gate for secondary care, its main role is likely to be in closing any second translation gap between primary research and practice, thereby ensuring that patients receive consistent, high quality, patient-centred care.

Research opportunities in Acute Medicine

The research opportunities span a broad range: from managing a single disease entity such as venous thromboembolism and stress hyperglycaemia to complex needs patients and polypharmacy, evaluation of illness severity assessment scores (including NEWS), technological interventions such as non-invasive ventilator support through to the design of health care systems. Some examples of recent research and future research opportunities are described in the next section.

Frailty in the context of Acute Medicine

Frailty is usually seen as a condition of ageing with two main models commonly used to describe frailty in the context of research: namely the phenotype and the cumulative deficit models ^{3, 4}.These models, while valuable, are probably too simplistic in the context of acute illness. While an acute presentation will usually be driven by a physical illness and the associated pathophysiological decompensation there is a complex interplay between the patients environment, social and psychological wellbeing. This may be seen as obvious in many cases, but assessing and measuring this to facilitate better clinical decision making and going support is not routine in clinical practice. To this end our research programme has recently published on the role of large data in defining outcomes for complex needs elderly patients in acute care based on the use of ‘geriatric syndromes’ ^{5, 6} and this work is now informing the basis of a four domain simple clinical frailty score that can be calculated at point of entry to care and longitudinally.

This score will use the four domains described above and the aim is to validate this work across a range of clinical environments, conditions such as brain injury, and age groups above 16 years old. This study is on-going, funded through the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North West London (CLAHRC NWL); but collaboratively across international centres would allow this work to be developed more effectively and help to minimise the translational gap that exists in this area.

CLAHRC NWL and patient leaders co-developed My Medication Passport, a hugely successful project. My Medication Passport is a written record, either in paper or smartphone app, of a person’s medication, designed to improve communication between healthcare professionals and patients, and to provide a record for the patient themselves to be in charge of their medication and any changes made to their medication ⁷. Also CLAHRC NWL is involved in de-prescribing and optimising medication review.

Acute Medicine and System design

Acute Medicine’s ability, in common with emergency medicine and intensive care, to deliver high quality and efficient care is influenced by the patient and staff environment. Yet relatively little research has been conducted in this area, whether at the level of building design or the optimal use of information technology. It could be argued that in hospital and departmental design we reproduce the mistakes of the past; for instance having large distance between Emergency Departments, and acute medical units slows patient flow. Equally, in relation to information technology, we use what is provided rather than as an enabler to facilitate high quality care; for example, differing IT systems between specialties hinders transfers of knowledge across transfers of care. To resolve this Medicine needs to move beyond the current research paradigms to work more closely with developing information technology and social media, and to look beyond traditional medical research (for instance collaborating with engineering, design, art, and other social sciences) to design responsive and adaptive health care systems, organisations and departments. High volume specialties, such as Acute Medicine, and patients will benefit most by embracing a varied epistemological approach, drawing on differing knowledge bases to provide innovative solutions. Preliminary work with the Royal College of Art and Imperial College London has suggested four design features for Acute Medical care:

– Visibility of information and the clinical (patient) areas

– Sharing of information between and across professional groups

– Empowerment of patients and staff in decision making

– Follow up of outcomes

Building on this will require a rethink of information and information systems to create a reliable and systematic view of care needs in real time, and a new approach to building and environmental design. Collaboration across different health care systems would provide enhancements to this work, providing greater generalisability of output.

Summary

The potential for academic medicine to develop in acute medicine is significant and will require new thinking that recognises the needs of the large cohort of patients who are admitted to hospitals around the world 24 hours per day seven days per week. Costs are related to patient needs and for most hospitals this reflects a large proportion of the budget. To improve care and efficiency requires research funders and industry to recognise the importance of acute care and to invest in the future for this vulnerable and complex patient group. Collaboration across disciplines and nations will provide innovative and generalizable knowledge for these improvements; and, coupled with the varied patient cohort, this provides many research opportunities and rewarding field in which to work.

References

1 Duerden M et al. Polypharmacy and medicines optimisation. Making it safe and sound. The Kings Fund. Nov 2013

2 Cooksey D. A review of UK health research funding. Dec 2006

3 Fried LP et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146–56.

4 Rockwood K et al. A global clinical measure of fitness and frailty in elderly people. CMA J, 2005, 173,(5), 489-95

5 Soong J et al. Quantifying the prevalence of frailty in English hospitals. BMJ Open 2015;5:e008456

6 Soong J et al. Developing and validating a risk prediction model for acute care based on frailty syndromes. BMJ Open 2015;5:e 008457

7 Barber S et al. Evaluation of My medication Passport: a patient completed aide-memoire designed by patients, for patients, to help towards medicines optimisation. BMJ Open 2014;4:e005608

Professor Derek Bell

Imperial College London

Tel: 020 3315 5845

d.bell@imperial.ac.uk

www.imperial.ac.uk/medicine/

Inferior Vena Cava Ultrasound and Shortness of Breath

November 11, 2015

The role of ultrasound for Inferior Vena Cava measurement (IVC) in patients presenting with shortness of breath is often debated. Authors have disputed different modes and points of measurement and with varying probe placement.^1-5 Additionally, patient position, habitus, degree of respiratory distress, and the presence of mechanical ventilation can influence the size and collapsibility of the IVC. Common agreement may be found from a recent metanalysis suggesting a moderate level of evidence supporting the IVC diameter is low in hypovolemic patients as compared with euvolemic patients.⁶

The caval index calculates the percentage collapse of the IVC: IVC expiratory diameter – IVC inspiratory diameter, divided by the IVC expiratory diameter x 100 = caval index (%). In the setting of shortness of breath, a caval index near 100% suggests complete collapse of the IVC and is indicative of volume depletion. The closer the number to 0% the more likely the patient has intravascular volume overload.⁷ Additionally, cardiac tamponade from pericardial effusion should be considered with a non-collapsable IVC in patients who present with shortness of breath. The BRIPPED scan is a screening tool for patients with shortness of breath of unclear etiology. Among its components discussed below, the scan simplifies the caval index by qualitatively evaluating the collapse of the IVC.

The IVC is visualised in the long axis plane in patients who are semi-recumbent or supine. The IVC should be visualised as it enters the right atrium, to differentiate it from the aorta that runs parallel to the IVC. With the BRIPPED protocol, the sonographer may image the IVC, and obtain cardiac windows using the same lower frequency phased array probe to evaluate ejection fraction and pericardial effusion. The probe is placed below the xiphoid bone, and the probe marker rotated towards the patient’s head. Alternatively, the probe may be placed anterior to the mid axillary line, with the probe marker towards the head.

BRIPPED Protocol:

The BRIPPED scan is an effective screening tool for shortness of breath that evaluates pulmonary B-lines, Right ventricle size and strain, Inferior Vena Cava (IVC) collapsibility, Pleural and Pericardial Effusion, Pneumothorax, Ejection Fraction of the left ventricle, and lower extremity Deep Venous Thrombosis.

B-lines: Sonographic pulmonary Blines have been shown to correlate with congestive heart failure.^{8-11, 15, 16} A high frequency linear probe is used to evaluate at minimum 2 mid clavicular apical lung windows.

RV strain: Right ventricular (RV) enlargement can be caused by a Pulmonary Embolus (PE), acute RV infarct, Congestive Heart Failure (CHF), pulmonary valve stenosis or pulmonary hypertension, and is a risk factor for early mortality in PE.¹⁷ A low frequency phased array probe is used to evaluate RV strain in an apical 4 chamber view.

IVC-size and collapsibility: Using an IVC size cut off of 2.0 cm has been shown to have a sensitivity of 73% and specificity of 85% for a Right Atrial Pressure (RAP) above or below 10 mmHg. The collapsibility during forced inspiration of less than 40% has even greater accuracy for elevated RAP (sensitivity 91%, specificity 94%, NPV 97%).¹⁸ A low frequency phased array or curvilinear probe is used to visualise the IVC long axis, and dynamic imaging is used to assess collapsibility as either complete or less than 40%.

Pneumothorax: Bedside ultrasound is more accurate than supine chest xray with diagnostic ability approaching that of CT. ^{19, 20} The same windows for B-lines are utilised for pneumothorax screening. Additionally any area of decreased breath sounds, or crepitus palpated along the chest wall is evaluated for pneumothorax with a high frequency linear probe.

Pleural effusion: EUS has been shown to have an accuracy similar to a CXR for evaluation of pleural effusion.¹³, ¹⁴ A low frequency phased array or curvilinear probe is used to evaluate each mid axillary line at the costophrenic angle in the sitting patient.

Pericardial effusion: EUS has a sensitivity of 96% and specificity of 98% compared to formal echocardiography. ²¹ A low frequency phased array probe is used to evaluate pericardial effusion from an apical 4 chamber view and a parasternal long axis view of the heart.

EF: The qualitative assessment of left ventricular ejection fraction by emergency physicians has been shown to correlate well with an assessment by a cardiologist.^22-24 The same low frequency probe and parasternal long axis used to evaluate pericardial effusion is used to evaluate ejection fraction. Dynamic qualitative assessment of ejection fraction is classified as normal, depressed, or severely depressed.

DVT in lower extremities: Ultrasound was performed by emergency physicians using a two point compression venous ultrasound on patients with suspected lower extremity DVT. This approach had a 100% sensitivity and 99% specificity in diagnosing DVT, compared to a reference venous ultrasound in radiology.²⁵ A high frequency linear probe evaluates compressibility of the common femoral and popliteal fraction. Dynamic qualitative assessment of ejection fraction is classified as normal, depressed, or severely depressed.

DVT in lower extremities: Ultrasound was performed by emergency physicians using a two point compression venous ultrasound on patients with suspected lower extremity DVT. This approach had a 100% sensitivity and 99% specificity in diagnosing DVT, compared to a reference venous ultrasound in radiology.²⁵ A high frequency linear probe evaluates compressibility of the common femoral and popliteal probe to evaluate the parasternal long axis and apical 4 chamber, noting the presence or absence of pericardial effusion, ejection fraction, and RV strain. Then the long axis of the IVC is evaluated for dynamic collapsibility. Moving laterally, the costophrenic angles are evaluated bilaterally for pleural effusion. The probe is switched to the high frequency probe to evaluate each lung apex is evaluated in the mid clavicular line for the presence of pneumothorax and B lines. Lastly, the dynamic 2 point DVT screening is performed with compression ultrasound. The BRIPPED protocol and other bedside ultrasound resources can be viewed here:

http://www.anatomyguy.com/b-rippedscan-for-evaluation-of-emergencydepartment-patients-with-shortness-of-breath/

References:

1 Kircher B, Himelman R, Schiller N. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. AM J Cardiol 1990; 66: 493-6.

2 Akilli B, Bayir A et al. Inferior vena cava diameter as a marker of early hemorrhagic shock: a comparative study. Ulus Travma Acil Cerrahi Derg 2010;16(2):113-8.

3 Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, Vieillard-Baron A. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid respon- siveness in ventilated septic patients. Intensive Care Med 2004; 30:1740–1746

4 Blehar DJ, Dickman E, Gaspari R. Identification of congestive heart failure via respiratory variation of inferior vena cava. Am J Em Med 2009;27:71–5.

5 Blehar et al. Inferior vena cava displacement during respirophasic ultrasound imaging. Critical Ultrasound Journal 2012, 4:18

6 Dipti A et al. Role of inferior vena cava diameter in assessment of volume status: a meta-analysis. A JEM 2012 (30). 1414 -19.

7 Nagdev AD, Merchant RC, Tirado-Gonzalez A, et al. Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. Ann. Emerg. Med. 2010;55:290-5.

8 Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med. 1997; 156:1640–6.

9 Soldati G, Copetti R, Sher S. Sonographic Interstitial Syndrome The Sound of Lung Water. J Ultrasound Med 2009; 28:163-174.

10 Reibig A, Kroegel C. Trasnthoracic sonography of diffuse parenchymal lung disease: the role of comet tail artifacts. J Ultrasound Med. 2003;22:173-180.

11 Rumack CM, Wilson SR, Charboneau JW. Diagnostic Ultrasound. 3rd ed. St. Louis, MO: Mosby; 2004.

12 Copetti R, Cattarossi L, Macagno F, Violino M, Furlan R. Lung Ultrasound in respiratory distress syndrome: a useful tool for early diagnosis. Neonatology. 2008:94(1):52-9.

13 Wernecke K. Sonographic features of pleural disease. A JR AM J Roentgenol. 1997;168:1061-1066. 14 Vignon P, Chastagner C, Berkane V, et al. Quantitative assessment of pleural effusion in critically ill patients by means of ultrasonography. Crit Care Med. 2005;33:1757-1763.

15 Lichtenstein D, Meziere G. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125.

16 Liteplo, A.S., et al., Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med, 2009; 16(3):201-10.

17 Kucher, N., et al., Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med, 2005; 165(15):1777-81.

18 Brennan, J.M., et al., Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr, 2007; 20(7):857-61.

19 Kirkpatrick, A.W., et al., Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma, 2004; 57(2): 288-95.

20 Xirouchaki N, Magkanas E, Vaporiid K, et al., Lung ultrasound in critically ill patients: Comparison with bedside chest radiography. Intensive Care Med, 2011; 37(9):1488-1493.

21 Mandavia, D.P., et al., Bedside echocardiography by emergency physicians. Ann Emerg Med, 2001; 38(4):377-82.

22 Alexander, J.H., et al., Feasibility of point-of-care echocardiography by internal medicine house staff. Am Heart J, 2004; 147(3): 476-81.

23 Moore, C.L., et al., Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med, 2002; 9(3):186-93.

24 Randazzo, M.R., et al., Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med, 2003; 10(9): 973-7.

25 Crisp, J.G., L.M. Lovato, and T.B. Jang, Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med, 2010; 56(6): 601-10.

Virginia M Stewart

MD RDMS RDCS RDMSK

Emergency Ultrasound Director, Emergency Ultrasound Fellowship Director

Department of Emergency Medicine

Tel: (757) 594 2000

www.rmgultrasound.com

3D body scanning: measuring body volume for obesity assessment

November 11, 2015

A research group at University College Ghent is developing a method to measure body fat using 3D body scanning.

Obesity is a condition in which the amount of fat tissue is increased resulting in adverse effects on health and is associated with increased morbidity and mortality ¹. This state of fat accumulation is linked to increased risks of type 2 diabetes, cardiovascular disease, fatty liver, sleep apnoea syndrome and certain types of cancer and a decreased life expectancy.

The prevalence of overweight and obesity has increased dramatically worldwide and the number of people struggling with obesity today has doubled the past three decades. Among the Belgian adult population, 48% are too heavy for their height: 34% of the adult population are overweight, while 14% suffer from obesity. Overweight is more frequent in men (41%) than women (28%), but there is no difference between men and women with regard to obesity (14%). What is distinctly alarming is that more than half of all individuals in the 45-54 age group are overweight and one of five people in the 55-74 age group are obese ².

Weight indexes

In both clinical and scientific practice, assessment of body fat is not always possible because of costs, available time or limited access to the necessary measuring devices. Therefore, body weight indexes are often used as a proxy measure for the assessment of the degree of adiposity. The body mass index (BMI), developed by the Belgian scientist Adolphe Quetelet in 1832, is calculated as the ratio of body weight in kg, over body height in meter. According to the World Health Organization, a person with a BMI equal to or more than 25 is considered to be overweight. A person with a BMI of 30 or more is generally considered obese.

Although the BMI is quick and easy to calculate, its accuracy to diagnose obesity has shown to be limited, particularly for individuals in the intermediate BMI ranges ³. Also, the BMI was originally designed to be used at the population level and is therefore not as effective in individual cases because body weight is influenced by more than fat tissue alone. Furthermore, the relationship between BMI and health can vary with ethnicity making global comparisons problematic.

Therefore, it has been suggested that future research on body composition measurement should focus more on body shape and volume rather than body mass. With the advent of 3D body scanning technology, it is possible to obtain accurate and reliable anthropometric measures of an individual. Also, 3D body scans provide information on an individual’s body volume and body shape. Because a body scan results in a digital avatar, the distribution of body mass and fat deposition can be visualised and processed on a higher level compared to manual anthropometric measurements.

Innovative research

At University College Ghent in Belgium a team of researchers is involved in the Anthropometric baseD Estimation of adiPoSity (ADEPS) project. They use state-of-the-art technology like 3D body scanning and air displacement plethysmography to study the extent to which body fat percentage can be predicted using anthropometric measurements. The objective of the ADEPS project is to gauge body fat percentage from readily available anthropometric measures that don’t require sophisticated equipment.

A 3D bodyscanner uses structured white light technology to produce consistent point clouds and body models with a 3D-point accuracy of less than 1 mm. From a set of body scans a procedure is developed to determine total body volume. Derivation of body volume, together with measurement of body mass permits calculation of body density and subsequent estimation of percent fat and fat-free mass.

Using advanced statistical modelling the investigators will identify which anthropometric measurements provided by the body scan are useful predictors for body fat percentage resulting in predictive models. These models will then be validated using a reference method for body fat percentage determination. Resulting predictive equations will be converted into population-specific nomograms for convenient assessment of body fat percentage from simple and manual measurable anthropometrics that are useful in clinical practice and research. In developing this tool, the ADEPS project offers a practical contribution to getting a grip on obesity, the largest preventable health problem of our time.

The results from the ADPES project are to be expected by the end of 2016.

References

1 Flegal KM, Kit BK, Orpana H et al. (2013) Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories A Systematic Review and Meta-analysis. Jama-Journal of the American Medical Association 309, 71-82.

2 Drieskens S (2014) Nutritional status. In Belgian Health Interview Survey 2013 Report 2: Health determinants & lifestyle [L Gisle and S Demarest, editors]. Brussels: Scientific Institute of Public Health.

3 Romero-Corral A, Somers VK, Sierra-Johnson J et al. (2008) Accuracy of body mass index in diagnosing obesity in the adult general population. Int J Obes (Lond) 32, 959-966.

Dr Willem De Keyzer

Research project coordinator

University College Ghent

willem.dekeyzer@hogent.be

www.adeps.net

www.hogent.be

https://be.linkedin.com/in/wdkeyzer

Improving healthcare in Belgium

November 11, 2015

AG outlines key priorities of the Belgian Minister for Public Health, Maggie De Block.

Ensuring citizens lead a healthy lifestyle is a cornerstone of policy for governments worldwide. Throughout Europe, Ministers and MPs are bringing the issue to the forefront with proposals for healthy eating strategies and taxes on sugary food and drink.

Healthy eating and reducing obesity is part of the action plan of the new Belgian Minister for Public Health, Maggie De Block (hyperlink). Since coming into office last year De Block has caused quite a media stir. The Minister has been criticised across Europe for being overweight herself. However, one of her main priorities in her new role has been to tackle obesity and, De Block who practiced medicine as a GP for 25 years, has subsequently been labelled the Thatcher of Belgian politics.

Obesity is a problem that is seen across the developed world, not just in Belgium. However, according to figures released by the World Health Organization (WHO) in May, the obesity crisis will affect 9 out of 10 women in Belgium by 2030.

In the fight against obesity the Belgian government have added a new tax on soft drinks, which also applies to diet drinks and sugar-free drinks. Public Health Minister De Block stated it was not feasible to differentiate between the two different soft drink categories in the short term.

“This is a first step. The sugar tax is still in the works, while the framework of the tax shift is moving along somewhat faster,” she said.

Despite criticism, in February 2015, the Minister was voted the most popular politician in Belgium. Other priorities including investing in innovation, as reflected in the government’s October healthcare budget announcement for 2016. The budget includes €402m to help IT departments in hospitals to implement the eHealth Action Plan. The aim is that by 2019 all hospitals will have an electronic record for each patient.

Speaking about the budget announcement, De Block said: “Our healthcare system must be able to follow the new trends and we must continue to invest in innovation, so that we guarantee out patients’ quality of care, and give them access to new, often highly individual therapies. That’s enough of a reason to cut back wherever possible, so that we can invest where necessary.”

Also included in the new budget plan is €4.68m for specialised psychiatric hospitals to ensure the diagnosis and treatment of mental healthcare. In parallel with cuts that have been made, Minister De Block authorised €164.3m to free up new initiatives both for the provision and organisation of care.

“These are not easy times,” said De Block. “We must cut our coat according to our cloth. We have to economise. But at the same time we must protect the patients. We see so precisely all the expanses and we consult with the sectors concerned.”

Despite what people might think about the new Health Minister, she certainly has the patients in mind when considering her policies. Whether she can make meaningful progress on the obesity problem, only time will tell.

AG

editorial@adjacentopenaccess.org

www.adjacentgovernment.co.uk

Are we standing in our own way on the path to a cure for HIV/AIDS

November 11, 2015

Although there are many reasons to celebrate the life-extending benefits from antiretroviral therapeutics (ART) for HIV/AIDS and the ability to chronically manage patients’ disease for decades, the majority of people around the world living with the virus do not have access to ART and those that do, have over decades developed life-threatening side effects. Our inability to identify a cure to HIV lies not only in the as of yet failure of the medical research community to identify and develop appropriate means of ridding the body of the virus but also government and industrial policies that promote public opinion exclusively focused on chronic management scenarios instead of broadly exploring innovation for cure.

“An inconvenient truth” (Davis Guggenheim)

There are approximately 37 million people living with HIV and 39 million have died of AIDS-related diseases since the start of the epidemic in 1981. As of March 2015, only 15 million people have access to treatments for HIV. It is estimated that one fifth of people infected with HIV in the USA have not been diagnosed and only half the patients with access to ART in the USA take prescribed medication. Durable suppression of HIV is only achieved in 25% of the patients who are linked to medical care and receiving ART. The etiologies for these statistics are hotly debated but as concerning as these numbers are, they are likely to be gross underestimates of the magnitude of the global epidemic. As the majority of Americans are not routinely tested for HIV, the virus can go years without being diagnosed in an HIV positive person. With these statistics it is no wonder that every day an estimated 5,600 people globally become newly infected with the virus. Importantly, the statistics we are analysing are biased for populations who can or are willing to access HIV testing/treatment programs and where government policies or cultural beliefs allow the health status of individuals to be revealed.

Despite the research on HIV and AIDS from academic institutions, industry and advocacy groups and dedicated efforts of AIDS treatment activists that forced government policy for early and expanded access to experimental drugs, the medical community and society are struggling with the fact that we are barely managing the HIV epidemic and AIDS crisis. For years we have been locked into thinking of solutions in terms of a chronic disease with life-long treatment. The past 30 years in which anti- retroviral drugs

(ARV) have been identified and treatment modalities have been refined are remarkable in their success in prolonging the lives of people infected with HIV. These years also have the inconvenient truth that they reflect with one exception, the Berlin patient, failure to discover a cure or achieve sustained viral suppression without ever changing drug regimens.

Cocktails, cascades and a conundrum

At this time, decision makers speak of an ‘HIV Care Continuum’, underwritten as policy by a United States Federal initiative and supported by the Center for Disease Control (CDC) and the National Institutes of Health (NIH). This four-part recommendation includes comprehensive HIV testing and diagnosis, linking and maintaining all HIV positive individuals to a healthcare provider, providing all HIV positive patients with life-long access to ART and ensuring that for each patient, viral loads remain suppressed. The impracticality of this management model as a solution to the global AIDS pandemic can be appreciated in both social and economic considerations. In fact, while the ink is still wet on the HIV Care Continuum initiative, we already know that its goals are not broadly achievable due to significant attrition from care and treatment dubbed as the ‘care cascade’. Two potential limitations of the new policy are the magnitude of chemical production that will be necessary to meet the global demand for ARV (i.e. how do we produce this quantity of chemistry, for that many people, for all years that their disease will need to be managed) and an inadequate mechanism in place that can ensure long term compliance (i.e. uninterrupted access to healthcare and ART to a diverse global community with disparate education, infrastructure, cultural and religious beliefs). The limitations of this model will be exacerbated by the recent announcement from the World Health Organization (WHO) that they have reversed their policy from one of ‘don’t treat with ART until individuals become significantly immune-compromised’ to advocating that ‘everyone be given ART immediately after diagnosis’. The recommendations go further to include pre-exposure prophylactic

ART treatment (PrEP) for HIV negative individuals who are at high risk of infection. We now are faced with the conundrum of an expanded and global epidemic with a need to supply ART and access to medical care for decades on a planetary scale. Given the improbability of this course of action, discovering a cure to HIV/AIDS has to become an overriding priority.

A challenge to the imagination for those who could make a difference

Key opinion leaders (KOLs) have in recent years said that they now “dare to imagine” a cure yet others say we cannot go there because ‘there be dragons’ in charting a course to cure, i.e. a cure is not possible. The HIV community is encouraged by talk about HIV eradication but are confused over the course that is being prescribed. The negative outlook toward curing HIV/AIDS actually has held back adequate funding for cure research by actively discouraging it for many years as ‘intellectually unsound’. There is a peer review system comprised of experts from academia and industry that adjudicates and ranks research proposals submitted to government and private foundations. A majority of those who served in peer review have been in lockstep with the dogma that a cure was not possible and they put the ‘thumbs down’ on priority scores that determine grant funding for hypotheses for the eradication of HIV. Simply put, if one could not state a hypothesis for a cure, then specific research objectives could not be articulated in a funding proposal for testing opportunities to cure HIV. Eventually word got out and such ideas no longer were submitted for consideration or they were couched as being for therapy. In that way, KOL’s and rank and file scientists themselves influenced capitalisation and development of new concepts. I hasten to add that in this era gone by, had academic scientists inadvertently found a cure to HIV, it is unlikely that they would have suppressed findings simply based on government or foundation funding priorities. But cure has the potential of being a disruptive technology for the pharmaceutical industry and Wall Street. So it is not clear how industries would manage the impact of a cure on sales of lifelong ART that have held reliable billion dollar profits from the sales of so-called ‘block buster’ drugs.

“A rose by any other name would smell as sweet” (William Shakespeare)

Many members of the drug discovery and drug development communities remain astonished by the about-face that is now referred to as ‘cure research’. The past structure leaves many scientists uncomfortable with the direction for and implementation of this change in emphasis. The many years of the chronic therapeutic management mind set has left the map for ideation with many information voids. The years required for exploration have been squandered. Confusion is a typical symptom of deep shock that may explain why eradication research has become mired in a debate over what the word ‘cure’ means? Recent media blitzes have tragically rushed to be first to proclaim (define) a cure that turned out not to be. Trying to define cure as what can or cannot be achieved has been distracting. We certainly will know a cure when we find the overt evidence in someone like the Berlin patient.

We have to accept and stop arguing about whether a cure can only be ‘functional’ (no replicating virus detectable but genetic analysis will demonstrate the presence of HIV genomes) or what most would understand to be an absolute cure (the complete elimination of HIV genetic material from the patient’s body). Will a cure be achievable for everyone who has HIV or only possible for certain strains of the virus? Will a cure only be achievable for patients with particular genetic backgrounds? Can a cure be achieved that enables an ARTfree future or will there be a remission period that requires maintenance boosts over time? While one might speculate about the answer to these questions, a cure in any form MUST be acceptable, no matter how limited.

Learning from the past but encumbered by it

Eradication of HIV and prevention of new infections with the use of an HIV vaccine is a logical and appealing cure strategy that has been evaluated for many years. In fact, this has been the only ‘cure talk’ that was tolerated before the recent glasnost on cure research. A vaccine strategy that is capable of neutralising one or multiple strains of HIV and does so for extended periods of time has not been achieved. Clearly there is precedent in other diseases that justifies continued pursuit of a broadly neutralising vaccine strategy. These endeavours have yielded a fascinating understanding of the acquired immune system relative to HIV that may yet triangulate investigators toward a curative vaccine strategy.

Otherwise, cure research includes a reversal on the epidemic-long policy endorsed by government and industry to restrict innovation to new classes of drugs that interact with proteins and functions encoded solely by HIV. We know that HIV encoded functions must co-opt cellular and biochemical infrastructure and raw materials in order to replicate the virus. However, therapeutic strategies to thwart the virus by targeting pathways in the cell are discouraged and side lined with speculation that they might be fraught with adverse effects. The development of many experimental ARV compounds has in fact been suspended by the systematic and industrial application of these criteria.

This position only makes sense if one chooses to ignore the fact that most FDA-approved ARVs can have serious side effects that will almost certainly manifest in chronically treated patients.

For decades the efficacy of a new drug candidate has been assessed pre-clinically by the ability of HIV to evolve drug resistance to it in the laboratory. This policy is based on the premise that if a drug is interacting with an important viral target, the virus will figure out a way to become drug resistant. Said in a different way, all ARVs that have been brought to market are already known to select for minority subspecies of HIV and therefore they have anticipated ‘use until dates’ (i.e. not curative). The industry and venture capital firms demand this proof and failure to establish it evokes silence in the room.

These policies certainly will become fodder for future debates on how to eradicate HIV. Would a new drug that is curative be able to satisfy these criteria? The Berlin patient was cured of HIV while treating him for his cancer. Certainly cancer eradication is not without significant side effects and risks. One has to wonder whether taking a toxic drug for 6 months to a year might not be worth the potential of a life-long cure for HIV/AIDS? If the answer to this question is yes, then it evokes concern that the rubric we have been following for drug approval may be responsible for why a cure has never been found in the 30 years of ARV development?

Given the industry-wide position of ‘well tolerated’ new drugs, it is curious that there has been lightning-fast uptake of the concept known as ‘shock and kill’. The premise is that viral reservoirs (cells infected by HIV but not shedding virus) are the major reason why ART cannot eradicate HIV. In this strategy, viral reservoirs are forced to express HIV so that the body’s inflammatory and immune responses can identify and eliminate them. The drugs being evaluated in clinical trials are known as histone deacetlylase inhibitors (HDACi) and are a class of drugs that induce gene expression by changing the structure of human chromosomes. Although these drugs have clinical applications as mood stabilisers, anti-epileptics, anti-inflammatory and anti-cancer treatments, they are fairly toxic, and their effect is not limited to viral genes. The use of HDACi treatment in HIV patients has been pushed through to clinical trials despite significant concern and scepticism in the scientific community. The public media has hastily portrayed HDACi as a ‘cure’ drug because in clinical trials it induced expression of HIV (viremia) from viral reservoirs in patients whose viral loads would have otherwise been suppressed by the ART they were receiving. Further studies will determine whether the activation of viral reservoirs with HDACi, or by any other means, will safely destroy all viral reservoirs, prevent the induced viremia from forming new reservoirs and provide, potentially in combination with ARV, a cure?

Links in the chain of responsibility

New findings from university and biotech labs have been largely portrayed as academic and ignored by the HIV media, KOLs and pharmaceutical industry. These new ideas are the background noise for a select cast of speakers invited to HIV conferences. Federal and foundation research grants are very difficult to get and typically only support incremental discoveries. Moreover, research universities due to their non-profit tax status and professed need to protect their intellectual freedom, largely do not see it as their responsibility to do more than basic science, patent their ideas and wait for an industrial partner. Faculty and their students are generally discouraged by institutional policy from participating in contract research for drug development and cannot participate in commercialisation. Venture capital will not invest in new ideas unless there is a clear path (flip) to an industrial partner. Consequently ideas for cure (and therapeutics) at an early stage of development and the biotech companies bold enough to push them forwards are struggling in a financial ‘valley of death’. The HIV-positive population will continue to grow unless everyone takes responsibility for discovering a cure and the monopoly on resources is dispersed.

“When you come to a fork in the road, take it” (Yogi Berra)

It is essential that new research ideas and innovative approaches for cure are rapidly reviewed and diverse and divergent proposals become adequately funded so that they can be vetted, not lost in endless KOL debates in the media and at meetings on HIV/AIDS. Biotechnology needs to be preserved and the biotech industry should be facilitated under a mandate to bridge the valley of death for the development of ideas for eradication as a matter of government policy. Government relationship with the pharmaceutical industry and taxation policies need to change such that resource allocations are incentivised for the development of new ideas for eradication. Society should demand of governments, foundations and HIV advocacy groups to demonstrate the political will to create a new fund, one of military budget proportions, for the discovery of a cure(s) for HIV/AIDS so that we can truly win a global war on HIV rather than manage the engagement.

Dr. Harold C. Smith, Ph.D. is the founder, CEO and President of OyaGen, Inc, a biotechnology company in Rochester, NY USA dedicated to the discovery and development of novel therapeutic approaches and eradication strategies for HIV/AIDS based on APOBEC host cell, viral restriction factors. He also is a tenured full professor in biochemistry and biophysics at the University of Rochester, School of Medicine and Dentistry where he conducts basic research on HIV and RNA biology and mentors undergraduates and graduate students in research and critical thinking. https://en.wikipedia.org/wiki/Harold_Smith_(scientist)

Dr. Harold Charles Smith, Ph.D.

Founder, CEO and President

OyaGen, Inc

Tel: 1 (585) 697 4351

hsmith@oyageninc.com

www.oyageninc.com

Sexual Health: an integral approach

November 11, 2015

Martin van Rijn, State Secretary of Health, Welfare and Sport in the Netherlands highlights how in all their programs they aim to build awareness and resilience to sexual health problems.

In the Netherlands we have found that an integral approach is the best way to promote good sexual health. Sexual health covers much more than controlling sexually transmitted infections (STIs). Sexual health is about enjoying healthy relationships based on equality and being resilient. Sexual health is about access to reliable education and contraception; about the reduction of unintentional pregnancies and about combatting sexual violence.

The gains of this integral approach can be measured by the broad access to low-threshold facilities, by good comprehensive sexual education and by a relatively low number of teenage pregnancies and abortions.

This article focuses on the sexual health of young people. From the age of 12 until the mid-twenties, people undergo almost continuous and critical changes in their sexual development. In order to gain an insight of the state of the sexual health of young people, I have commissioned a program to monitor this group at 5 year intervals.

STI-clinics and local health authorities

At the base of the Dutch approach lies the regular health care system. General practitioners work according to standardised guidelines on sexual health. They offer STI testing and care, as well as referral to regular specialised help in case of unintended pregnancies, abortion or sexual violence. Additionally and in support of public health issues relating to infectious diseases I subsidise STI-clinics and sexuality counselling by local health authorities.

These facilities test for and treat STIs, including HIV, but they also deal with regular sexual health issues. Low-threshold help is offered free of charge, anonymously if needed. It is offered to targeted, well-defined high risk groups, vulnerable populations, young people and victims of sexual violence. STIs and HIV are not mandatorily reported diseases in the Netherlands, but thanks to the monitoring and registration at these sexual health care centres, we can gain a good insight into the incidence of STIs in key populations, including young adults. Other sexual topics can likewise be monitored. Moreover, local health authorities have customised their approach to fit the needs of young people by offering e-health facilities such as chat and email consultations.

Non-governmental organisation (NGOs)

Several NGOs receive government funding to support professionals in various settings of sexual health. NGOs, in cooperation with the local health authorities, provide comprehensive sexual education in schools. They have also developed educational resources about love, relationships and sexuality, such as the docu-series ‘Long live Love’. These resources address the needs of secondary schools but are adaptable to the needs of other schools, such as vocational institutions. The series covers issues such as puberty, falling in love, relationships, sexual diversity, safe sex, contraception among others, in an integrated way.

Another example is the widely appreciated television program ‘Dokter Corrie’ aimed at primary school children. The program dares to touch taboo issues in a humorous and respectful way.

NGOs have also developed specific resources for social media; some of which have received awards internationally for their innovative approach and broad reach. I am very proud of the recently international acknowledgement of the website www.sense.info, a website with interactive information on all sexual health related topics, inclusive the online game ‘Can you fix it’ in which youngsters themselves can direct the outcome of a film scene by changing the communication or behaviour of one of the actors.

The game was awarded the prestigious Lovie in the European online awards for winning gold as the ‘people’s winner’, as well as the jury’s silver award.

In all our programs we aim to build awareness and resilience, to allow young people to make informed and sensible choices, and to access reliable information and care when needed.

International awareness

I believe sexual health requires ongoing attention because young people continuously reach new milestones in their sexual development as they mature. Also internationally, sexual health needs constant awareness. In the first place because infectious diseases themselves are crossing borders, but also because sexual health is still a complex and difficult topic, not in the least because of cultural differences, association with shame and stigmatisation. This trend will only increase, because of the globalisation, with more people travelling, migrant problems etc. The subject also affects human rights, violence, human trafficking and infectious disease control.

Different countries need different solutions, but we can learn from each other. As a start, let’s all aim for meeting the goals set internationally by the WHO, UNAIDS and ECDC in the elimination of HIV. For instance, even though the Dutch are a worldwide exception to the rule of HIV being a notifiable disease, the Dutch approach of registration and monitoring of people in care is exemplary. All HIV-treatment centres enter patient data into a national registry guaranteeing a well-documented continuation of care. From this data, it is evident that the Netherlands meets the international goals.

In the same way, we are determined to achieve our aims of an emotionally and physically resilient, well-informed youth population in our own cultural setting.

Martin van Rijn

State Secretary of Health, Welfare and Sport

Ministry of Health, Welfare and Sport – Netherlands

www.government.nl

An action plan for a sustainable Stockholm

November 10, 2015

Katarina Luhr, Vice Mayor of Environment in the City of Stockholm outlines how they strive to become a truly sustainable city for generations to come.

Sweden’s capital city Stockholm has been working on climate change mitigation and adaptation since the 1990s. The city is a frontrunner, with well implemented climate action plans and pioneering policies to ensure it meets its ambitious environmental targets. It was the first city to receive the European Green Capital award by the EU Commission in 2010. The Award acknowledged the change of mind set in policy making that had long been evident in the city’s administration. Subsequently, environmental policies have become even more prioritised and sustainability is now an integral part of all strategies and city planning.

In February 2009, Stockholm signed the Covenant of Mayors. This agreement commits cities in Europe to work to reduce greenhouse gas emissions to a greater extent than required by the EU. Stockholm’s carbon dioxide emissions per capita have been cut by 25% since 1990 and the city is now going to reduce its greenhouse gas emissions further – to 2.3 tonnes per capita/year by 2020 and to become a fossil fuel free city by 2040.

The climate and energy action plan describes how this goal is to be accomplished, detailing measures that provide the greatest reductions. A significant portion of the projected CO2 reduction relates to the district heating system in Stockholm which currently utilises different kinds of waste and increasingly biofuels, replacing fossil fuels for energy.

The city’s position in northern Europe puts tough demands on heating. Stockholm has chosen to invest in district heating and biofuels, the district heating grid dates back more than 50 years and covers 80% of all buildings in the city. A biomass-fuelled heating plant will come online in 2016 with a capacity for heating 190 000 homes whilst producing 750 GWh of electricity and reducing CO2, equivalents by 120 000 tonnes.

By increasing the ratio of olive in the energy mix in another plant, the portion of coal being used can simultaneously be reduced, lowering CO2 emissions by another 50 000 tonnes of CO2 equivalents. New business models for recovering energy previously going to waste were recently introduced through the Open District Heating market which enable businesses with a large surplus of heat, such as data centres and grocery stores, to sell that energy to the district heat producer.

Stockholm has also set the goal of having at least 70% of the city’s food waste to be collected for the production of biogas by 2020. The gas can be used to replace natural gas in the city’s gas network as well as fuel for vehicles. Currently there are more than 300 buses, as well as all refuse freighters and approximately 10.000 cars including most taxies in the city fuelled by biogas.

Successful tests have been conducted using green bags for food waste. The bags are disposed of along with the rest of a household’s waste with sorting taking place at a later stage at a new facility which allows for optical sorting of waste bags. This site has been commissioned and planned to be built over the coming years.

The Eco city district Hammarby Sjöstad is based on a closed eco-cycle in which waste and energy consumption is minimised and recycling is used whenever possible. The target is for the environmental impact to be cut by 50% as compared to conventional standards. Currently the next generation of eco city districts – the Stockholm Royal Seaport – is being developed in a former industrial and port area. Plans are under way for 12,000 new housing units and 35,000 workplaces that will be combined with modern port operations. The area has even higher environmental requirements than Hammarby Sjöstad and the target is to be fossil-fuel free by 2030. Innovative green technology will enable residents to manage their own energy consumption using their smart phones. Effective public transport and car pools will make it easier for residents to cope without a car of their own. Garages will have charging posts for electric cars and kitchens will be equipped with a waste disposal unit that turns food scraps into raw materials for biofuels.

The Stockholm Biochar Project is another example of how the city engages its citizens and it will use waste from parks and gardens to produce biochar and renewable energy. Biochar is not just a carbon sink but also a fantastic soil conditioner that retains water, air and nutrients in the soil. The energy released in the production process becomes heat for the city’s district heating network within the Open District Heating mentioned previously. The city will also expand the hours and areas of operation for mobile recycling centres making it easier for citizens to reuse and recycle different items but also to leave the garden waste for biochar production.

Katarina Luhr

Vice Mayor of Environment

City of Stockholm, Sweden

www.international.stockholm.se

Gender pay gap means women work for nothing until 2016

November 9, 2015

A campaign group has highlighted the plight of women workers, warning those in full-time employment will in effect work for nothing between now and 2016.

The debate over women’s pay is nothing new, but it certainly is an issue that has been at the forefront of discussion recently.

According to official figures, men earn 14.2 per cent more per hour than women. However, while the gap is showing signs of narrowing, campaigners warn it is not closing fast enough.

Equal Pay Day is set at the point of the year when the average woman in effect stops being paid compared with the average man. This year, the date is five days later than in 2014, but it is still a stark reminder the pay gap is significant.

The Fawcett Society, which campaigns for women’s rights in the labour market, said while progress has been seen the current rate of change means it will take around 50 years to close the pay gap.

Chief executive of the Fawcett Society Sam Smethers said: “There has never been a better opportunity to close the pay gap for good.

“Progress has stalled in recent years but with real commitment for government and employers, together with action from women and men at work, we could speed up progress towards the day when we can consign it to history.

“It is time to have the conversation and ask your employer if they are ready for the new pay gap reporting requirements.”

The results were further supported by a report from trade union TUC. This revealed the pay gap was even more pronounced among high earned. Figures showed the top five per cent of earners saw men earn 45.9 per cent more than women. Among the top two per cent this difference grew to 54.9 per cent.

General secretary of the TUC Frances O’Grady said: “It is shocking the UK still has such a large gender pay differences at the top of the labour market after more than four decades of equal pay and sex discrimination legislation.

“We need pay transparency, equal pay audits and a requirement on companies to tackle gender inequality – or face fines.”

How Europe should act on childhood obesity

November 6, 2015

Nikolai Pushkarev, Policy Officer at the European Public Health Alliance (EPHA), outlines the importance of tackling obesity in children.

We are drowning in declarations, strategies and action plans dedicated to tackling the problem of obesity.[1] But today, about 40 years after the start of obesity’s spectacular ascent, the World Health Organisation (WHO) still concludes that being overweight is on the rise in all European countries. [2] Obesity has increased to over 20% of the EU population, with over half of Europeans now overweight. Obesity is a risk factor for major chronic diseases, like diabetes, cancer and cardio vascular disease. It also leads to psychological suffering, affects productivity and drains health systems.

Obesity is not an individual choice. Childhood obesity, a condition now shared by a third of 11-year-olds, even less so.[3] Most cultures see the child as especially worthy of protection. We attribute to children a sense of innocence and vulnerability and invest in them the hope that they may lead more accomplished lives. According to opinions within WHO, future generations may, for the first time in modern history, face a life expectancy lower than our own.[4]

So what should the EU do to tackle childhood obesity, a condition many consider particularly unfair?

The European Commission should target childhood obesity to mobilise support for policy intervention. At the same time policy-makers must realise that an effective response cannot be limited to actions aimed at children only. Children grow up in societies, not in regulatory silos. Childhood obesity already starts in the womb. [5], [6], [7] As it is impossible to fence off children from environments that consistently promote unhealthy behaviours, these environments themselves must change. Such a transition is vital to achieve meaningful progress in rolling-back the tide of obesity.

The European Commission should abandon its over reliance on self-regulatory approaches. After over a decade of the voluntary approach – see e.g. EU Platform on Diet and Physical Activity – the figures for obesity speak for themselves, particularly for children: Self-regulation has failed. Even with the best intentions it involves a conflict of interests that is practically impossible for companies to overcome. Industry members will often say they need more time to reformulate, diversify product portfolios, to shift the focus of advertising. But time is quite a lot to ask for when limited in supply. At the end of the day, will food producers not be relieved from insecurity if an equal level playing field, high in public health, is set at European scale? They can then focus on their core business and innovation.

The European Commission must facilitate Member States’ experimentation with public health measures. We already know quite a bit about what types of measures will succeed in promoting public health. Too often the Commission is more eager to protect the internal market than people’s wellbeing. So Finland was recently warned about its ‘candy tax’, which it subsequently repealed despite health benefits.[8] Rather than issuing such warnings, a more constructive way would be to work with countries to improve national laws thereby assisting authorities live up to their commitments before citizens.

A very practical opportunity to act presents itself with the revision of the Audiovisual Media Services Directive. This instrument can be significantly enhanced to protect minors from exposure to the insidious effects of marketing of high fat, sugar and salty foods. The food industry has already applied its technique of diversion by launching a new, extended version of the voluntary “EU Pledge”. The main objective of the Pledge is not to protect children – witness that ads for sugar-pumped cereals and fizzy drinks still relentlessly reach our kids – but to fend off regulation. The European Commission should not again fall into the trap of such delaying tactics. Another opportunity for action is to restrict the use of trans-fatty acids in food. Several European countries are introducing national bans. In October 2015, in an unprecedented move, public health and consumer groups together with some of the world’s biggest food producers wrote a common letter asking the European Commission to follow suit at EU level. The harm from trans-fats is undeniable and directly linked to obesity and cardio vascular disease, and particularly affects disadvantaged socio-economic groups.

Finally, the European Commission should show intellectual leadership on public health. It should, as promised, come forward with a comprehensive, prevention-oriented Framework on Non-Communicable Diseases and start drawing the incoherent policies governing the food system into a sustainable, health-compatible policy on agriculture and food. Then it will give true meaning to the “Health in All Policies” obligation contained in the European Treaties.

[1] See for instance: EU Action Plan on Childhood Obesity; EU Health Strategy “Together for Health,” Community Strategy on “Nutrition, Overweight, and Obesity-related Health Issues”

[2] WHO (2015) European Health Report 2015

[3] WHO European Childhood Obesity Surveillance Initiative (COSI)

[4] Boseley, S. (2015) Young Europeans may die at earlier age than their grandparents, says WHO. The Guardian

[5] Lobstein, T. et al. (2015) Child and adolescent obesity: part of a bigger picture. The Lancet

[6] Hirst, J.E. et al. (2015) Preventing childhood obesity starts during pregnancy. The Lancet

[7] Gugusheff, J.R. et al. (2012) A maternal “junk-food” diet reduces sensitivity to the opioid antagonist naloxone in offspring post weaning. The Journal of the Federation of American Societies for Experimental Biology

[8] Gray, N. (2015) Finland set to scrap tax on sweets and ice cream. FoodNavigator.com

Nikolai Pushkarev

Policy Officer

European Public Health Alliance

Tel: +32 22 333876

nikolai@epha.org

www.epha.org

Drought, Food, and Trees

October 28, 2015

As we consider the challenges that global climate change poses for food security, it is insightful to look at past episodes of food insecurity for possible solutions that can be adapted to current situations or for any mistakes made and lessons learned. Historically, one of the major causes of food insecurity has been crop failure due to lack of rainfall. In some regions, droughts are infrequent and/or short and less severe while, other regions are more drought-prone in both number and severity. The steppes of Russia are one region known for the frequency and severity of drought conditions that often resulted in extensive famine and human suffering. It was another drought-induced crop failure that led to important developments for agroforestry.

In response to yet another drought and subsequent famine in 1891 that affected over 30 million people, a scientific expedition was dispatched to the drought-stricken region of Russia. The objective given to the expedition team was that of alleviating drought conditions and reducing the risk of future famines. The leader of the 39-member expedition was Vasily V. Dokuchaev, a renowned geographer who was highly regarded within the Russian scientific community. Dokuchaev observed that precipitation in much of the steppe region was marginal for small grain production and naturally inconsistent. If the essential summer rains failed to come or sukhoveys (“thirsty winds”) blew in from more arid regions to the southeast, complete crop failure was often the result.

Dokuchaev quickly designed a plan to address drought alleviation that focused on maximizing the capture and storage of precipitation to be used for crop growth. In addition to using small dams and other practices to reduce runoff, targeting land use based on soil conditions, and enhancing crop selection, he also encouraged the planting of tree windbreaks. The windbreaks were designed to conserve moisture by reducing heat stress, providing physical protection from the sukhoveys, and capturing snow in winter that would melt and become available for crop growth in the spring. By 1900, over 130,000 hectares of windbreaks had been planted and the practice continued to expand throughout the region in the 20^th century.

In the 1930’s, it was the U.S. Great Plains in the grip of a prolonged drought that again resulted in decisive action by a national government. The Prairie States Forestry Project (PSFP) was developed and managed by the U.S. Forest Service to control wind erosion and alleviate drought conditions in six plains states. In 1935, “Possibilities of Shelterbelt Planting in the Plains Region” was published as a comprehensive feasibility analysis for tree windbreak planting across the drought-affected areas. Over the next 7 years 217 million trees were planted in 30,000 km of windbreaks from the state of Texas to the Canadian border in the largest single afforestation project in U.S. history. One of the key figures behind the planning and implementation of the PSFP was a forester named Raphael Zon. Zon was born in Russia in 1874 and was familiar with the work of Dokuchaev and windbreaks on the Russian steppes. It was the demonstrated success of the extensive windbreak planting in Russian, which studies have shown increased crop yields by an average of 15% that led Zon to champion a similar strategy for the drought-stricken U.S. Great Plains.

Dokuchaev’s role in encouraging the establishment of tree windbreaks to modify the local microclimate in not well-known. However, he is widely-recognized as the founder of modern soil science. His 1883 publication “Russian Chernozem” is considered a seminal contribution to the science of soils. He developed the characterization of soils as embodying the unique influences of 5 soil-forming factors: time, parent material, topography, organisms, and climate. The focus on interaction among the 5 factors embodies the ecosystem perspective that is needed for effective land management. A comprehensive ecosystems perspective is essential as we develop climate change mitigation and adaptation strategies in the 21^st century. We can use the efforts of Dokuchaev and Zon as examples for successful project development relying on science-based and comprehensive research, planning, and implementation.

Dr. Thomas J. Sauer

Research Leader

Supervisory Research Soil Scientist

U.S. Department of Agriculture

Agricultural Research Service

National Laboratory for Agriculture and the Environment

2110 University Boulevard

Ames, IA 50011-3120

Voice (515)294-3416

Fax (515)294-8125

Email tom.sauer@ars.usda.gov

http://www.ars.usda.gov/pandp/people/people.htm?personid=47746

WHO says processed meat is carcinogenic

October 26, 2015

A new report published by the World Health Organization has classified processed meat as carcinogenic to humans.

To the discerning meat eater there is nothing better than a bacon or sausage butty to start the day. However, a new report released today will classify these types of processed meats as dangerous, placing them in the same category as cigarettes, arsenic, and asbestos.

Bacon, ham, and sausages are among the meats included in this report from the World Health Organization (WHO), but fresh red meat does not come off well either, as it is deemed to be “probably carcinogenic”.

The WHO said 50g of processed meat a day saw the chances of developing colorectal cancer increase by 18 per cent.

The news is not the first time meat has come under fire. The links between cancer and eating red meat has been brought up repeatedly over the years, with the World Cancer Research Fund warning there is “strong evidence” that eating lots of it can lead to bowel cancer. It is thought the organic pigment in red meat known as haem may damage the lining of the bowel.

Additionally, researchers believe meat that has been smoked, cured or salted can also increase the chances of developing cancer.

Despite these warnings the report notes the findings do not mean people who eat a lot of processed meat are as likely to develop bowel cancer as those who smoke are to get lung cancer. However, it warns people should limit the amount of processed and red meat they eat.

Sarah Williams, of Cancer Research UK said: “The announcement from the WHO deals with how certain we can be – so it’s how strong the evidence is, rather than how big a risk red and processed meat might pose.

“Certainly Cancer Research UK’s opinion is that eating red and processed meat isn’t anywhere near as risky as smoking.”

Dr Kurt Straif, of the WHO said: “For an individual, the risk of developing colorectal (bowel) cancer because of their consumption of processed meat remains small, but this risk increases with the amount of meat consumed.”

The news will undoubtedly be a blow for the farming sector, which has already faced numerous struggles in the past few months over the price of produce. The National Farmers’ Union said people should moderate the amount of red meat in a balanced diet and warned against “polarising” health advice.

Is nuclear energy the answer to climate change?

October 23, 2015

Dr Jonathan Cobb, Senior Communications Manager at the World Nuclear Association details why nuclear power could be part of the solution to tackling climate change.

From 30th November, for 2 weeks, thousands of negotiators will meet in Paris for the COP21 climate change conference. They will be joined by tens of thousands more delegates representing non-governmental groups such as environmentalists, businesses, scientists, women, trade unions, youth and religious leaders, along with thousands of journalists. If these people genuinely wish to save the climate, they had best give serious consideration to the future role of nuclear energy.

The COP21 organisers describe the event as crucial, as it needs to achieve a new international agreement on the climate, applicable to all countries, with the aim of keeping global warming below 2°C. A key feature of the latest agreement are Intended Nationally Determined Contributions (INDCs), where governments have declared in advance what steps they are committed to taking to combat climate change. A rather big problem is that the INDCs declared so far do not go far enough.

Many of the INDCs include a description of what each government plans to do in the energy sector, in particular for electricity. Globally, electricity and heat production account for more than 40% of CO2 emissions. That is because much of the world’s electricity is currently generated by burning fossil fuels. However, electricity generation is an important focus for climate efforts, as it is one of the few major sectors where proven technologies are available that can reduce greenhouse gas emissions by the required amount.

According to the latest available data the largest single source of low carbon, non-fossil electricity generation is hydropower, supplying around 16% of the world’s electricity. Second comes nuclear energy, generating about 11% with renewables other than hydro such as wind, solar and biomass, generating around 6%. In combination about one third of global electricity comes from these low carbon sources.

Some countries have already shown the potential to achieve much greater use of low carbon electricity in their electricity generation mixes. Brazil, Sweden, Switzerland and France have all reduced reliance on fossil fuels to less than 20% of supply, as has the Canadian province of Ontario. This has been achieved through combinations of nuclear, large hydro and other renewables.

Generation mixes with low greenhouse gas emissions

Other sectors may prove a lot harder to decarbonise, which places the onus on the electricity sector to lead the way. Electricity may also be used as an alternative energy source in these other sectors. Transport for example is another major source of greenhouse gas emissions. Electric cars are progressing to be a real alternative to petrol and diesel, but to maximise emissions reductions the additional electricity demand needs to be met by low carbon generation. Electric trains require the same. Those traveling to the Paris climate conference by Eurostar will be taking advantage of France’s low carbon generation, primarily from nuclear power plants.

One question sometimes raised is whether all these low carbon generation options are truly low carbon, when the full life cycle of the technology is considered. Nuclear generation, for example, relies on the production of nuclear fuel. Similarly, wind turbines have to be manufactured and then supported by concrete foundations. Large hydro schemes often require flooding of areas of vegetation, which releases methane, a much more powerful greenhouse gas than carbon dioxide. All these activities either may release greenhouse gases, or require energy which may come from fossil fuel sources.

However, many studies show (including our own review of the literature) that the lifecycle emissions for nuclear energy and different forms of renewables, are much less than the emissions arising from burning coal, oil or gas in fossil fuel power plants.

The IPCC notes that “The life cycle GHG emissions per kWh from nuclear power plants are two orders of magnitude lower than those of fossil fuelled electricity generation and comparable to most renewables”

It is necessary to use all available low carbon energy options to achieve the emissions reductions required to avoid the worst effects of climate change. The International Energy Agency has produced a scenario showing what would be required to limit the average level of global warming to 2 degrees Celsius. By the end of this century fossil fuel generation will need to be all but eliminated, with significant reductions by 2050. Nuclear generation is the largest single source of low carbon electricity in this scenario, with an installed capacity of 930 GWe by 2050, up from around 370 GWe today.

The task for governments is not only to agree emissions targets in Paris this December, but also to enact effective policy measures to ensure those targets will be met. Negotiators need to know that nuclear energy is part of the solution to climate change.

Dr Jonathan Cobb

Senior Communications Manager

World Nuclear Association

world-nuclear.org

Are teachers under too much pressure?

October 22, 2015

Unions warn teachers are under so much pressure they are being “reduced to tears”, highlighting yet another difficulty facing the sector.

It certainly seems as if the education sector is in disarray lately. Last week it reported difficulties retaining staff, with teachers leaving in droves. In a leaked letter, it was revealed the situation has become so dire the Department for Education is seeking teaching staff from overseas.

There is no question teachers are under a significant amount of pressure to do more with less, as are most of the public sector. However, as class sizes continue to grow and workload continues to creep, the pressure will increase. In a sector already pushed to breaking point it is difficult to see how much more teachers can take.

This is not the first time the difficult workload facing teachers has been under scrutiny. Teachers are known for working long hours, preparing lessons at home and marking work all weekend. However, the response to this is usually about the number of holidays teachers get in the year. No one stops to consider the fact teachers will work through most of their time off when they should be recharging their batteries. Why is this the case? Why do we expecting such unrealistic dedication from the profession?

There is something fundamentally broken in the system and it has to change. It is becoming a worrying trend that some of the most talented teachers across the country are leaving the profession due to a poor work-life balance and increasing stress.

General Secretary of the Association of Teachers and Lectures (ATL) Mary Bousted revealed this is certainly the experience she has had. She warned the workload facing teachers was leaving some staff in tears and unable to cope with the stress.

Bousted also said it was concerning that high stress levels were now considered part of the job.

She cited an example of a newly qualified teacher who had asked for help with an impossible workload. The new teacher was working until 11pm each night and all of the weekend. The teacher was told “that’s the way teaching is.”

It is this acceptance of the situation that continues to drive the idea it is acceptable for staff to work seven days a week. It is hardly surprising a vast number of teachers are leaving for greener pastures—or at least for professions that give them time to sleep.

Bousted said: “Teachers, as professionals, expect to work hard but should not be expected to devote every minute of their lives to their work.

“Teachers need time to relax, to pursue hobbies, to talk to their families and friends. They need time to be human.”

And this is the crux of the matter: teachers are entitled to a life. The sector is currently failing to provide this, and while the government is seeking to find a way to reduce workloads it seems like a case of too little, too late.

General Secretary of the Association of School and College Leaders (ASCL) Brian Lightman also shared Bousted’s views. He said: “It’s essential that we all pay attention to the well-being of staff. That’s a shared responsibility between colleagues of the same level, middle leaders, senior leaders and governors, who ultimately carry the duty of care.”

As the number of pupils needing school places continues to grow the situation is only going to get worse. Falling numbers of teachers undertaking training and vast numbers leaving the profession is creating the perfect storm for the education system to come to its knees. If Britain wants to continue to be successful, to promote social mobility, to be innovative it must take the education of the next generation seriously. To do this the country must train, but most importantly retain quality teaching staff. This will require a significant overhaul of the profession, starting with the amount of work expected.

£500m for heart disease research

October 19, 2015

Cardiac charity the British Heart Foundation has revealed it will pump £500m into researching heart disease.

A new strategy launched by the British Heart Foundation will pump hundreds of millions of pounds into cardiovascular disease.

The move was made after an independent analysis revealed a significant disparity between the amount spent on researching heart disease and the cost of the condition in the UK.

Recent figures showed the number of cardiovascular events across the UK in 2013/14 totalled 1.7 million.

Additionally, over the past decade there has been a 10 per cent rise in the amount of cardiovascular events. However, despite this fact only nine per cent of funding is set aside for heart disease.

With more than seven million people living with some form of cardiovascular disease more funding is needed.

BHF Medical Director Professor Peter Weissberg said: “Research has provided the health service with the tests and treatments used every day to tackle heart disease.

“That progress, powered by BHF-funded research, has meant deaths from cardiovascular disease have more than halved in the UK since the BHF was founded.

“Despite this there are still seven million people in the UK living with cardiovascular disease, which blights their daily lives and makes them fearful for the future. And it is only through research that we can hope to reduce this burden.

“This new analysis of research funding is a stark reminder of the importance of the BHF in fighting cardiovascular disease.

“Our new research strategy outlines how over half a billion pounds will be spent over the next five years but progress will only continue with support from the public, the sustained financial input from the Government and close collaboration between all medical research funders.”

Tackling cancer in children and adolescents

October 19, 2015

Professor Giles Vassal, President of the European Society for Paediatric Oncology outlines why it is crucial for Europe to come together and tackle and prevent cancer in children.

Compared to the incidence in adults, cancer is rare in children and adolescents but concerns 35,000 young people each year in Europe. Despite high survival rates (80% of them are disease free at 5 years) – thanks to high quality academic clinical research run by the European community over the last 4 decades – cancer remains the first cause of death by disease beyond 1 year of age. 6,000 children die each year. In addition, two thirds of childhood cancer survivors have long term sequellae of their treatment. There are more than 300,000 European citizens who are childhood cancer survivors.

Cancer is still a major health issue for young people in Europe that needs to be tackled by all stakeholders.

SIOPE – the European Society of Paediatric Oncology – just launched its 10 years strategic plan to increase both cure rate and quality of cure, as well as to tackle inequalities across Europe. It is crucial that policy-makers at the European and national levels make the right decisions and set up the legal environment that will make this European Cancer Plan for children and adolescents a success.

The Plan was first elaborated within the ENCCA network of excellence (European Network for Cancer research in Children and Adolescents, FP7 2011-2015), and enriched through the contributions of SIOPE members and partners, as well as parents, patients, and survivors’ advocates. At the conference ‘Joining efforts for a brighter future for children and adolescents with cancer – The European roadmap to Horizon 2020’ (18-19 September 2014, Brussels) approximately 160 participants from 31 countries publicly endorsed the proposal and called for a European Cancer Plan for Children and Adolescents that would address both clinical care and research.

The ultimate goal of the SIOPE Strategic Plan is to increase the survival that is free from disease and late effects- after 10 years from the disease (and beyond) by achieving the following 7 objectives:

1 . Innovative treatments: to introduce safe and effective innovative treatments (i.e. new drugs, new technologies) into standard care;

2. Precision cancer medicine: to use improved risk classification as well as biological characteristics of both the tumour and patient (such as molecular and immunological factors) to help guide decisions on which therapies to use;

3. Tumour biology: to increase knowledge of tumour biology and speed up translation from basic research to clinical care to benefit patients;

4. Equal access: to bring about equal access across Europe to standard care (in both diagnosis and treatment), expertise and clinical research;

5. TYA: to address the specific needs of teenagers and young adults (TYA), in cooperation with adult oncology;

6. Quality of survivorship: to address the consequences of cancer treatment such as long-term side effects, to better understand the genetic background/risk of an individual, and to improve quality of life of childhood cancer survivors;

7. Causes of cancer: to understand the causes of paediatric cancers and to address prevention wherever possible and answer the question: “Why did my child get cancer?”

Cross-tumour platforms and projects are being set up to facilitate the Plan’s implementation spanning the critical variables influencing success, such as outcomes research to monitor progress made, a platform to provide radiotherapy quality assurance, a multi-stakeholder platform with academia, industry, regulators and parents to improve paediatric development of new oncology drugs, as well as a research program to address ethics and psycho-social aspects of childhood cancer.

A European Reference Network will be created to facilitate cross-border healthcare and access to expertise for paediatric cancer patients across Europe no matter where they live. An efficient e-Health infrastructure is set to support such system building on the ExPO-r-Net project.

The ‘Oncopolicy’ programme will advocate better EU policies to address the needs of young people with cancer. Indeed, SIOPE will help the implementation of cross border clinical trials within the new Clinical trial regulation and advocate for a Data Protection regulation that will not jeopardise research efforts for children and adolescents while assuring privacy to all citizens. The implementation of the EU paediatric medicine regulation must urgently be improved in order to adequately address the needs of children with cancer. Specific new incentives might be required.

SIOPE will steer and coordinate the effective implementation of this Plan, together with all stakeholders; existing partnerships will be strengthened with adult oncologists as well as professionals from other continents, while public-private partnerships – recognising the specificities of paediatric haematology-oncology – will be established with industry. SIOPE established a partnership with Childhood Cancer International, the federation of parents, patients and survivors organisations to implement the Plan.

The SIOPE Strategic Plan was officially presented during the European Cancer Congress (25-29 September 2015, Vienna, Austria), and will be also further discussed at the EU-policy level during an event which will take place on 18th November 2015 at the European Parliament in Brussels, Belgium (more information: www.siope.eu/?p=3428 ).

We trust that this Plan will inspire many future initiatives in the field. It has to date already achieved an important milestone of broad multi-stakeholder consensus and we look forward to working with all relevant stakeholders to make it a success, preparing a brighter future for children and adolescents with cancer in our region.

Discover the SIOPE European Cancer Plan for Children and Adolescents here: www.siope.eu/SIOPE_StrategicPlan2015

Professor Giles Vassal

President

European Society for Paediatric Oncology

Tel: +32 2 775 0212

office@siope.eu

www.siope.eu

Top company for apprenticeships named

October 16, 2015

Ernest & Young has been named the UK’s top firm for apprenticeships in a new survey…

Rate My Apprenticeship’s annual survey has named Ernest & Young the highest ranking firm for apprenticeships.

The Top 60 Employers Table was drawn from over 2,500 reviews written by students. It ranks organisations that have at least 10 reviews on the website.

The survey, which offers insight into the status of training across the UK, revealed that more than 50 per cent of parents and teachers want to see compulsory apprenticeship targets. This would apply to the number of under-25s taken on by firms.

Ernest & Young currently has over 100 people on training programmes at any one time. Students involved in the survey gave feedback on areas such how valued they felt within the company to how much they earn.

Maggie Stilwell, Managing Partner for Talent in the UK and Ireland, EY, said’: “Our number one ranking is a great achievement and it demonstrates just how much our trainees and interns value their experience with us.

“We have invested heavily in our school-leaver programme since its launch three years ago, and a key part of that has been listening to and acting on feedback from our trainees, as well as involving them in shaping their own training and development.

“This not only helps us to stay competitive, but also ensures our trainees are prepared for a successful career in business.”

The respondents gave an interesting insight into who is responsible for recruiting young people. A total of 32 per cent said pupils, 50 per cent parents, 44 per cent teachers, and 48 per cent of businesses said employers were responsible. A total of 51 per cent agreed schools should be doing more to tell pupils about non-traditional routes into employment.

Ollie Sidwell, co-founder of RateMyApprenticeship.co.uk, said: “The Top 60 Employers Table is a great chance to celebrate and reward those companies that are leading the way in this area and really providing opportunities for the next batch of talent, across the UK.

“In the last year EY has demonstrated their commitment to their school leaver programmes and the benefit it has, not only to the company, but to their industry as well.

“EY has become a great role model for companies looking to do the same.”

He added: “The latest apprenticeship report from IPPR suggests that apprenticeship figures have become heavily skewed towards older workers – as the UK’s voice for student apprentices, this is shocking.

“A quota on the number of under-25s on company programmes would help raise the bar, but it shouldn’t be seen as a tick list process.

“Targets could be a good way of ensuring that all school leavers have the opportunity to choose the path that’s right for them.

“Eventually this broadening of choice could mean that more women and those from ethnic minorities will end up in the boardrooms of the UK’s top companies and everyone can play a part in making this a viable option for young people.

“Young people now have more opportunities than ever to make an excellent start in the world of work and they can do so in the knowledge that non-academic routes are no longer seen as the poorer cousin of traditional degrees”.

Can TB be eliminated altogether?

October 16, 2015

Dr Masoud Dara, Senior Advisor at the World Health Organization explains the challenges of tackling TB to Editor Laura Evans, and why antibiotic resistance is such a problem…

According to the World Health Organization, infectious diseases are caused by ‘pathogenic microorganisms, such as bacteria, viruses, parasites and fungi. Such diseases can be spread from person to person, directly or indirectly. Tuberculosis, measles, meningococcal meningitis, chikungunya virus, malaria, plague, HIV/AIDS, rubella, and viral hepatitis all fall under the category of infectious diseases.

Tuberculosis (TB) in particular is a global public health threat which resulted in 1.5 million deaths in 2013 and caused 9 million people to fall ill in the same year. Editor Laura Evans spoke to Dr Masoud Dara from the World Health Organization Regional Office for Europe about tuberculosis (TB), and what the main challenges are in regards to treating this infectious disease.

“There is good news and bad news when we’re talking about TB,” explained Dr Dara. “The good news is that through effective implementation of the WHO recommended strategy, 37 million lives were saved between 2000 and 2013 in the world and the number of TB cases is reducing in Europe. In the last 5 years we have noticed a 6% annual decrease, which is the fastest decline among all WHO regions.

“The bad news, however, is that the rate of drug resistance among new cases is on rise. This form of the disease is very difficult to cure.”

Tackling tuberculosis has become a major public health priority and Dr Dara believes that infectious diseases can be treated by “breaking the transmission cycle”. He believes that it is crucial at a policy level that infectious diseases such as tuberculosis become a priority for governments worldwide, translating to adequate human and financial resources are needed to move towards eliminating the disease.

“If you do not invest now you have to spend much more in the future,” he adds.

“Every case that is not treated correctly is going to infect 10-15 people per year – that’s why it’s important to scale up targeted activities to detect and cure all cases now. TB prevention and control programmes are very cost effective. A recent analysis published in the Economist presented TB control interventions as the fourth most effective value for money intervention to reach the Sustainable Development Goals1 with every $1 spent leading to $43 saving.”

Most people with TB are cured with a 6 month treatment regime, and in many countries 80-90% of people are successfully cured following the recommended treatment. However, drug resistance can occur if medicines not taken properly or are of poor quality. Under these conditions, amplification of resistance can occur and multidrug resistance tuberculosis (MDR-TB) can emerge, which is a form of the disease, resistant to the two most important medicines we have. Resistant strains can then be transmitted to others particularly in crowded settings such as prisons or hospitals, leading to further spread of the disease.

“If the patient has MDR-TB then they need further treatment which can last up to 2.5 years,” says Dr Dara. “This treatment is with 6 or 7 drugs and there can be many adverse events – including suicidal thoughts, liver damage and hearing problems. Due to these side effects, patients often stop the treatment or only take some of their medicines, which can make it even more difficult to treat.”

In 2013, 480,000 people developed multidrug-resistant TB in the world. Currently only half of those patients are successfully cured. It is believed that $2bn per year is needed to fill the resource gaps for implementing the existing TB interventions.

“The treatments success heavily depends on whether you have good diagnostic tools to rapidly detect resistance,” says Dr Dara. “Time is very precious in terms of diagnosing the right pattern of resistance to give the right treatment. If the patient is given treatment that is not based on the resistance pattern, you could create more resistance. This is then called amplification, which you need to avoid because it will lead to more and more resistance and the patient will have no options for treatment.”

In September the World Health Organization launched a new End TB Strategy. The new agenda highlights strategic directions to integrate digital health into TB prevention and care activities.

“The End TB Strategy is quite important and has 3 main pillars to focus on,” explains Dr Dara. “The first is ensuring the best care is given to patients, and all patients. The second is making sure you have a patient-centred health system and supportive environment which can cater for the patient’s needs.

If the patient has to travel and get a bus every day for treatment for example, that could lead to interrupting the treatment.”

Another very important aspect is special support such as nutritional and psychological support to help patients finish their treatment. The third pillar of the End TB Strategy is research and development. Dr Dara emphasises that it is extremely important to scale up research and development for new tools particularly a new effective vaccine and shorter and more effective treatment regime.

“In WHO Office for Europe we have worked with our Member States and partners and adapted the End TB Strategy to the Regional context and prepared a 5 year Tuberculosis Action Plan 2016-2020 with even more ambitious targets than those of the global level. The 65th WHO Regional Committee adopted this plan on 17 September 2015. Together with our partners, we will assist the Member States to implement the Plan.

“The main goal is to decrease TB rates faster and improve treatment outcomes of all TB cases, which are achievable if all countries fully implement the Action Plan” he says.

The question stands as to whether we can eliminate TB altogether, and Dr Masoud is hopeful. Elimination would be less than 1 TB case per million of the population, he believes that to reach this we need substantial increase in investment in research and development for new tools including new vaccines and rapid access to them across the world.

1 The economics of optimism, The Economist 24 January 2015 http://www.economist.com/news/finance-and-economics/21640361-debate-heats-up-about-what-goals-world-should-set-itself-2030

Dr Masoud Dara

Senior Advisor

World Health Organization

MDD@euro.who.int

www.euro.who.int

Crossrail is creating a skills vacuum

October 16, 2015

According to new analysis, Crossrail’s demand for skilled workers is leaving many parts of the UK with shortages.

New analysis from specialist recruiter Randstad CPE has revealed more than a quarter of Crossrail’s workforce is based in regions more than 30 miles away.

Crossrail, which has cost billions to build and will improve transport in the capital, is a fantastic feat of engineering. However, the impacts of such a vast project are being felt across the rest of the country.

The analysis shows the scale of the problem, revealing one in 20 Crossrail workers have relocated more than 100 miles to work on the project.

Randstad CPE analysed over 40,000 individual construction and engineering placements across the UK. This includes more than 150 different Crossrail-related jobs titles.

The firm found that more than half of this number have taken up Crossrail jobs 50 miles from their home address. Additionally, just under one in 20 Crossrail workers have moved 100 miles or more. Out of the total 14,000 estimated to have worked on Crossrail since May 2009, 4,000 workers have commuted or relocated more than 30 miles towards the London region. A total of 2,100 originally came from 50 miles away.

Managing Director of Randstad Construction, Property & Engineering Owen Goodhead said: “Britain’s construction and engineering skills gap has been a dilemma for decades. But now it is biting.

“The infrastructure challenges of the 21st century make this an urgent issue. Crossrail is just one major project, and the effect is felt sharply across the UK.

“Employers want the right person for the right job – absolutely the correct approach – but this is unleashing a spiral of competition.

“Skills shortages are here to stay for the foreseeable future, and candidates looking for construction and engineering jobs are benefitting.

“At the start of the project in 2009, the draw of Crossrail was accentuated by the recession, and today it is one of the brightest symbols of recovery in the UK jobs market.

“The downside is in local areas at the other end of this skills vacuum.

“Crossrail will revolutionise the daily commute for thousands. But the people creating this engineering marvel have their own stories of relocation and long commutes – and their home towns will tell the story of a skills exodus.”

One of the main draws for the project is the money. Tunnelling engineers can earn £25,000 and Project Managers up to £51,000 per annum. By 2018, it is estimated the average Crossrail worker could have earnt an extra £10,701 just by moving to London.

Salary for those involved in work such as heavy engineering, rail, tunnelling, and infrastructure projects earn on average £23,952. For the same Crossrail-related job titles outside of the London area, earnings average £22,763. This means Crossrail workers have effectively earned an extra £1,189 per year by working on the project.

Average earnings are broken down as such:

– Senior Quantity Surveyor – £75,000

– Quantity Surveyor – £53,000

– Project Manager – £51,000

– Site Engineer – £34,000

– Assistant Quantity Surveyor – £33,000

– Site Project Manager – £30,000

– Tunnelling Engineer – £25,000

The analysis also showed that since 2009, workers have been recruited at an average distance of 30.1 miles. This peaked to 36.9 miles in 2011. So far in 2015, the distance averages 24.5 miles.

Goodhead continued: “Filling quantity surveyor jobs and project manager jobs can be a challenge for employers right across the UK. But London is the white-hot core – where the same job titles command an even greater premium. Especially for high-profile projects, employers are stumping up the cash to get the right skills.”

“All rail workers, tunnellers, automotive and structural engineers get a bonus for living in London – but those employed by Crossrail itself are likely to see even higher earnings again.

“Not only is Crossrail an iconic project for any CV, it has its own training and learning opportunities – and its own additional earnings premium, even in London.

“Crossrail will be winding down within the next two years, and ambitious skilled people may start to look to other regions. But for a decade one railway will have defined a huge portion of the jobs market.”

It is expected by 2018 the majority of recruits will have come from London, dominating the demand for almost a decade. Almost half (48 per cent) of Crossrail-competent placements handled by Randstad CPE since 2009 had been in the London area.

Goodhead said: “London and the South East are now powering the whole UK construction industry. Crossrail represents a particular crunch point for even scarcer skills – but the trend is now growing.

“Property prices around London provide a steady underpinning to returns from residential house building – while huge infrastructure projects like Crossrail, the Thames Tideway and soon HS2, all radiate out from the capital.

“But while all roads may lead to London, the rest of the UK still needs skilled engineers and construction workers. In a world where jobs are increasingly outnumbering the best candidates, employers need to up their game to find the right people for the job.

“As a country we need more people to start from scratch in construction and engineering – which means training. In particular, apprenticeships can be a huge part of the solution, invigorating the workforce with a fresh cohort of skilled people, and widening access to the very best jobs.

“This year we’ve launched the Randstad Williams Engineering Academy, giving school leavers work experience, mentorship and a chance to join the Williams Formula One team.

“But in every field, this country needs not just more Formula One engineers, but more rail engineers, electricians, quantity surveyors, project managers and bricklayers to come through these routes.

“In the meantime savvy job seekers should look for ways to train up, earn more – and fill the growing competence chasm across every nation, city and region of the UK.

“That may mean following the glittering allure of the capital, or branching out for adventure and a greater variety of life in other towns and cities.”

Is the education sector in trouble?

October 15, 2015

With teachers leaving the profession in droves, many failing to even last the first year after qualifying, AG asks if the education sector is in trouble.

It has been a turbulent week for education. Over the weekend, the media had a field day over the mass exodus of thousands of teachers. Less than a week later and the contentious issue of grammar school education is once again stirring the pot and bringing up questions of a two-tier system. The education sector certainly feels as if it has been on a rollercoaster ride over the last five years, and it is a ride most of us would like to get off.

There is little doubt that since the Conservatives have had a hand in education policy things have been fraught. Former Education Secretary Michael Gove did little to endear himself to teachers and unions during his tenure at the Department for Education. In fact, prior to the cabinet reshuffle in July last year, Gove was referred to as the “most hated education secretary in history”. While an impressive title, it is probably not the legacy Gove imagined for himself when he came to the role.

During his time as Secretary of State, Gove was responsible for a number of contentious policy changes, including performance-related pay for teachers, an overhaul of the national curriculum, and the development of academies. In fact, Gove’s ability to create sensationalist headlines must have made him something of a headache for Cameron, which is probably why he was moved out during a reshuffle of the cabinet.

However, it was his disregard for the teaching unions that earned him the most criticism. Gove’s failure to address any union conferences during his four years in power did not sit well with the sector. It is little wonder that he caused such a furore among teaching unions and academic groups, who felt ignored and belittled by his lack of interest in their views. Gove certainly did not help his case by referring to them as “the blob” and “enemies of promise”.

Gove’s successor, Nicky Morgan, has seemingly done a little better since taking over, but she is still facing insurmountable challenges. Over the weekend a new survey revealed over half of teachers are considering leaving the profession because of workload and low morale.

Recruitment issues are hardly a new thing. Figures from the Association of Teachers and Lectures in March revealed only 62 per cent were still teaching a year after gaining Qualified Teacher Status (QTS). Data also showed the number of trainees who complete their training but never enter the classroom tripled between 2006 and 2011 from 3,600 to 10,800.

However, seven months later not much has changed. The survey released over the weekend showed that almost four in 10 teachers quit within a year of qualifying. The data, which was collected by YouGov on behalf of the National Union of Teachers, highlights the major issues facing education in this country and it is a worrying picture.

Speaking at the time, General Secretary of the NUT Christine Blower said the “crisis in the schools system” had to be address urgently to stop teachers from “leaving in droves”.

The education sector, like other public services, is under increasing pressure to do more with less. It is expected nearly one million pupils will enter the school system over the next ten years and with the number of teachers leaving the profession it will be difficult to meet this influx of students.

Despite the numerous concerns raised by those within the profession the government seems blind to the issue-or perhaps in denial. Commenting on the findings from the survey Schools Minister Nick Gibb said teaching remained a “hugely popular profession” with record numbers joining.

He cited figures that reveal the number of teachers returning to the classroom has grown from 14,720 in 2011 to 17,350 in 2014. However, the issue remains with recruiting. If the sector cannot get trainees through the door to start with it won’t matter how many teachers return to the profession.

In a bid to tackle one of the major issues leading to the mass exodus of teaching staff, Morgan launched three new review groups. These groups will investigate the workload of teachers and how to reduce the amount. Many teachers are currently working 60 hours a week to keep up with marking and other paper pushing exercises. This has to stop if the sector hopes to retain current teachers and attract new ones.

In leaked letter, the government said it had been forced to look for teaching staff abroad. The letter, which was sent to a recruitment agency from the Department for Education stated ministers will “help widen the existing recruitment pool by supporting schools to confidently recruit where necessary internationally”. While this is a short term solution it does not fix the problem. The government should be asking why the country cannot retain talented teachers coming through training schemes.

What is clear is going forward the government has a massive challenge on its hands. Education is one of the main paths to social mobility and it is imperative children receive a good start in life. While teachers face growing classes, reduced staffing levels, and increasing targets it is difficult to see how these problems can be overcome. However, if the government does not get a grip of these issues quickly the sector will struggle to recover.

If teachers are leaving by the thousands, perhaps the government should stop to ask why—rather than attempting to stick a plaster over the problem.

An action plan for a sustainable Stockholm

Katarina Luhr, Vice Mayor of Environment in the City of Stockholm outlines how they strive to become a truly sustainable city for generations to come.

Gender pay gap means women work for nothing until 2016

A campaign group has highlighted the plight of women workers, warning those in full-time employment will in effect work for nothing between now and 2016.

Drought, Food, and Trees

Is nuclear energy the answer to climate change?

Dr Jonathan Cobb, Senior Communications Manager at the World Nuclear Association details why nuclear power could be part of the solution to tackling climate change.

Generation mixes with low greenhouse gas emissions

Are teachers under too much pressure?

Unions warn teachers are under so much pressure they are being “reduced to tears”, highlighting yet another difficulty facing the sector.

£500m for heart disease research

Cardiac charity the British Heart Foundation has revealed it will pump £500m into researching heart disease.

Top company for apprenticeships named

Ernest & Young has been named the UK’s top firm for apprenticeships in a new survey…

Crossrail is creating a skills vacuum

According to new analysis, Crossrail’s demand for skilled workers is leaving many parts of the UK with shortages.

Is the education sector in trouble?

With teachers leaving the profession in droves, many failing to even last the first year after qualifying, AG asks if the education sector is in trouble.

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