Validation of the Cardiovascular Limitations and Symptoms Profile (CLASP) in chronic stable angina

PURPOSE

This study aimed to establish the reliability, validity, and sensitivity of the Cardiovascular Limitations and Symptoms Profile (CLASP) in a group of patients with chronic stable angina.

METHODS

After 226 patients with angina had been recruited, they were randomly allocated to one of three groups: a 10-week hospital-based angina management program (n = 75; men = 56; age = 60 +/- 8 years), routine care (n = 74; men = 52; age = 61 +/- 7 years), and exercise therapy (n = 77; men = 60; age = 60 +/- 7 years). All the patients were assessed with CLASP on two occasions: at baseline and at 10 weeks. The Sickness Impact Profile (SIP), the Hospital Anxiety and Depression Scale (HADS), and the Sleep Problems Questionnaire (SPQ) also were administered at the same time.

RESULTS

Significant positive correlations between the actual number of angina episodes and the CLASP angina subscale scores (r =.60, P <.001) were observed. The CLASP subscale scores for shortness of breath (r = -.36; P <.001) and ankle swelling (r = -.24; P <.001) were significantly correlated with the total treadmill time. The CLASP tiredness subscale score showed a significant positive correlation with the SPQ score (r =.48; P <.001). The CLASP subscale scores were significantly correlated with their corresponding SIP subscale scores: the tiredness score with the sleep and rest score (r =.49; P <.001), the social and leisure score with the recreation and pastimes score (r =.41; P <.001), the home score with the home management score (r =.45; P <.001), and the mobility score with the mobility (r =.37; P <.001) and total treadmill time scores (r = -.49; P <.001).

CONCLUSIONS

The findings show CLASP to be a reliable, valid, sensitive measure of health-related quality of life in patients with chronic stable angina. Before it can be recommended for all patients with heart disorders, similar data will be required from other diagnostic groups such as patients with heart failure or those who have sustained an acute myocardial infarction.

The nigrostriatal dopaminergic system in familial early onset parkinsonism with parkin mutations

Nigrostriatal dopaminergic function and cerebral energy metabolism were measured with PET in two brothers with early-onset parkinsonism caused by mutation of the parkin gene. Energy metabolism did not differ, but the nigrostriatal dopaminergic pattern was clearly different than that of sporadic PD. Thus parkinsonism in these two patients was shown to be pathophysiologically different than PD.

Twenty questions for retirement

In the course of my citywide peregrinations over the past six years I have encountered many retired colleagues. Oddly, their response to retirement has been mixed; that prompted me to survey this group to get some sense of how they are dealing with such a dramatic change in lifestyle. A set of twenty questions was mailed to 80 individuals from varying specialties in the Oklahoma County area; 56 (70%) were completed and returned. Here is a list of the questions and a summary of the answers. The answers vary widely but do reveal some trends.

Effects of diary food supplements on bone mineral density in teenage girls

BACKGROUND

Bone mineral density (BMD) is largely genetically determined and this influence is most powerful in the period of rapid skeletal development in childhood and late adolescence but environmental factors such as exercise and dietary calcium intake may influence up to 20%.

AIMS OF THE STUDY

The aims of the study were to examine healthy late adolescent females for the effects and benefits of a high calcium intake from dairy product foods on bone mineral density, body composition, lipids and biochemistry. The secondary aim is determine whether a high intake of dairy product foods in the diet is acceptable for this age group long term.

METHODS

Ninety-one teenage girls who participated in a two-year randomised controlled study on the effect of dairy food supplementation on dietary patterns, body composition and bone density in post-pubertal teenage girls were approached one year after the cessation of the study to determine the effects of the cessation of dairy supplements on bone mineral density, dietary habits, biochemical markers, body composition and blood lipids. Bone mineral density and bone mineral content were assessed at the hip, spine and total body. Anthropometric data were collected, and exercise, Tanner, dietary assessment, preference and compliance questionnaires were administered. Lipid profiles, hydroxyproline excretion and urinary calcium and sodium excretion measurements were performed.

RESULTS

There were no significant differences between the 2 groups for height, weight, lean and fat mass. The supplemented group had significantly higher calcium, phosphorus and protein intake during the supplementation period (p < 0.001). No differences were seen between the groups 12 months after supplementation finished. There were no significant differences in exercise level, preference or acceptability of dairy products or in the lipids and bone markers between baseline the end of supplementation and 1 year follow-up. There was a significant increase in trochanter (4.6%), lumbar spine (1.5%) and femoral neck (4.8%) BMD (p < 0.05) in the high calcium group at the end of supplementation. There was an increase in bone mineral content at the trochanter (p < 0.05) and lumbar spine; however the latter was not statistically significant, in the high calcium group at the end of supplementation. There was no difference in vertebral height or width at any stage of the study, indicating no influence on bone size.

CONCLUSIONS

In this 3 year study (2 years of supplementation, 1 year follow-up), teenage girls, aged 15-18 years, were able to significantly increase their BMD at the trochanter, femoral neck and lumbar spine when supplemented with dairy product foods to a mean calcium intake of 1160 mg/d. There was also an effect seen on the BMC particularly at the trochanter and to a lesser extent at the lumbar spine. The dietary calcium intake achieved did not adversely affect body weight, fat and lean mass or blood lipid profiles. Twelve months after the supplementation finished the girls had returned to their baseline diet, indicating self-selection of a high dairy product diet may be hard to achieve.

Student assessment in undergraduate medical education in the United Kingdom, 1998

This report describes the results of the project 'Assessment of Undergraduate Medical Education: Re-inventing the Wheel?' funded by the Nuffield Trust. The project was initiated in order to obtain information on current assessment practices in medical schools across the UK, to determine the extent of change as a consequence of the curricular reforms recommended by the General Medical Council (GMC) in 1993 and, if necessary, to stimulate debate about assessment and provide an impetus for change. The data obtained provide a detailed profile of the timing and nature of assessments used in medical schools and provide information for comparison with the survey of basic medical education in the British Isles carried out in 1977 and any subsequent studies. The study provides confirmatory and unexpected evidence. Schools are clearly revising their curricula consistent with recommendations made by the GMC. The main components of the study were as follows: a postal questionnaire sent to all UK medical schools, a national workshop, and four case studies of innovative assessment practices.

Group process: the black box of studies on problem-based learning

A considerable number of medical schools worldwide have implemented, at least in part, a problem-based learning (PBL) approach in their curricula. Research to date has largely neglected the issue of the actual activities and learning processes that mediate and moderate the relationship between these programs and their cognitive outcomes. In this essay the authors discuss the few studies that have empirically investigated what students actually do in PBL tutorials, which arguably is the pivotal mediating process. These studies demonstrate that it is possible to observe, identify, and describe group activities (such as brainstorming and the joint identification of learning issues) that promote interactionally shared and achieved cognition. However, such studies have been confined to case studies in which isolated fragments of tutorials have been analyzed and described. Future studies need to provide a broader description and analysis of actually performed cognitive activities in all relevant phases of the entire PBL process.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

The safety and efficacy of ALLERVAX CAT in cat allergic patients

Conventional immunotherapy for cat allergy is effective in reducing cat allergy symptoms in many patients, but this type of immunotherapy can cause severe reactions, including anaphylaxis, and often requires years of injections for successful desensitization. To improve the efficacy of immunotherapy for cat allergic patients, synthetic cat allergen peptides (ALLERVAX CAT) were generated, based on analysis of the immunodominant T cell epitopes of cat allergen. These peptides lack the tertiary structure of native Fel d1 and possess a significantly reduced capacity to bind to Fel d1-specific IgE. Using these peptides, we performed a multicenter, randomized, double-blind, placebo-controlled study of 133 cat allergic patients chronically exposed to cats or who had failed previous conventional cat immunotherapy. We evaluated the safety of ALLERVAX CAT treatment and determined whether ALLERVAX CAT treatment improved tolerance to cat allergen, as measured by symptom analysis and pulmonary function testing. Three of the ALLERVAX CAT-treated patients required systemic epinephrine for adverse reactions, but the frequency of all adverse reactions in both groups was not statistically different from that of the placebo group. The majority of adverse events were "late" events, most commonly associated with respiratory symptoms, and these events declined with successive injections. ALLERVAX CAT given at a dose of 750 microg/dose improved pulmonary function in patients with reduced baseline FEV1, and global evaluation of the subjects' ability to tolerate cats improved significantly in the actively treated groups relative to placebo. Thus, although therapy with ALLERVAX CAT is associated with some adverse events in patients with severe cat sensitivity, such therapy is an effective approach for the management of cat allergy, since it improves tolerance to cats and improves pulmonary function in cat allergic patients with reduced FEV1.

Measurement of communication skills in cancer care: myth or reality?

Despite wide agreement about the importance of effective communication in cancer care there is continuing evidence of the need for nurses, doctors and colleagues to be helped to improve their communication skills. Consequently, there has been a growing demand for effective methods for evaluation of communication training programmes. This paper discusses theoretical perspectives in this field and describes the rationale underpinning the development of a detailed objective method of assessing interviews between health professionals and cancer patients. The method enables an utterance by utterance rating of transcribed interviews to be made which can be used to construct profiles of interviewer and patient behaviours and interactions. All categories were developed from interviews drawn from a large sample of participants (n=206) at counselling skills workshops. Six domains have been identified and these are: grammatical style; the purpose of each technique; what is being discussed, the degree of feeling expressed; explicit avoidance; and the use made of patients' cues. Each domain contains a mutually exclusive set of categories. In addition the method enables the sequence of events to be plotted. Using these methods, examples from published studies will be given to show how the processes of interaction within a health care interview can be better understood, thus enabling the most effective techniques to be taught, the effectiveness of different teaching methods to be assessed and how changes brought about by training have the potential to make a significant clinical difference to patients.

The treatment of high-grade soft tissue sarcomas with preoperative thermoradiotherapy

PURPOSE

To explore the use of a novel program of preoperative radiation and hyperthermia in the management of high-grade soft tissue sarcomas (STS).

METHODS AND MATERIALS

Eligible patients were adults over 18 with Grade 2 or 3 STS, surgically resectable without a local excision prior to referral to Duke University Medical Center and without distant metastases. Patients were staged generally with CT and/or MR imaging. The diagnosis was established with fine needle aspiration or incisional biopsy. Patients were then treated with 5000 to 5040 cGy, 180-200 cGy per fraction. Chemotherapy was usually not employed. Generally two hyperthermia treatments per week were given with a planned thermal dose of 10-100 CEM 43 degrees T90. Invasive thermometry and thermal mapping were done in all patients. Surgical resection was planned 4-6 weeks after the completion of radiation and hyperthermia.

RESULTS

Ninety-seven patients were treated on study between 1984 and 1996. Follow-up ranged from 12 to 155 months (median 32). All tumors were high-grade in nature, 44 greater than 10 cm in size (maximum tumor diameter), 43 5-10 cm in size, 10 less than 5 cm. Seventy-eight of the 97 tumors were located in an extremity. Of the 97 patients, 48 remain alive and continually free of disease following initial therapy. Of the remaining 49 patients, 44 have relapsed (34 dead, 10 living with disease), 3 have died secondary to complications of therapy, and 2 have died of unrelated causes. Ten-year actuarial overall survival, cause-specific survival, and relapse-free survival are 50, 47, and 47% respectively. The predominant pattern of failure has been distant metastases with only 2 patients developing local failure alone. Ten-year actuarial local control for extremity tumors is 94%, 63% for the 19 patients with tumors at sites other than the extremity. Of the 78 patients with extremity lesions, 63 have had limb preservation and remain locally controlled. Overall 38 patients experienced 57 major complications. There were 3 deaths, one due to adriamycin cardiomyopathy and two secondary to wound infections. Four patients required amputation secondary to postoperative wound healing problems. Complications directly attributable to hyperthermia occurred in 15 patients with 11 instances of second- or third-degree burns and two instances of subcutaneous fat necrosis. The hyperthermia complications were generally not severe and either healed readily or were excised at the time of surgical resection of the primary tumor.

CONCLUSIONS

For these aggressive high-grade soft tissue sarcomas, this treatment program of preoperative thermoradiotherapy provided excellent local regional control for extremity lesions (95%) and satisfactory local regional control (63%) of nonextremity sarcomas, but did not appear to influence the rate of distant metastases or survival. Complications were frequent but apart from the direct thermal burns, not too different from those reported for preoperative radiotherapy alone. More effective adjuvant systemic therapy is necessary to impact favorably on survival.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

Onset of sucrase-isomaltase deficiency in late adulthood

Sucrase-isomaltase deficiency is a rare disorder usually manifested as diarrhea in infancy. The presentation of such a deficiency in adulthood is even more rare, particularly when the individual has no history of childhood diarrhea. After a literature search, the 59-yr-old patient we report is the oldest to have been identified with this condition. The difficulties encountered in diagnosis when such a case occurs at this age that have not previously been reported are highlighted.

The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses

The findings of two meta-analyses of trials of psychological interventions in patients with cancer are presented: the first using anxiety and the second depression, as a main outcome measure. The majority of the trials were preventative, selecting subjects on the basis of a cancer diagnosis rather than on psychological criteria. For anxiety, 25 trials were identified and six were excluded because of missing data. The remaining 19 trials (including five unpublished) had a combined effect size of 0.42 standard deviations in favour of treatment against no-treatment controls (95% confidence interval (CI) 0.08-0.74, total sample size 1023). A most robust estimate is 0.36 which is based on a subset of trials which were randomized, scored well on a rating of study quality, had a sample size > 40 and in which the effect of trials with very large effects were cancelled out. For depression, 30 trials were identified, but ten were excluded because of missing data. The remaining 20 trials (including six unpublished) had a combined effect size of 0.36 standard deviations in favour of treatment against no-treatment controls (95% CI 0.06-0.66, sample size 1101). This estimate was robust for publication bias, but not study quality, and was inflated by three trials with very large effects. A more robust estimate of mean effect is the clinically weak to negligible value of 0.19. Group therapy is at least as effective as individual. Only four trials targeted interventions at those identified as at risk of, or suffering significant psychological distress, these were associated with clinically powerful effects (trend) relative to unscreened subjects. The findings suggest that preventative psychological interventions in cancer patients may have a moderate clinical effect upon anxiety but not depression. There are indications that interventions targeted at those at risk of or suffering significant psychological distress have strong clinical effects. Evidence on the effectiveness of such targeted interventions and of the feasibility and effects of group therapy in a European context is required.