Epidemic occupational pseudo-illness: the plague of acronyms

Genuine disorder caused by repetitive movement has unmistakable features vitally different from occupational pseudo-illness, which comes and goes in new guises and massive epidemics wherever the label legitimizes gain from compensation. The assumption of an existing label such as the carpal tunnel syndrome gives the false idea of greater potential for deception. The solution to the menace lies in logical reasoning, which recognizes falsity before it begins to dominate the minds of the community.

Randomized testing of alternative survey formats using anonymous volunteers on the World Wide Web

Consenting visitors to a health survey Web site were randomly assigned to a "matrix" presentation or an "expanded" presentation of survey response options. Among 4,208 visitors to the site over 3 months, 1,615 (38 percent) participated by giving consent and completing the survey. During a pre-trial period, when consent was not required, 914 of 1,667 visitors (55 percent) participated (odds ratio 1.9, P<0.0001). Mean response times were 5.07 minutes for the matrix format and 5.22 minutes for the expanded format (P=0.16). Neither health status scores nor alpha reliability coefficients were substantially influenced by the survey format, but health status scores varied with age and gender as expected from U.S. population norms. In conclusion, presenting response options in a matrix format may not substantially speed survey completion. This study demonstrates a method for rapidly evaluating interface design alternatives using anonymous Web volunteers who have provided informed consent.

Improved glycemic control with use of continuous subcutaneous insulin infusion compared with multiple insulin injection therapy

OBJECTIVE

To compare, in a long-term study, glycemic control by means of continuous subcutaneous insulin infusion (CSII or insulin pump therapy) versus multiple insulin injection therapy (MIIT) in routine clinical practice.

METHODS

We identified, from a search of medical records, all active patients (N = 90) receiving CSII who had previously received MIIT. The primary objective was to compare the mean glycemic control, as documented by frequent measurements of glycosylated hemoglobin (HbA(1c)), during the 3-year period before initiation of CSII versus the mean glycemic control during the 3-year period after the first year of CSII. We included all patients for whom we had sufficient data for at least 1 year for both the pre- and post-CSII periods and only those patients who had received MIIT before CSII (N = 58). To eliminate potential biases, we excluded HbA(1c) values for the first year after initiation of CSII therapy.

RESULTS

For the entire study group, the mean HbA(1c) +/- standard error for the 3-year period before insulin pump therapy (during MIIT) was 8.4 +/- 0.2% versus a mean HbA(1c) of 7.7 +/- 0.1% for the 3-year period after the first year of CSII. This 0.7% improvement in HbA(1c) was statistically significant (P = 0.001). Of the 34 patients with HbA(1c) values above 8.0% during MIIT, the mean HbA(1c) decreased from 9.2 +/- 0.2% with use of MIIT to 8.2 +/- 0.2% with CSII (P = 0.0006). In the 17 patients with HbA(1c) values above 9.0% during MIIT, the mean HbA(1c) declined from 10.0 +/- 0.3% with use of MIIT to 8.4 +/- 0.3% with CSII (P = 0.0006).

CONCLUSION

We conclude that implementation of intensive insulin therapy with CSII improves glycemic control, even in patients in whom MIIT has previously been used to its maximal effect.

The roles of orthostatic hypotension, orthostatic tachycardia, and subnormal erythrocyte volume in the pathogenesis of the chronic fatigue syndrome

BACKGROUND

Orthostatic hypotension during upright tilt is an important physical disorder in patients with chronic fatigue syndrome. We have tested its occurrence during prolonged standing, whether it is correctable, and whether reduced circulating erythrocyte volume is present.

METHODS

Fifteen patients were randomly selected from a large population of patients with chronic fatigue syndrome, studied, and observed for several years (by DSB). Blood pressure (BP) and heart rate (HR) measured with Dinamap every minute for 30 minutes supine and 60 minutes standing were compared with these findings in 15 healthy age- and gender-matched control subjects and later during lower body compression with military antishock trousers (MAST). Plasma catecholamines and circulating erythrocyte and plasma volumes were also measured by isotopic dilution methods.

RESULTS

Abnormal findings in the patients included excessive orthostatic reductions in systolic (P < 0.001) and diastolic BP (P < 0.001) and excessive orthostatic tachycardia (P < 0.01), together with presyncopal symptoms in 11 of the 15 patients and in none of the control subjects after standing for 60 min. Lower body compression with the MAST restored all orthostatic measurements to normal and overcame presyncopal symptoms within 10 min. Circulating erythrocyte but not plasma volumes were subnormal in the 12 women (P < 0.01) and plasma norepinephrine concentration rose excessively after standing for 10 min.

CONCLUSION

Delayed orthostatic hypotension and/or tachycardia caused by excessive gravitational venous pooling, which is correctable with external lower-body compression, together with subnormal circulating erythrocyte volume, are very frequent, although not invariably demonstrable, findings in moderate to severe chronic fatigue syndrome. When present, they may be involved in its pathogenesis.

How long can insulin therapy be avoided in the patient with type 2 diabetes mellitus by use of a combination of metformin and a sulfonylurea?

OBJECTIVE

To assess the effective longevity of combination double oral therapy before insulin or triple oral therapy is needed in patients with type 2 diabetes mellitus.

METHODS

We retrospectively reviewed the outcomes of our first 100 patients with type 2 diabetes who were successfully transferred from twice-daily mixed NPH and regular insulin to a combination of metformin and a sulfonylurea.

RESULTS

Of the 100 study patients, 40 had well-controlled plasma glucose (glycosylated hemoglobin levels <8.0%) with use of metformin and a sulfonylurea. Good glycemic control was achieved with triple oral therapy (a sulfonylurea, metformin, and a thiazolidinedione) in 14 patients and with a sulfonylurea, metformin, and evening-administered mixed NPH and regular insulin in 7. In addition, plasma glucose was effectively controlled with twice-daily mixed NPH and regular insulin in conjunction with metformin or a thiazolidinedione (or both) in 22 patients and with twice-daily mixed NPH and regular insulin alone in 17. The mean time (+/- standard error) from primary failure of sulfonylurea monotherapy to the time when a third hypoglycemic agent was needed was 7.9 +/- 1.1 years (95% confidence interval, 5.7 to 10.1).

CONCLUSION

When oral monotherapy fails (that is, glycosylated hemoglobin values exceed 8.0%) in patients with type 2 diabetes, combination therapy with a sulfonylurea and metformin is potentially effective in maintaining glycemic control and avoiding the addition of insulin or a thiazolidinedione for a mean duration of 7.9 years.

Self-study from web-based and printed guideline materials. A randomized, controlled trial among resident physicians

BACKGROUND

On-line physician education is increasing, but its efficacy in comparison with existing self-study methods is unknown.

OBJECTIVE

To compare knowledge, learning efficiency, and learner satisfaction produced by self-study of World Wide Web-based and print-based guidelines for care after acute myocardial infarction.

DESIGN

Randomized, controlled trial.

SETTING

12 family medicine and internal medicine residency programs at four universities.

PARTICIPANTS

162 residents.

INTERVENTIONS

In proctored sessions, participants were randomly assigned to study from printed materials or from SAGE (Self-Study Acceleration with Graphic Evidence), a Web-based tutorial system. Both methods used identical self-assessment questions and answers and guideline text, but SAGE featured hyperlinks to specific guideline passages and graphic evidence animations.

MEASUREMENTS

Scores on multiple-choice knowledge tests, score gain per unit of study time, and ratings on a learner satisfaction scale.

RESULTS

Immediate post-test scores on a 20-point scale were similar in the SAGE and control groups (median score, 15.0 compared with 14.5; P>0.2), but SAGE users spent less time studying (median, 27.0 compared with 38.5 minutes; P<0.001) and therefore had greater learning efficiency (median score gain, 8.6 compared with 6.7 points per hour; P = 0.04). On a scale of 5 to 20, SAGE users were more satisfied with learning (median rating, 17.0 compared with 15.0; P<0.001). After 4 to 6 months, knowledge had decreased to the same extent in the SAGE and control groups (median score, 12.0 compared with 11.0; P = 0.12).

CONCLUSIONS

On-line tutorials may produce greater learning efficiency and satisfaction than print materials do, but one self-study exposure may be insufficient for long-term knowledge retention. Further research is needed to identify instructional features that motivate greater final learning and retention.

Inflammation, insulin resistance, infection, diabetes, and atherosclerosis

OBJECTIVE

To review the relationship between poor control of blood glucose in patients with diabetes and potential for occurrence of the acute coronary syndrome.

METHODS

The role of advanced glycosylated end products in endothelial dysfunction is discussed, and the possible contributions of inflammation and infection in the rupture of atheromatous plaques are described.

RESULTS

Hyperglycemia predisposes to infection by decreasing the efficacy of leukocytes and allowing increased formation of advanced glycosylated end products. The associated endothelial permeability facilitates bacterial infiltration of atheromatous plaques. Reported associations between chronic infection and coronary artery disease have involved primarily Chlamydia pneumoniae. The insulin resistance syndrome is also characterized by compromised endothelial function, which may predispose patients to unstable plaques and cardiac events.

CONCLUSION

In patients with diabetes, poor glycemic control may lead to excessive advanced glycosylated end products, inflammation and infection of atheromatous plaques, and plaque rupture that can cause angina or myocardial infarction.

Design and analysis of a Web-based guideline tutorial system that emphasizes clinical trial evidence

OBJECTIVE

To describe a Web-based guideline tutorial system and evaluate its features.

METHODS

A Web-based tutorial system called SAGE (Self-study Acceleration with Graphic Evidence) was constructed to teach knowledge important for care after myocardial infarction. SAGE features a pretest, followed by an overview that coordinates studying resources for a set of learning objectives. Resources include pretest answers, guideline passages, and graphical presentations of clinical trial results. Data on the use of SAGE was obtained from 79 residents participating in a larger trial. Linear regression was used to correlate the amount learned with resource-use, and resource-use with user characteristics.

RESULTS

On average, users accessed less than half of the guideline passages and very little of the graphic evidence. Greater use of guideline passages was correlated with greater immediate learning, but use of graphic evidence was not.

CONCLUSIONS

Further research is needed to motivate more thorough self-study and to integrate clinical trial evidence with guideline-based education.