Treatment effect of canagliflozin for patients on therapy for heart failure: Pooled analysis of the CANVAS program and CREDENCE trial

BACKGROUND

Canagliflozin is a sodium-glucose cotransporter 2 inhibitor that has been shown to reduce cardiovascular events in diabetic patients with and without heart failure (HF). Whether the clinical benefits and safety profile of canagliflozin are different in those on a beta blocker and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (BB + RAASi) is unknown.

METHODS

We pooled participants with HF at baseline from the CANVAS Program and CREDENCE trial and assessed major adverse cardiovascular events and its components; hospitalization for heart failure (HHF); HHF or CV death; all-cause mortality; a renal composite; and a combined renal and CV composite.

RESULTS

Of 14,543 participants, 2113 had HF at baseline, and 1280 were on BB + RAASi. In those with a history of HF, participants on BB + RAASi therapy were more likely to have coronary atherosclerotic disease (82 vs 72%, p < 0.001), history of myocardial infarction (42 vs 29%, p < 0.001), higher mean body mass index (34 vs 32 kg/m2, p < 0.001), and lower mean estimated glomerular filtration rate (67 vs 70 mL/min/1.73 m2, p < 0.01). They were also more likely to be on insulin, a statin, antithrombotic agent, and a diuretic (all p < 0.001). In unadjusted analysis and when adjusted for selected baseline factors, there was no heterogeneity in canagliflozin treatment effect except for HHF/CV death in those on baseline BB + RAASi vs. those not on baseline BB + RAASi (Pheterogeneity = 0.02).

CONCLUSION

Canagliflozin mostly improved CV and kidney outcomes in participants with a history of HF irrespective of use of BB + RAASi at baseline, with possible greater benefit on HHF/CV death in participants on BB + RAASi.

Aortic Root Thrombosis in patients with HeartMate 3 left ventricular assist device support

BACKGROUND

Aortic root thrombosis(ART) is a complication of continuous-flow left ventricular assist device therapy. However, the incidence and related complications of ART in HeartMate 3 (HM3) patients remain unknown.

METHODS

Patients who underwent HM3 implantation from November 2014 to August 2020 at a quaternary academic medical center were included. Demographics and outcomes were abstracted from the medical record. Echocardiograms and contrast-enhanced computed tomography studies were reviewed to identify patients who developed ART and/or moderate or greater aortic insufficiency (AI) on HM3 support.

RESULTS

The study cohort included 197 HM3 patients with a median postimplant follow-up of 17.5 months. Nineteen patients (9.6%) developed ART during HM3 support, and 15 patients (7.6%) developed moderate or greater AI. Baseline age, gender, race, implantation strategy, and INTERMACS classification were similar between the ART and no-ART groups. ART was associated with an increased risk of death, stroke, or aortic valve (AV) intervention (subhazard ratio [SHR] 3.60 [95% confidence interval (CI) 1.71-7.56]; p = 0.001) and moderate or greater AI (SHR 11.1 [CI 3.60-34.1]; p < 0.001) but was not associated with a statistically significantly increased risk of death or stroke on HM3 support (2.12 [0.86-5.22]; p = 0.10). Of the 19 patients with ART, 6 (31.6%) developed moderate or greater AI, necessitating more frequent AV interventions (ART: 5 AV interventions [3 surgical repairs, 1 surgical replacement, 1 transcatheter replacement; 26.3%]; no-ART: 0).

CONCLUSIONS

Nearly 10% of HM3 patients developed ART during device support. ART was associated with increased risk of a composite end-point of death, stroke, or AV intervention as well as moderate or greater AI.

Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes

BACKGROUND

Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis.

OBJECTIVES

The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods.

METHODS

Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations.

RESULTS

Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0.

CONCLUSIONS

Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention.

Impact of Periprocedural Adverse Events After PCI and CABG on 5-Year Mortality: The EXCEL Trial

BACKGROUND

The relative risks for different periprocedural major adverse events (MAE) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) on subsequent mortality have not been described.

OBJECTIVES

The aim of this study was to assess the association between periprocedural MAE occurring within 30 days postprocedure and early and late mortality after left main coronary artery revascularization by PCI and CABG.

METHODS

In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with left main disease were randomized to PCI vs CABG. The associations between 12 prespecified nonfatal MAE and subsequent 5-year all-cause and cardiovascular death in 1,858 patients were examined using logistic regression.

RESULTS

One or more nonfatal MAE occurred in 111 of 935 patients (11.9%) after PCI and 419 of 923 patients (45.4%) after CABG (P < 0.0001). Patients with MAE were older and had more baseline comorbidities. Within 5 years, all-cause death occurred in 117 and 87 patients after PCI and CABG, respectively. Experiencing an MAE was a strong independent predictor of 5-year mortality after both PCI (adjusted OR: 4.61; 95% CI: 2.71-7.82) and CABG (adjusted OR: 3.25; 95% CI: 1.95-5.41). These associations were present within the first 30 days and between 30 days and 5 years postprocedure. Major or minor bleeding with blood transfusion ≥2 U was an independent predictor of 5-year mortality after both procedures. Stroke, unplanned revascularization for ischemia, and renal failure were significantly associated with mortality only after CABG.

CONCLUSIONS

In the EXCEL trial, nonfatal periprocedural MAE were strongly associated with early and late mortality after both PCI and CABG for left main disease.

Clinical and economic burden of obstructive hypertrophic cardiomyopathy in the United States

AIMS

Obstructive hypertrophic cardiomyopathy (oHCM) is a disease of the cardiomyocyte in which dynamic left ventricular outflow track obstruction may lead to heart failure, valvular disease, and sudden death. Little is known about healthcare resource utilization (HRU) and costs associated with oHCM. This study investigated the clinical and economic burden of oHCM in patients with or without symptoms associated with oHCM.

METHODS

We used the US IBM MarketScan Commercial and Medicare Supplemental database to identify patients with oHCM (January 2009-March 2019). Control patients without cardiomyopathy were matched to each patient with oHCM based on age, sex, region, and index year (3:1 ratio). One-year HRU and cost data were compared between all oHCM, symptomatic oHCM, and asymptomatic oHCM subgroups, and their respective controls.

RESULTS

Among 11,401 eligible patients with oHCM (mean age 57 years, 42% female), 5,667 (50%) were symptomatic (23% chest pain, 57% dyspnea, 29% fatigue, 17% syncope). oHCM was associated with significant increases in all-cause hospitalizations, hospital days, outpatient visits, and total healthcare costs (mean ± standard deviation: $26,929 ± 77,720 vs. $6,808 ± 25,712, p<.001) compared with matched controls. These differences were driven mainly by the clinical and economic burden of symptomatic oHCM, which was associated with significant increases in 1-year hospitalization rates (38.0 vs. 6.9%), hospital days (3.7 ± 9.9 vs. 0.4 ± 3.0), and total healthcare costs ($43,586 ± 103,756 vs. $6,768 ± 27,618; all p<.001). Adjustment for comorbidities had minimal impact on these differences.

LIMITATIONS

The use of claims data relies on International Classification of Diseases (ICD-9 and ICD-10) diagnosis codes, which might be inaccurate. Only commercially insured patients were included.

CONCLUSION

In a real-world population, oHCM was associated with substantial increases in HRU and incremental costs of ∼$20,000/year when compared with matched controls-a difference that increased to ∼$35,000/year among symptomatic patients. Further studies are warranted to understand the potential impact of specific therapies on HRU and the economic burden of oHCM.

Admission Cardiac Diagnostic Testing with Electrocardiography and Troponin Measurement Prognosticates Increased 30-Day Mortality in COVID-19

Background

Cardiovascular involvement in coronavirus disease 2019 (COVID‐19) is common and leads to worsened mortality. Diagnostic cardiovascular studies may be helpful for resource appropriation and identifying patients at increased risk for death.

Methods and Results

We analyzed 887 patients (aged 64±17 years) admitted with COVID‐19 from March 1 to April 3, 2020 in New York City with 12 lead electrocardiography within 2 days of diagnosis. Demographics, comorbidities, and laboratory testing, including high sensitivity cardiac troponin T (hs‐cTnT), were abstracted. At 30 days follow‐up, 556 patients (63%) were living without requiring mechanical ventilation, 123 (14%) were living and required mechanical ventilation, and 203 (23%) had expired. Electrocardiography findings included atrial fibrillation or atrial flutter (AF/AFL) in 46 (5%) and ST‐T wave changes in 306 (38%). 27 (59%) patients with AF/AFL expired as compared to 181 (21%) of 841 with other non‐life‐threatening rhythms (P<0.001). Multivariable analysis incorporating age, comorbidities, AF/AFL, QRS abnormalities, and ST‐T wave changes, and initial hs‐cTnT ≥20 ng/L showed that increased age (HR 1.04/year), elevated hs‐cTnT (HR 4.57), AF/AFL (HR 2.07), and a history of coronary artery disease (HR 1.56) and active cancer (HR 1.87) were associated with increased mortality.

Conclusions

Myocardial injury with hs‐cTnT ≥20 ng/L, in addition to cardiac conduction perturbations, especially AF/AFL, upon hospital admission for COVID‐19 infection is associated with markedly increased risk for mortality than either diagnostic abnormality alone.

An Evaluation of Biometric Monitoring Technologies for Vital Signs in the Era of COVID-19

The novel coronavirus disease 2019 (COVID-19) global pandemic has shifted how many patients receive outpatient care. Telehealth and remote monitoring have become more prevalent, and measurements taken in a patient's home using biometric monitoring technologies (BioMeTs) offer convenient opportunities to collect vital sign data. Healthcare providers may lack prior experience using BioMeTs in remote patient care, and, therefore, may be unfamiliar with the many versions of BioMeTs, novel data collection protocols, and context of the values collected. To make informed patient care decisions based on the biometric data collected remotely, it is important to understand the engineering solutions embedded in the products, data collection protocols, form factors (physical size and shape), data quality considerations, and availability of validation information. This article provides an overview of BioMeTs available for collecting vital signs (temperature, heart rate, blood pressure, oxygen saturation, and respiratory rate) and discusses the strengths and limitations of continuous monitoring. We provide considerations for remote data collection and sources of validation information to guide BioMeT use in the era of COVID-19 and beyond.

The Prognostic Value of Electrocardiogram at Presentation to Emergency Department in Patients With COVID-19

OBJECTIVE

To study whether combining vital signs and electrocardiogram (ECG) analysis can improve early prognostication.

METHODS

This study analyzed 1258 adults with coronavirus disease 2019 who were seen at three hospitals in New York in March and April 2020. Electrocardiograms at presentation to the emergency department were systematically read by electrophysiologists. The primary outcome was a composite of mechanical ventilation or death 48 hours from diagnosis. The prognostic value of ECG abnormalities was assessed in a model adjusted for demographics, comorbidities, and vital signs.

RESULTS

At 48 hours, 73 of 1258 patients (5.8%) had died and 174 of 1258 (13.8%) were alive but receiving mechanical ventilation with 277 of 1258 (22.0%) patients dying by 30 days. Early development of respiratory failure was common, with 53% of all intubations occurring within 48 hours of presentation. In a multivariable logistic regression, atrial fibrillation/flutter (odds ratio [OR], 2.5; 95% CI, 1.1 to 6.2), right ventricular strain (OR, 2.7; 95% CI, 1.3 to 6.1), and ST segment abnormalities (OR, 2.4; 95% CI, 1.5 to 3.8) were associated with death or mechanical ventilation at 48 hours. In 108 patients without these ECG abnormalities and with normal respiratory vitals (rate <20 breaths/min and saturation >95%), only 5 (4.6%) died or required mechanical ventilation by 48 hours versus 68 of 216 patients (31.5%) having both ECG and respiratory vital sign abnormalities.

CONCLUSION

The combination of abnormal respiratory vital signs and ECG findings of atrial fibrillation/flutter, right ventricular strain, or ST segment abnormalities accurately prognosticates early deterioration in patients with coronavirus disease 2019 and may assist with patient triage.

Indications for and Findings on Transthoracic Echocardiography in COVID-19

Background

Despite growing evidence of cardiovascular complications associated with coronavirus disease 2019 (COVID-19), there are few data regarding the performance of transthoracic echocardiography (TTE) and the spectrum of echocardiographic findings in this disease.

Methods

A retrospective analysis was performed among adult patients admitted to a quaternary care center in New York City between March 1 and April 3, 2020. Patients were included if they underwent TTE during the hospitalization after a known positive diagnosis for COVID-19. Demographic and clinical data were obtained using chart abstraction from the electronic medical record.

Results

Of 749 patients, 72 (9.6%) underwent TTE following positive results on severe acute respiratory syndrome coronavirus-2 polymerase chain reaction testing. The most common clinical indications for TTE were concern for a major acute cardiovascular event (45.8%) and hemodynamic instability (29.2%). Although most patients had preserved biventricular function, 34.7% were found to have left ventricular ejection fractions ≤ 50%, and 13.9% had at least moderately reduced right ventricular function. Four patients had wall motion abnormalities suggestive of stress-induced cardiomyopathy. Using Spearman rank correlation, there was an inverse relationship between high-sensitivity troponin T and left ventricular ejection fraction (ρ = −0.34, P = .006). Among 20 patients with prior echocardiograms, only two (10%) had new reductions in LVEF of >10%. Clinical management was changed in eight individuals (24.2%) in whom TTE was ordered for concern for acute major cardiovascular events and three (14.3%) in whom TTE was ordered for hemodynamic evaluation.

Conclusions

This study describes the clinical indications for use and diagnostic performance of TTE, as well as findings seen on TTE, in hospitalized patients with COVID-19. In appropriately selected patients, TTE can be an invaluable tool for guiding COVID-19 clinical management.

COVID-19 and Cardiovascular Disease

Coronavirus disease 2019 (COVID-19) is a global pandemic affecting 185 countries and >3 000 000 patients worldwide as of April 28, 2020. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, which invades cells through the angiotensin-converting enzyme 2 receptor. Among patients with COVID-19, there is a high prevalence of cardiovascular disease, and >7% of patients experience myocardial injury from the infection (22% of critically ill patients). Although angiotensin-converting enzyme 2 serves as the portal for infection, the role of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers requires further investigation. COVID-19 poses a challenge for heart transplantation, affecting donor selection, immunosuppression, and posttransplant management. There are a number of promising therapies under active investigation to treat and prevent COVID-19.

Outcome of cataract extraction and posterior chamber intraocular lens implantation following glaucoma filtration surgery

PURPOSE

To evaluate the outcome of cataract extraction (CE) after glaucoma filtering surgery (GFS).

METHODS

A total of 77 eyes (77 patients) who underwent CE with posterior chamber intraocular lens (PCIOL) implantation following GFS by a single surgeon were reviewed. Main outcome measures were preoperative and postoperative intraocular pressures (IOPs), visual acuities, medications, astigmatism, bleb survival, time of surgical failure, complications, and success rate.

RESULTS

Mean time interval between GFS and CE was 46.8+/-50.9 months (range, 2-348 months). The mean preoperative IOP was 13.9+/-4.7 mmHg (range 3-27 mmHg) and mean postoperative IOP at 3 weeks was 13.6+/-5.5 mmHg (range, 6-44 mmHg). The mean follow-up was 19.5+/-20.1 months (range, 1.4-73 months; median 10.6 months). Complete success was achieved in 59 eyes (76.7%). The cumulative probability of complete success was 91.3+/-3.7, 82.0+/-5.6 and 78.1+/-6.5% at the end of 6 months, 1, and 2 years, respectively. Visual acuity before CE was < or =20/50 in all eyes (100%). Visual acuity at last visit was > or =20/40 in 33 eyes (42.8 %), 20/50-20/80 in 30 eyes (39.0%), < or =20/100 in 14 eyes (18.2%). Risk factors identified for qualified success included age at CE>60 years, interval of < or =5 months between GFS and CE, use of preoperative glaucoma medications, and postoperative IOP >19 mmHg within 2 weeks.

CONCLUSIONS

IOP and bleb function was maintained after CE with PCIOL implantation following successful GFS with good visual recovery.

Anterior capsular staining with trypan blue for capsulorhexis in mature and hypermature cataracts. A preliminary study

PURPOSE

To study the efficacy and safety of 0.1% Trypan Blue dye to stain the anterior capsule for capsulorhexis in mature and hypermature cataracts.

METHODS

This preliminary study included 25 eyes of 25 patients with a unilateral mature or hypermature cataract, including one case of traumatic mature cataract. In all these cases 0.2 ml of 0.1% trypan blue dye was used to stain the anterior capsule. The efficacy and safety of the dye was evaluated on the basis of intraoperative and postoperative observations.

RESULTS

In all 25 eyes the capsulorhexis was completed. There was peripheral extension of the capsulorhexis in the eye with traumatic cataract and the stained edge of the anterior capsule helped identification and redirection of the capsulorhexis. Successful phacoemulsification with intraocular lens implantation was performed in all eyes. Adverse reactions related to the dye such as raised intraocular pressure, anterior chamber inflammation and endothelial damage were not observed in the immediate postoperative period or at the end of mean follow-up of 3 months.

CONCLUSION

Trypan blue dye staining of the anterior capsule appears to be a very useful and safe technique that simplifies capsulorhexis in mature and hypermature cataracts.

Measuring professionalism in a physiatry residency training program

A 12-item questionnaire modeled after the one prepared by the American Board of Internal Medicine dealing with professionalism was distributed to 122 physiatry residents representing six training programs, of whom 59% (72) responded. The mean item score on the survey was 7.7 (SD = 1.0) on a scale from 1 to 10, where 10 represents the highest level of professionalism. The internal reliability of the questionnaire was found to be satisfactory (Cronbach's alpha = 0.75). A factor analysis of the questionnaire items resulted in three factors explaining 64% of the variance. These factors were: excellence, honor/integrity, and altruism/respect; Eigen values were 3.35, 2.37, and 1.31, respectively. These factors are similar to those obtained in the American Board of Internal Medicine survey. This similarity is a positive feature in ongoing efforts to develop a reliable tool for measuring professionalism in physiatry residency training.

One program's experience of OSCE vs. written board certification results: a pilot study

The objective structured clinical examination (OSCE) has been the focus of a lot debate with respect to reliability and validity. Much of the controversy surrounding these components lies in a lack of comparison with a "gold standard." Further work is needed to improve the evaluation of clinical skills to the point that a gold standard can truly be said to exist.

Malignant melanoma of ciliary body: a case report

Ocular malignant melanomas are infrequently seen in Indian patents and most them involve the choroid. Ciliary body malignant melanoma is rather rare. This case report illustrates an occurrence in an Indian patient.

Lipaemia retinalis in a case of juvenile diabetic ketoacidosis

A rare case of diabetic retinal lipaemia is described in a 5-year-old child.

Evidence-based medicine in physiatry: the experience of one department's faculty and trainees

Evidence-based medicine is regarded by many as the new paradigm in medical practice. Sixty-seven medical school faculty and trainees in a physical medicine and rehabilitation department were surveyed with regard to training and competence in the use of evidence-based medicine techniques. The majority of subjects in the present study supported the use of evidence-based medicine techniques, although a number of the respondents indicated that they lacked adequate training or competence in their use. It is suggested that medical schools and physiatry residency programs provide a greater emphasis on training in evidence-based medicine. Recommendations are provided that individuals can use to develop a systematic strategy to keep up with the rapidly expanding medical literature.

Physiatric research fellows' perceptions of the quality of their training

A survey was conducted to evaluate the physiatric research fellowship training. A 22-item questionnaire was sent to the 42 identified physiatrists who had completed at least a 1-yr research fellowship. Twenty-nine of these individuals (69%) responded. The physiatrists, all of whom have completed their research fellowships, uniformly cited competent faculty research mentors as being critical, even if they were not in the same department. Having protected research time as well as a research didactic program and journal club were highly rated issues. The trainees preferred a 2-yr fellowship that also stressed initiation of their own research, grant writing and management experience, and first authorship on research papers. We conclude that the majority of the research fellows agree on what are important issues with respect to their training.

Further experience in development of an objective structured clinical examination for physical medicine and rehabilitation residents

Since the last report, two additional objective structured clinical examinations (PGY-2, PGY-3, and PGY-4, as well as incoming PGY-2) have been administered. As a result, our curriculum has been modified to strengthen physical examination skills, including specific workshops. Interrater reliability of evaluators has been tested for the first time to verify reliability, and refinements have been made in the standardized checklist grading system. The interrater grading of history-taking had good reliability (0.73-0.96), as did neurological and spine physical examination (0.84-0.88). The interrater grading reliability of small and large joint examination was more problematic (0.46-0.62) because of examiners' inability to have full visibility, evaluator's fatigue, and confusing evaluation scoring descriptions. We now use a two-point grading scale (correct or incorrect) for history but continue a three-point scale (correct, partially correct, or incorrect) for physical examination. The examination schedule is being modified to add more encounters, give time for trainee feedback, and further refinement of grading expectations for a more efficient and reliable scoring system.

Residency training in physiatry during a time of change: funding of graduate medical education and other issues

Decision makers at the federal and state level are considering, and some states have enacted, a reduction in total United States residency positions, a shift in emphasis from specialist to generalist training, a need for programs to join together in training consortia to determine local residency position allocation strategy, a reduction in funding of international medical graduates, and a reduction in funding beyond the first certificate or a total of five years. A 5-page, 24-item questionnaire was sent to all physiatry residency training directors. The objective was to discern a descriptive database of physiatry training programs and how their institutions might respond to cuts in graduate medical education funding. Fifty-eight (73%) of the questionnaires were returned. Most training directors believe that their primary mission is to train general physiatrists and, to a much lesser extent, to train subspecialty or research fellows. Directors were asked how they might handle reductions in house staff such as using physician extenders, shifting clinical workload to faculty, hiring additional faculty, and funding physiatry residents from practice plans and endowments. Physiatry has had little experience (29%; 17/58) with voluntary graduate medical education consortiums, but most (67%; 34/58) seem to feel that if a consortium system is mandated, they would favor a local or regional over a national body because they do not believe the specialty has a strong enough national stature. The major barriers to a consortium for graduate medical education allocation were governance, academic, fiscal, bureaucratic, and competition.

Chronic fatigue syndrome: a literature review from a physiatric perspective

To examine the literature on chronic fatigue syndrome (CFS), especially as it relates to cognitive deficits and exercise, more than 200 articles related to CFS were selected from computer-based research as well as pertinent articles noted in the references of individual articles. All were relevant articles on CFS, although articles in a foreign language were excluded. CFS is a controversial diagnosis of exclusion, but certain subgroups do appear to exist. It may represent multiple diseases or multiple stages of the same disease. Although cognitive deficits are commonly reported, the measured impairments are relatively subtle and are in the area of complex information processing speed, or efficiency. Magnetic resonance imaging, single-photon emission computer tomography, and neuroendocrine studies present preliminary evidence suggestive of the cerebral involvement primarily in the white matter. The weakness and fatigue may be the result of alterations in the central nervous system, not in the peripheral muscles. However, it is hard to separate the documented weakness and endurance deficits from deconditioning. Autonomic symptoms such as orthostatic intolerance and a predisposition to neurally mediated syncope may be explained by cardiovascular deconditioning, a postviral idiopathic autonomic neuropathy, or both. The review points out the need for more carefully designed studies of CFS that focus on the relationship between neuropathology, psychopathology and neuropsychologic functioning. The role of exercise as a stimulus for exacerbation or in treatment needs to be further studied using clear diagnostic criteria as well as control groups that carefully match the activity level.

Clinical dysautonomia in diabetes mellitus--a study with seven autonomic reflex function tests

Thirty-eight patients of NIDDM, 12 of IDDM and 10 healthy age matched controls were subjected to seven standardised autonomic reflex function tests. A scoring criteria was utilised for diagnosing and grading the severity of dysautonomia. Eight patients of IDDM and 24 of NIDDM had dysautonomia. One-third of the patients in each group had grade IV autonomic dysfunction. Severity of autonomic dysfunction was directly related to the duration of disease in NIDDM whereas in IDDM this relation was not seen. Peripheral neuropathy was almost always associated with dysautonomia in NIDDM. On the contrary, in IDDM dysautonomia was independent of peripheral neuropathy. Charcot's arthopathy, dysphagia, constipation and nocturnal diarrhea were always associated with evidence of dysautonomia. Other symptoms viz. gustatory sweating, postural dizziness and impotence did not necessarily indicate dysautonomia.

Practice and career satisfaction among physiatrists. A national survey

To evaluate physiatrist career satisfaction and current practice patterns, a 15-page survey was mailed randomly to 400 fellow members of the American Academy of Physical Medicine and Rehabilitation. The 208 questionnaires (52%) returned revealed respondents' level of satisfaction with career choice, current practice, relationships with other physicians, their own residency training, and problems experienced that impede their practice. Factor analysis identified six areas of satisfaction: time demands, organizational support, current practice, current specialty, profession, and training. Problems with work consisted of four factors: external intrusions into practice, having to deal with non-rehabilitation problems, dealing with PM&R problems, and insufficient time for patients. Results showed that 75% of physiatrists were satisfied with their practice/profession. Satisfaction with current practice was greater with fewer external intrusions into practice, a larger percentage of income from traditional non-managed payment sources (including Medicaid), and less competition. Changes in health care, such as managed care, competition, and increased external regulations, appear to interfere with current practice. Variation in satisfaction was not significantly correlated with size of community, variation in rates of payment denials, workloads of greater than 50 hours per week, and a number of other factors that one might expect to affect satisfaction. Physiatrists had made many changes in their practice in response to the changes in the health care environment but had not cut care for indigent patients. Needs for greater residency training in outpatient clinics, physicians' offices, managed care, and long-term care settings were expressed. This is the first comprehensive published report on physiatric satisfaction in a changing health care environment. Further research in some of the areas will be required.

Development of an objective structured clinical examination (OSCE) for physical medicine and rehabilitation residents

Clinical competency is poorly measured by knowledge-based written examinations. A five-station, four-interstation objective structured clinical examination (OSCE) has been developed in consultation with the National Board of Medical Examiners as a pilot study to standardize assessment methods that serve to evaluate the clinical competency of senior physical medicine and rehabilitation residents. Various stations demonstrating musculoskeletal and neurologic conditions commonly encountered in physiatric practice were included, incorporating the use of standardized patients into the OSCE format. This is a descriptive study of individual stations-evaluated history-taking, physical examination, and communication skills, whereas the interstations measured the residents' ability to write therapy and prosthetic/orthotic prescriptions, as well as interpret x-ray and electrodiagnostic data. The OSCE program development including case background, principal tasks, time allotment, evaluation objectives, performance criteria, therapeutic plan, standardized patients case descriptions, and assessment checklists as well as the training procedure is discussed. Additionally, cost analysis and scheduling issues are reviewed. This information should aid other training programs or consortiums in developing similar clinical evaluation tools.

Clinical assessment of autonomic functions in anemics

Sixty five anemics and 20 healthy control subjects carefully age and sex matched were subjected to seven standardised tests to evaluate autonomic status. Due care was taken to remove factors which could interfare with the results. Tests concerned with the basal parasympalhetec tone viz heart rate response to standing (p < 0.001) and intravenous atropine test (p < 0.05) showed significant difference which persisted with severity and type of anemia. Test requiring stimulation of the parasympathatic system i.e. deep breathing test, valsalva maneuver and carotid sinus massage did show not significant difference. No difference of significance was found with postural fall of blood pressure and sustained hand grip test, chiefly concerned with the sympathatic system. These results suggest that anemics have low basal parasympathatic outflow to increase the heart rate as compensatory mechanism. Stimulation of parasympathatic and sympathetic system arouse normal response.

Factors influencing the specialty choice of the physical medicine and rehabilitation graduating class of 1994 and the entering class of 1995

To understand better how career choices are made by physiatrists, a 16-item, 7-page questionnaire was sent to all 1994 graduating physical medicine and rehabilitation (PM&R) resident physicians in the United States. Of the 343 senior residents, 202 completed the questionnaire for a response rate of 59%. The questionnaire focused on the following areas: timing of the decision to enter PM&R; and how the medical school curriculum, certain groups of people, and certain specific factors influenced their choices. There were 130 factors modeled after the American Association of Medical Colleges (AAMC) annual medical student questionnaire that the recipients were asked to grade on a numerical scale: 1 = unimportant to 5 = very important. Of the graduating residents, 60.1% (119/198) made the decision to enter PM&R in their 3rd or 4th yr of medical school, 13.1% (26/198) in the first 2 yr, and 11.1% (22/198) after starting another residency. The five factors ranked most important in the decision were (mean rank score): sufficient time/flexibility for family obligations (4.60); opportunity to make a difference in peoples lives (4.57); interest in helping people (4.55); types of patient problems encountered (4.50); and consistency with personality (4.49). We also obtained the AAMC's 1993 annual data on medical students choosing PM&R. Their top five factors were the same as those listed by the graduating residents, but in a slightly different rank order. Profiles have also been derived on those graduating PM&R residents who chose an academic career (n = 68) v nonacademic (n = 133) and fellowship (n = 34) v nonfellowship (n = 163).

Postoperative transcutaneous oxygen measurement in the prediction of delayed wound healing and prosthetic fitting among amputees during rehabilitation. A pilot study

Postoperative assessment of amputation wound healing remains largely subjective in nature, being based on the physician's clinical judgement. These considerations significantly impact on the rehabilitation course, as premature prosthetic fitting may result in wound breakdown. Alternatively, delayed healing may result in prolonged hospital length of stay. Few attempts have been made to correlate objective parameters of limb perfusion with amputation wound healing or prosthetic fitting outcome during the rehabilitation phase of treatment. A pilot study was conducted, in which the transcutaneous oxygen monitor, a noninvasive device measuring transcutaneous partial pressure of oxygen (tcpO2), was applied to the stumps of 11 consecutive above-or below-knee amputees admitted for rehabilitation after amputation. All patients were tested within 1 wk of admission and 45 days of amputation. The treatment team was blinded as to the test results. A direct correlation was observed between wound healing outcome and tcpO2 results (Fisher's exact test [FET], P = 0.03), and no patient with a tcpO2 of < or 15 mm Hg healed during their rehabilitation stay (FET, P = 0.006). TcpO2 of < or = 15 mm Hg was significantly correlated with prolonged length of stay (Point Biserial Correlation Coefficient [rpbi], = -0.835; P = 0.01), delayed prosthetic fitting (rpbi = 0.742; p = 0.01), and poorer wound healing at admission (rpbi = 0.932; P = 0.001). Postoperative tcpO2 measurement may have use in objectively identifying patients at greater risk of delayed wound healing and prosthetic fitting, although further study is warranted.

Methods used in the evaluation of clinical competency of physical medicine and rehabilitation residents

A 17-item questionnaire was designed to determine how physical medicine and rehabilitation (PM&R) training directors assess their residents' clinical competency. A response rate of 83% (62/75) was obtained. Seventy-nine percent (49/62) have a written resident supervision policy, and 73% (45/62) have a written resident probation policy. Ninety-four percent (58/62) believe that their system of evaluating residents' clinical competency is effective, although many commented that it could be improved. 76% (47/62) of the residency training directors made the final decision regarding residents' clinical competency. Fifty-two percent (32/62) have a departmental written examination, and 23% (14/62) have formal oral examinations. Eighteen percent (11/62) use an objective structured clinical examination (OSCE), 8% (5/62) use standardized patients and 3% (2/62) use videotaped patient encounters. Forty percent (25/62) use medical record audits. Fifty percent of the programs have rated at least one resident unsatisfactory during a clinical rotation in the past 3 yr, and 11% (7/62) have reported to the American Board of Physical Medicine and Rehabilitation that the overall clinical evaluation of one resident was unsatisfactory in the past 3 yr. Forty-seven percent (29/62) of the programs have asked at least one resident to leave their program in the past 3 yr. The OSCE is emerging as the state-of-the-art method for assessing clinical skills, although it is expensive. The measurement of clinical competency is important in the certification and recertification process, and our specialty needs better methods to assess these performance skills.

Factors used by physical medicine and rehabilitation residency training directors to select their residents

A 17-item questionnaire was designed to assess the relative importance of various factors to physical medicine and rehabilitation (PM&R) training directors when ranking PM&R resident applicants during the National Resident Match. The questionnaire was sent to all PM&R residency training directors. The recipients were asked to grade most selection factors based on a numerical scale: 1, unimportant; 2, some importance; 3, important; 4, very important; 5, critical. The specific factors addressed in the questionnaire were: academic criteria, letters of recommendation, individual applicant characteristics and aspects of the interview process. Twelve yes-or-no questions were also designed to determine the weight that residency training directors place on certain academic criteria. A response rate of 88% (66/75) was obtained. The most important academic criteria were grades in a PM&R clerkship in their facility (4.1 +/- 0.8), followed by grades in a PM&R clerkship in another facility (3.6 +/- 0.9). The most important letters of recommendation were from a PM&R faculty member in the respondent's department (4.0 +/- 0.8), followed by the dean's letter (3.7 +/- 1.0) and the PM&R chairman's letter (3.7 +/- 1.0). The three most important applicant characteristics evaluated during the interview were compatibility with the program (4.4 +/- 0.8), the ability to articulate thoughts (4.2 +/- 0.8) and the ability to work with the team (4.2 +/- 0.8). Most program directors used multiple criteria to complete their rank list, but the most important were based upon the interview (4.5 +/- 0.9), letters of recommendation (3.7 +/- 0.9), medical school transcript (3.6 +/- 0.8) and the dean's letter (3.6 +/- 1.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Chief residents in physiatry. Expectations v training

A large majority of physical medicine and rehabilitation residencies have chief resident positions, but little has been written about the expectations of the program directors and the training of the chief resident to fulfill those expectations. A 20-item questionnaire was mailed to 73 program directors in physical medicine and rehabilitation in May 1992. The participants were asked about selection methods, their perception of the duties of the chief resident(s), their concerns about the chief resident(s) position, the training and the evaluation of the chief resident(s). An 85% (62/73) response rate was achieved. There was a chief resident position(s) in 98% of the programs responding. Chief resident selection was made mostly by appointment of the chairman and/or program director and/or the vote of the faculty. The program directors perceived the most important duties of the chief resident to be: act as a liaison between faculty and the residents, act as a role model, do scheduling, build teamwork and give constructive feedback. The most important skills were considered to be leadership and stress management. Causes of concern were time pressure, abuse of power, stress and work overload. Opportunities to develop leadership and administrative/management skills were considered the most exciting aspects of the position. It was surprising, however, that only 15 of 61 (25%) provided some formal training. Only 28 of 61 (46%) had a position description.

A method to assess the trainee profiles of medical students attracted to our physical medicine and rehabilitation residency training program

A 35-item questionnaire was designed to assess the relative importance of various factors to medical students when ranking physical medicine and rehabilitation (PM&R) residency training programs. The questionnaire was used to assess the relative importance of the various factors to three groups of medical students: those who interviewed, those who matched and those who were listed on the match list of the UMDNJ-New Jersey Medical School (NJMS) Department of PM&R, as well as our current residents. Recipients were asked to grade selection factors based on a numerical scale: 1, extremely important; 2, very important; 3, important; 4, minimally important; 5, not important. A response rate of 100% (n = 72 medical students + 25 residents) was attained. The analysis indicates that, overall, there is no significant difference in ranking of the factors by each of the four groups. However, the medical students who recently matched with the UMDNJ-NJMS PM&R program rated the opportunity to conduct research significantly higher than the current house staff or the medical students on the entire match list. This is a desirable result, as the program strives to provide an environment that is conducive to the growth of research and academic physiatrists. This questionnaire could also be used by other residency training directors to guide the development of their program and to gain valuable information regarding the perception of their program among in-coming residents and the importance of various factors to the students interested in their program.

Current status of chairpersons in physical medicine and rehabilitation

There are currently 77 academic departments, divisions or units of physical medicine and rehabilitation (PM&R) in the United States. The authors conducted a survey to develop a profile of the current chairpersons of PM&R, as well as to assess the short- and long-term needs of the field. The survey addressed basic demographic information as well as the level of formal training and/or experience in various management, patient care and academic areas. The level of satisfaction with various aspects of the position such as workload, relationship with the university and role as a researcher were also measured. The chairpersons were asked when they plan to vacate their position and if they felt there were any members of their faculty who are qualified and ready to assume a chairperson position. Those that identified a qualified individual were then asked whether the person had formal training and/or experience in the various management, patient care and academic areas. The results indicate that, although the chairpersons have a high level of job satisfaction with respect to the challenge of the position and their administrative and supervisory roles, they are least satisfied with their role as a researcher. The field must be concerned with this finding, because academic PM&R units in the United States will experience a substantial change in leadership by the end of the 20th century. Approximately 39% of the current chairpersons who returned the questionnaire are planning to step down by 1999, with an additional 37% unsure when they will vacate the position.(ABSTRACT TRUNCATED AT 250 WORDS)

Selecting a physical medicine and rehabilitation residency

A 35-item questionnaire, designed to assess the relative importance of various factors to medical students when ranking physical medicine and rehabilitation (PM&R) residency training programs during the Match, was sent to all members of the 1991 senior class after Match Day. This mailing was coordinated with the National Resident Matching Program. The questionnaire was also sent to all PM&R residency training program directors and all physiatrist faculty members at the University of Medicine and Dentistry of New Jersey--New Jersey Medical School (UMDNJ-NJMS). Recipients were asked to grade selection factors based on a numerical scale: 1, extremely important; 2, very important; 3, important; 4, minimally important; 5, not important. A response rate of 41% (73/179) for medical students, 87% (62/71) for residency training directors and 71% (22/31) for UMDNJ-NJMS faculty members was attained. Analysis of the results indicates that, overall, there is no significant difference in ranking of the factors by each of the three groups surveyed. The intergroup responses for one-third of the factors were significantly different. Diversity of the training experience, current house officer satisfaction, it "feels" right and house officer quality were the four most important selection factors to the medical students.

Resident interest in physical medicine and rehabilitation fellowships. Results of a survey

Physiatry, one of the six medical specialties that does not currently offer added or special qualification certification examinations, does not have accredited fellowships in potential subspecialty areas. These issues are currently being debated by the leadership organizations within physical medicine and rehabilitation such as the Association of Academic Physiatrists, the American Academy of Physical Medicine and Rehabilitation, the Physical Medicine and Rehabilitation Residency Review Committee and the American Board of Physical Medicine and Rehabilitation. Recent events, such as the establishment of funding agencies with an interest in medical rehabilitation research training, suggest that physiatric fellowships may become more available. A survey was conducted to determine whether physiatric residents desire postresidency training and, if interested, what type of additional training they would seek. This information could be used in formulating policies regarding the establishment, accreditation and certification of subspecialty fellowships within physical medicine and rehabilitation. Of 968 physiatric residents currently in training, 525 (54%) responded to a 22-question survey assessing resident interest regarding fellowship training, the different subspecialty areas, salary expectations, fellowship duration, preferred amount of time devoted to clinical v research work, mentorship, double boarding, accreditation, certification and a section for general comments. The results of the survey indicate considerable interest in fellowship training, which diminishes as residents approach graduation. Residents favored clinically oriented fellowships of 1-yr duration, which should be accredited and certified. Sports medicine was identified as the area of greatest subspecialty interest.

Successful prosthetic fitting of a patient with epidermolysis bullosa dystrophica. Case report

A patient with recessive dystrophic epidermolysis bullosa developed a squamous cell carcinoma of the right foot resulting in a below the knee amputation. Despite the multiple real and potential skin problems of the stump, she was successfully fitted with a simply designed prosthesis and rehabilitated.