Metabolic equivalents fail to indicate metabolic load in post-myocardial infarction patients during the modified Bruce treadmill walking test

AIM

To investigate the suitability of metabolic equivalents (METs) for determining exercise intensity in phase-IV post-myocardial infarction (MI) men during the modified Bruce treadmill walking test (MBWT).

METHODS

Twenty phase-IV post-MI men (mean±SD, aged 64.4±5.8 years) and 20 healthy non-cardiac male controls (59.8±7.6 years) participated. Participants performed a MBWT. Throughout the participants' heart rate (HR), heart rhythm, expired air parameters and ratings of perceived exertion (RPEs) were measured. MET values were compared between groups and those currently ascribed to each stage of the MBWT.

RESULTS

General linear model analysis found no significant differences between groups during the MBWT for VO2, VCO2, HR, METs or RPEs (Borg 6-20 scale). Ascribed METs did not differ from mean METs of post-MIs or controls other than at stage 5 where post-MI METs were significantly lower. Irrespective, the post-MI group worked at a higher percentage of their anaerobic threshold (AT) (respiratory exchange ratio, RER=1.0) (F(2,5)=7.22, p<0.008), higher RER (F(2,5)=11.25, p<0.001) with increased breathing frequency (F(2,5)=7.22, p<0.001). Regression analysis revealed AT to be VO2 25.6 (mL/kg/min) for post-MI versus VO2 31.1 (mL/kg/min) for controls. Gross energy expenditure (kcal/min) was greater for the post-MI group compared with controls (F(2,5)=11.22, p<0.001). Throughout the MBWT, post-MI group worked at a higher %AT/MET than controls (F(2,196)=211.76, p<0.01). Body composition did not strongly influence %AT/MET, parameters of VO2, METs or RPE.

CONCLUSION

During the MBWT, post-MI men worked more anaerobically per MET (%AT/MET) than controls. Therefore, current METs based on non-cardiac individuals appear unsuitable in determining the full metabolic load of the exercise intensity for cardiac patients during the MBWT.

Automated immunoassays for 25-hydroxyvitamin D (25-OHD): do plasticisers interfere?

The international quality assessment scheme for vitamin D metabolites (DEQAS) was established in 1989. The scheme involves the quarterly distribution of 5 serum samples prepared from blood collected in plain plastic bags. Following transfer of the donors to a clinic using different bags, sera were found to contain a contaminant that interfered in both the local LC-MS/MS assay and the NIST reference measurement procedure for 25-OHD. It seemed likely that the contaminant was a substance, possibly a plasticiser, leached from the plastic bag. It was subsequently suggested that the unidentified contaminant might also cause interference in certain automated non-extraction assays for 25-OHD. This was investigated in 3 automated immunoassays by comparing serum 25-OHD results from blood collected simultaneously into plain glass tubes and plastic bags. There was no significant difference in results, indicating that the leached substance had no effect on any of the 3 immunoassays examined.

Structured care of diabetes in general practice: a qualitative study of the barriers and facilitators

This qualitative study explored general practitioner's and practice nurse's perceptions of barriers and facilitators to the proposed transfer of diabetes care to general practice. Qualitative data were collected through five focus groups. Participants included GPs (n = 55) and practice nurses (n = 11) representing urban (44%), rural (29%) and mixed (27%) practices, in the Irish Mid-West region. Barriers and facilitators were mentioned 631 times (100%). Barriers were mentioned 461 times (73%), facilitators 170 times (27%). The most frequently identified barriers were lack of financial incentive (119/631; 19%), lack of access to secondary resources (93/631; 15%), lack of staff and increased workload (59/631; 9%) and time constraints (52/631; 8%). Identified facilitators were access to secondary care (49/631;7.8%), the holistic nature of general practice and continuity of care (48/631;7.6%). Although many are enthusiastic, there remains significant reluctance among GPs and practice nurses to take responsibility for diabetes care without addressing these barriers.

Apparent improvement in survival for carcinoma of the cervix following the introduction of chemoradiation--a Will Rogers phenomenon

The improved survival for bulky cervical cancers (> 4cm) reported with combination platinum based chemoradiation (1999) prompted a move away from surgery as these cases frequently received adjuvant radiotherapy and were exposed to the morbidity of multimodality treatment. The period pre-1999 (Group 1) was compared with post-1999 (Group 2) when chemoradiation was the preferred treatment for bulky operable cervical cancer. Significantly more cases were treated surgically among Group 1 compared with Group 2 (79% vs. 62%; P < 0.001). Switching from surgery to radiotherapy improved survival in both treatment categories (73% vs. 78% and 37% vs. 44%, respectively) but with no improvement in overall survival (70%/ov.s 70%). Survival (86%) was similar in both groups among surgically treated women with tumors < 4 cm, but significantly more in Group 2 with negative nodes received postoperative adjuvant chemoradiotherapy (Groups 1 vs. 2; 16% vs.37.5%: P < 0.001) and overall the surgically treated patients received more not less multimodality treatment (46.5% vs. 59%; P = 0.7).

Patient satisfaction in radiation oncology

As part of a quality improvement exercise at the Perth Radiation Oncology Centre, a survey was undertaken to ascertain the current level of patient satisfaction with the information they were receiving from their treating radiation oncologist. In addition, the effect of radiation on patients' anxiety levels was investigated. Two questionnaires were given to patients having radical radiotherapy for malignancy. The first questionnaire consisted of the Information Satisfaction Questionnaire and the State Trait Anxiety Index. It was given to patients before the commencement of their course of radiotherapy. The second questionnaire consisted of the State Trait Anxiety Index and was given at the completion of their radiotherapy. A total of 120 patients completed both the questionnaires. The majority of patients were satisfied/very satisfied with the explanation of their illness and radiation toxicities. Fewer patients were satisfied with the explanation of lifestyle (e.g. diet, exercise, smoking) and practical issues such as parking and treatment costs. The patients showed a statistically significant reduction in both their State and Trait Anxiety scores following radiotherapy. Following this study, we have developed new information booklets addressing lifestyle and practical issues, which were not being adequately addressed as shown in this study. Our next study will assess the effect of these new information booklets.

At HOME in Scotland: validation of the home observation for measurement of the environment inventory

BACKGROUND

This study used the Home Observation for Measurement of the Environment (HOME) Inventory to measure aspects of the quality and quantity of psychological stimulation and cognitive support available in the home environment of a sample of Scottish children and to examine the effectiveness of this measure in a British context.

METHODS

Forty-seven families who had previously attended parent-training programmes at family centres were assessed. The Middle Childhood (MC) and Early Adolescent (EA) version of the HOME were used with children aged between 8 and 13 years old. Measures of family adversity were also taken.

RESULTS

There were no significant differences in the demographics of the MC-HOME and EA-HOME groups nor in their total HOME scores. Total HOME scores were compared with independent measures of family adversity. The results of the MC-HOME and the EA-HOME were similar to results reported for socially deprived American samples.

DISCUSSION

This Scottish sample had similar MC-HOME and EA-HOME scores as previously reported in American samples and the HOME scores related strongly to family adversity, supplying a proximal link between social conditions and the environment of children. These results suggest that the HOME Inventory is reliable and has concurrent validity with measures of social adversity in a British sample.

Non-specialist management of acute renal failure

In a 12-month prospective study of the initial management of patients with acute renal failure (ARF) in East Kent (population 593 000), we evaluated the initial management of ARF and assessed what proportion of ARF may have been preventable. Patients were seen and assessed on a daily basis, and were followed until discharge from hospital or death; survivors were subsequently followed for 3 years. Overall, 288 patients developed ARF (486 per million population/year). Mean age at presentation was 73 years (range 14-96). Initial assessment was often suboptimal, and key features in investigation and initial management were often lacking. In 108 cases, ARF was iatrogenic and/or potentially preventable (53 preventable, 99 iatrogenic, 44 both). Overall survival was 56% at discharge from hospital, 35% at 1-year follow-up, 31% at 2 years, and 28% at 3 years. In discharged patients, recovery of function was complete in 69%. A significant proportion of ARF is preventable. Clear guidelines, easily accessible at the point of care, could aid the diagnostic evaluation of the patient with ARF and indicate where referral for a specialist opinion is appropriate.

Three-year follow-up of the Oxford Cholesterol Study: assessment of the efficacy and safety of simvastatin in preparation for a large mortality study

We report the results of a randomized single-centre study designed to assess the effects of simvastatin on blood lipids, blood biochemistry, haematology and other measures of safety and tolerability in preparation for a large-scale multicentre mortality study. Six hundred and twenty-one individuals considered to be at increased risk of coronary heart disease were randomized, following a 2-month placebo 'run-in' period, to receive 40 mg daily simvastatin, 20 mg daily simvastatin or matching placebo. Their mean age was 63 years, 85% were male, 62% had a history of prior myocardial infarction (MI), and the mean baseline total cholesterol was 7.0 mmol.l-1. Median follow-up in the present report is 3.4 years. Eight weeks after randomization, 40 mg daily simvastatin had reduced non-fasting total cholesterol by 29.2% +/- 1.1 (2.03 +/- 0.08 mmol.l-1) and 20 mg daily simvastatin had reduced it by 26.8% +/- 1.0 (1.87 +/- 0.07 mmol.l-1). Almost all of the difference in total cholesterol at 8 weeks was due to the reduction in LDL cholesterol (40.8% +/- 1.6 and 38.2% +/- 1.4 among patients allocated 40 mg and 20 mg of simvastatin daily respectively), but simvastatin also reduced triglycerides substantially (19.0% and 17.3%) and produced a small increase in HDL cholesterol (6.4% and 4.8%). These effects were largely sustained over the next 3 years, with 40 mg daily simvastatin producing a slightly greater reduction in total cholesterol at 3 years (25.7% +/- 1.9 reduction) than did 20 mg daily simvastatin (22.2% +/- 1.8). There were no differences between the treatment groups in the numbers of reports of 'possible adverse effects' of treatment or of a range of different symptoms or conditions (including those related to sleep or mood) recorded at regular clinic follow-up. Mean levels of alanine aminotransferase, aspartate aminotransferase and creatine kinase were slightly increased by treatment, but there were no significant differences between the treatment groups in the numbers of patients with significantly elevated levels. A slightly lower platelet count in the simvastatin group was the only haematological difference from placebo, with no difference in the numbers of patients with low platelet counts. In summary, the simvastatin regimens studied produced large sustained reductions in total cholesterol, LDL cholesterol and triglyceride and small increases in HDL cholesterol. They were well tolerated, with no evidence of serious side-effects during the first 3 years of this study.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of intravenous clonidine on the forearm circulation

The effect of two doses of clonidine on forearm blood flow was compared with an inert treatment using mercury strain gauge venous occlusive plethysmography. In the clonidine treated groups, forearm blood flow was unaffected in the resting state, but decreased sharply with tracheal intubation. In the saline group, blood flow increased with intubation. Forearm vascular resistance increased in the clonidine treated groups, but decreased in the saline group. These results suggest that clonidine has a peripheral action in anaesthetised normotensive individuals, and is not a purely centrally acting drug.

Rural/urban differences of diabetes--impaired glucose tolerance, hypertension, obesity, glycosolated haemoglobin, nutritional proteins, fasting cholesterol and apolipoproteins in Fijian Melanesians over 40

Two populations of Fijian Melanesians over 40 years of age were compared. The first population was located in a remote rural area and the other in an urban environment. There was no significant difference between the two populations in age, height and diastolic blood pressure. Highly significant differences were observed in mean weight, body mass index, prevalence of impaired glucose tolerance, prevalence of diabetes, mean glycosolated haemoglobin, mean systolic blood pressure, fasting cholesterol, immunological albumin, immunological transferrin, and A1 and B apolipoproteins. The higher value was associated with urban living. Thus urban living is associated with obesity, impaired glucose tolerance, diabetes, higher systolic blood pressure, higher levels of fasting lipids and increased risk factors for cardiovascular disease.

Adaptation of coenzyme stimulation assays for the nutritional assessment of vitamins B1, B2 and B6 using the Cobas Bio centrifugal analyser

Adaptation of coenzyme stimulation assays for the nutritional assessment of thiamine, riboflavin and pyridoxine on the Cobas Bio centrifugal analyser are described. Whole blood was collected into acid-citrate dextrose, which preserves the erythrocytes, prior to assay for several days. Washed erythrocytes stored at -70 degrees C and subsequently thawed, showed altered enzyme activities. The methods offer improved precision over existing procedures and take advantage of the high throughput capabilities of the instrumentation.

Fibre-optic bronchoscopy in small cell lung cancer: findings pre and post chemotherapy

The aim of our study was to evaluate the role of fibre-optic bronchoscopy both in diagnosing patients with small cell lung cancer, and in assessing remission status following combination chemotherapy. Diagnostic bronchoscopic examination was performed in 40 patients and revealed that in all cases the lesion was located in the central bronchi. Following combination chemotherapy remission status in 18 patients was assessed by comparing the findings at repeat bronchoscopy with those of chest radiology. In ten patients there was no relationship between the findings at bronchoscopic examination and the chest radiograph (normal or abnormal). Adequate assessment of response of small cell lung cancer to therapy requires bronchoscopy in addition to chest radiology.

Interdisciplinary inpatient warfarin education program

An educational program on warafarin counseling for inpatients of a 200--bed community hospital which uses both pharmacy and nursing personnel is described. Following a physician's request for the educational service, a registered nurse arranged for the patient to view a slide presentation of anticoagultants and provided a booklet designed to reinforce the learning objectives for the warfarin education program. After the patient viewed the film and read the booklet, a pharmacist or nurse made a follow-up visit to answer questions and reinforce the objectives. The checklist of learning objectives was completed by the pharmacist or nurse and remained in the patient's chart as a permanent record of medication counseling. Forty-five request for warfarin patient education were received during the program's first six months of operation. The pharmacist spent an average of 30 minutes with each patient; the nurse spent an average of 15 to 20 minutes with each patient. The average time required of nursing and pharmacy service to provide the program was one and two hours per week, respectively. The warfarin education program provides an important patient service with a reasonable expenditure of time by pharmacy and nursing personnel.

Interdisciplinary diabetic team in a community hospital

An interdisciplinary diabetic team which provides inpatient and outpatient diabetic instructional services in a 200-bed community hospital is discussed. The team consists of a pharmacist, a dietitian, and a registered nurse, each of whom is assigned to a specific area of diabetic education. Instructional objectives include coordination of teaching efforts by hospital personnel, standardization of education, and development of evaluation procedures. Upon notification of a physician request for diabetic team services, a form which contains competency-based instructional objectives and patient referral questions is placed in the patient's chart. Diabetic instruction may then be initiated by ward personnel or a member of the diabetic team. Outpatient classes are offered for those who desire or require additional or indepth instruction.