Comparative analysis of mortality in patients admitted with an infection with influenza A/B virus, respiratory syncytial virus, rhinovirus, metapneumovirus or SARS-CoV-2

Background

While influenza virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are recognised as a cause of severe illness and mortality, clinical interest for respiratory syncytial virus (RSV), rhinovirus and human metapneumovirus (hMPV) infections is still limited.

Methods

We conducted a retrospective database study comparing baseline characteristics and 30-day mortality in a large cohort of adult patients admitted for an overnight stay or longer with an influenza virus (A/B), rhinovirus, hMPV, RSV or SARS-CoV-2 infection. For non-SARS-CoV-2 viruses, data were included for the period July 2017-February 2020. For SARS-CoV-2, data between March 2020 and March 2022 were included.

Results

Covariate-adjusted 30-day mortality following RSV, hMPV or rhinovirus infections was substantial (crude mortality 8-10%) and comparable with mortality following hospitalisation with an influenza A virus infection. Mortality following a SARS-CoV-2 infection was consistently higher than for any other respiratory virus, at any point in time (crude mortality 14-25%). Odds of mortality for SARS-CoV-2 compared with influenza A declined from 4.9 to 1.7 over the course of the pandemic. Patients with SARS-CoV-2 infection had less comorbidity than patients with other respiratory virus infections and were more often male. In this cohort, age was related to mortality following hospitalisation, while an association with comorbidity was not apparent.

Conclusions

With the exception of SARS-CoV-2 infections, we find the clinical outcome of common respiratory virus infections requiring hospitalisation more similar than often assumed. The observed mortality from SARS-CoV-2 was significantly higher, but the difference with other respiratory viruses became less distinct over time.

MicroRNA-208b progressively declines after spinal cord injury in humans and is inversely related to myostatin expression

The effects of long-term physical inactivity on the expression of microRNAs involved in the regulation of skeletal muscle mass in humans are largely unknown. MicroRNAs are short, noncoding RNAs that fine-tune target expression through mRNA degradation or by inhibiting protein translation. Intronic to the slow, type I, muscle fiber type genes MYH7 and MYH7b, microRNA-208b and microRNA-499-5p are thought to fine-tune the expression of genes important for muscle growth, such as myostatin. Spinal cord injured humans are characterized by both skeletal muscle atrophy and transformation toward fast-twitch, type II fibers. We determined the expression of microRNA-208b, microRNA-499-5p, and myostatin in human skeletal muscle after complete cervical spinal cord injury. We also determined whether these microRNAs altered myostatin expression in rodent skeletal muscle. A progressive decline in skeletal muscle microRNA-208b and microRNA-499-5p expression occurred in humans during the first year after spinal cord injury and with long-standing spinal cord injury. Expression of myostatin was inversely correlated with microRNA-208b and microRNA-499-5p in human skeletal muscle after spinal cord injury. Overexpression of microRNA-208b in intact mouse skeletal muscle decreased myostatin expression, whereas microRNA-499-5p was without effect. In conclusion, we provide evidence for an inverse relationship between expression of microRNA-208b and its previously validated target myostatin in humans with severe skeletal muscle atrophy. Moreover, we provide direct evidence that microRNA-208b overexpression decreases myostatin gene expression in intact rodent muscle. Our results implicate that microRNA-208b modulates myostatin expression and this may play a role in the regulation of skeletal muscle mass following spinal cord injury.

Altered content of AMP-activated protein kinase isoforms in skeletal muscle from spinal cord injured subjects

AMP-activated protein kinase (AMPK) is a pivotal regulator of energy homeostasis. Although downstream targets of AMPK are widely characterized, the physiological factors governing isoform expression of this protein kinase are largely unknown. Nerve/contractile activity has a major impact on the metabolic phenotype of skeletal muscle, therefore likely to influence AMPK isoform expression. Spinal cord injury represents an extreme form of physical inactivity, with concomitant changes in skeletal muscle metabolism. We assessed the influence of longstanding and recent spinal cord injury on protein abundance of AMPK isoforms in human skeletal muscle. We also determined muscle fiber type as a marker of glycolytic or oxidative metabolism. In subjects with longstanding complete injury, protein abundance of the AMPKγ3 subunit, as well as myosin heavy chain (MHC) IIa and IIx, were increased, whereas abundance of the AMPKγ1 subunit and MHC I were decreased. Similarly, abundance of AMPKγ3 and MHC IIa proteins were increased, whereas AMPKα2, -β1, and -γ1 subunits and MHC I abundance was decreased during the first year following injury, reflecting a more glycolytic phenotype of the skeletal muscle. However, in incomplete cervical lesions, partial recovery of muscle function attenuated the changes in the isoform profile of AMPK and MHC. Furthermore, exercise training (electrically stimulated leg cycling) partly normalized mRNA expression of AMPK isoforms. Thus, physical activity affects the relative expression of AMPK isoforms. In conclusion, skeletal muscle abundance of AMPK isoforms is related to physical activity and/or muscle fiber type. Thus, physical/neuromuscular activity is an important determinant of isoform abundance of AMPK and MCH. This further underscores the need for physical activity as part of a treatment regimen after spinal cord injury to maintain skeletal muscle metabolism.

Insulin-mediated suppression of lipolysis in adipose tissue and skeletal muscle of obese type 2 diabetic men and men with normal glucose tolerance

AIMS/HYPOTHESIS

Impaired regulation of lipolysis and accumulation of lipid intermediates may contribute to obesity-related insulin resistance and type 2 diabetes mellitus. We investigated insulin-mediated suppression of lipolysis in abdominal subcutaneous adipose tissue (AT) and skeletal muscle (SM) of obese men with normal glucose tolerance (NGT) and obese type 2 diabetic men.

METHODS

Eleven NGT men and nine long-term diagnosed type 2 diabetic men (7 ± 1 years), matched for age (58 ± 2 vs 62 ± 2 years), BMI (31.4 ± 0.6 vs 30.5 ± 0.6 kg/m(2)) and [Formula: see text] (28.9 ± 1.5 vs 29.5 ± 2.4 ml kg(-1) min(-1)) participated in this study. Interstitial glycerol concentrations in AT and SM were assessed using microdialysis during a 1 h basal period and a 6 h stepwise hyperinsulinaemic-euglycaemic clamp (8, 20 and 40 mU m(-2) min(-1)). AT and SM biopsies were collected to investigate underlying mechanisms.

RESULTS

Hyperinsulinaemia suppressed interstitial SM glycerol concentrations less in men with type 2 diabetes (-7 ± 6%, -13 ± 9% and -27 ± 9%) compared with men with NGT (-21 ± 7%, -38 ± 8% and -53 ± 8%) (p = 0.014). This was accompanied by increased circulating fatty acid and glycerol concentrations, a lower glucose infusion rate (21.8 ± 3.1 vs 30.5 ± 2.0 μmol kg body weight(-1) min(-1); p < 0.05), higher hormone-sensitive lipase (HSL) serine 660 phosphorylation, increased saturated diacylglycerol (DAG) lipid species in the muscle membrane and increased protein kinase C (PKC) activation in type 2 diabetic men vs men with NGT. No significant differences in insulin-mediated reduction in AT interstitial glycerol were observed between groups.

CONCLUSIONS/INTERPRETATION

Our results suggest that a blunted insulin-mediated suppression of SM lipolysis may promote the accumulation of membrane saturated DAG, aggravating insulin resistance, at least partly mediated by PKC. This may represent an important mechanism involved in the progression of insulin resistance towards type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01680133.

Regulation of miRNAs in human skeletal muscle following acute endurance exercise and short-term endurance training

  The identification of microRNAs (miRNAs) has established new mechanisms that control skeletal muscle adaptation to exercise. The present study investigated the mRNA regulation of components of the miRNA biogenesis pathway (Drosha, Dicer and Exportin-5), muscle enriched miRNAs, (miR-1, -133a, -133b and -206), and several miRNAs dysregulated in muscle myopathies (miR-9, -23, -29, -31 and -181). Measurements were made in muscle biopsies from nine healthy untrained males at rest, 3 h following an acute bout of moderate-intensity endurance cycling and following 10 days of endurance training. Bioinformatics analysis was used to predict potential miRNA targets. In the 3 h period following the acute exercise bout, Drosha, Dicer and Exportin-5, as well as miR-1, -133a, -133-b and -181a were all increased. In contrast miR-9, -23a, -23b and -31 were decreased. Short-term training increased miR-1 and -29b, while miR-31 remained decreased. Negative correlations were observed between miR-9 and HDAC4 protein (r=-0.71; P=0.04), miR-31 and HDAC4 protein (r=-0.87; P=0.026) and miR-31 and NRF1 protein (r=-0.77; P=0.01) 3 h following exercise. miR-31 binding to the HDAC4 and NRF1 3 untranslated region (UTR) reduced luciferase reporter activity. Exercise rapidly and transiently regulates several miRNA species in muscle. Several of these miRNAs may be involved in the regulation of skeletal muscle regeneration, gene transcription and mitochondrial biogenesis. Identifying endurance exercise-mediated stress signals regulating skeletal muscle miRNAs, as well as validating their targets and regulatory pathways post exercise, will advance our understanding of their potential role/s in human health.

Influence of chronic and acute spinal cord injury on skeletal muscle Na+-K+-ATPase and phospholemman expression in humans

Na(+)-K(+)-ATPase is an integral membrane protein crucial for the maintenance of ion homeostasis and skeletal muscle contractibility. Skeletal muscle Na(+)-K(+)-ATPase content displays remarkable plasticity in response to long-term increase in physiological demand, such as exercise training. However, the adaptations in Na(+)-K(+)-ATPase function in response to a suddenly decreased and/or habitually low level of physical activity, especially after a spinal cord injury (SCI), are incompletely known. We tested the hypothesis that skeletal muscle content of Na(+)-K(+)-ATPase and the associated regulatory proteins from the FXYD family is altered in SCI patients in a manner dependent on the severity of the spinal cord lesion and postinjury level of physical activity. Three different groups were studied: 1) six subjects with chronic complete cervical SCI, 2) seven subjects with acute, complete cervical SCI, and 3) six subjects with acute, incomplete cervical SCI. The individuals in groups 2 and 3 were studied at months 1, 3, and 12 postinjury, whereas individuals with chronic SCI were compared with an able-bodied control group. Chronic complete SCI was associated with a marked decrease in [(3)H]ouabain binding site concentration in skeletal muscle as well as reduced protein content of the α(1)-, α(2)-, and β(1)-subunit of the Na(+)-K(+)-ATPase. In line with this finding, expression of the Na(+)-K(+)-ATPase α(1)- and α(2)-subunits progressively decreased during the first year after complete but not after incomplete SCI. The expression of the regulatory protein phospholemman (PLM or FXYD1) was attenuated after complete, but not incomplete, cervical SCI. In contrast, FXYD5 was substantially upregulated in patients with complete SCI. In conclusion, the severity of the spinal cord lesion and the level of postinjury physical activity in patients with SCI are important factors controlling the expression of Na(+)-K(+)-ATPase and its regulatory proteins PLM and FXYD5.

Differential expression of metabolic genes essential for glucose and lipid metabolism in skeletal muscle from spinal cord injured subjects

Skeletal muscle plays an important role in the regulation of energy homeostasis; therefore, the ability of skeletal muscle to adapt and alter metabolic gene expression in response to changes in physiological demands is critical for energy balance. Individuals with cervical spinal cord lesions are characterized by tetraplegia, impaired thermoregulation, and altered skeletal muscle morphology. We characterized skeletal muscle metabolic gene expression patterns, as well as protein content, in these individuals to assess the impact of spinal cord injury on critical determinants of skeletal muscle metabolism. Our results demonstrate that mRNA levels and protein expression of skeletal muscle genes essential for glucose storage are reduced, whereas expression of glycolytic genes is reciprocally increased in individuals with spinal cord injury. Furthermore, expression of genes essential for lipid oxidation is coordinately reduced in spinal cord injured subjects, consistent with a marked reduction of mitochondrial proteins. Thus spinal cord injury resulted in a profound and tightly coordinated change in skeletal muscle metabolic gene expression program that is associated with the aberrant metabolic features of the tissue.

Intra-arterial AICA-riboside administration induces NO-dependent vasodilation in vivo in human skeletal muscle

In animal models, administration of the adenosine analog AICA-riboside has shown beneficial effects on ischemia-reperfusion injury and glucose homeostasis. The vascular and/or metabolic effects of AICA-riboside administration in humans remain to be established. AICA-riboside was infused intra-arterially in four different dosages up to 8 mg x min(-1) x dl(-1) in 24 healthy subjects. Forearm blood flow (FBF) and glucose uptake and plasma glucose, free fatty acid, and AICA-riboside concentrations were assessed. We also combined AICA-riboside infusion (2 mg x min(-1) x dl(-1)) with the intra-arterial administration of the adenosine receptor antagonist caffeine (90 microg x min(-1) x dl(-1); n = 6) and with the endothelial NO synthase inhibitor l-NMMA (0.4 mg x min(-1) x dl(-1); n = 6). Additional in vitro experiments were performed to explain our in vivo effects of AICA-riboside in humans. AICA-riboside increased FBF dose dependently from 2.0 +/- 0.2 to 13.2 +/- 1.9 ml x min(-1) x dl(-1) maximally (P < 0.05 for all dosages). The latter was not reduced by caffeine administration but was significantly attenuated by l-NMMA infusion. Despite high plasma AICA-riboside concentrations, forearm glucose uptake did not change. In vitro experiments showed rapid uptake of AICA-riboside by the equilibrative nucleoside transporter in erythrocytes and subsequent phosphorylation to AICA-ribotide. We conclude that AICA-riboside induces a potent vasodilator response in humans that is mediated by NO. Despite high local plasma concentrations, AICA-riboside does not increase skeletal muscle glucose uptake.

Intravenous AICAR administration reduces hepatic glucose output and inhibits whole body lipolysis in type 2 diabetic patients

AIMS/HYPOTHESIS

The 5'-AMP-activated protein kinase (AMPK) pathway is intact in type 2 diabetic patients and is seen as a target for diabetes treatment. In this study, we aimed to assess the impact of the AMPK activator 5-aminoimidazole-4-carboxamide riboside (AICAR) on both glucose and fatty acid metabolism in vivo in type 2 diabetic patients.

METHODS

Stable isotope methodology and blood and muscle biopsy sampling were applied to assess blood glucose and fatty acid kinetics following continuous i.v. infusion of AICAR (0.75 mg kg(-1) min(-1)) and/or NaCl (0.9%) in ten male type 2 diabetic patients (age 64 +/- 2 years; BMI 28 +/- 1 kg/m(2)).

RESULTS

Plasma glucose rate of appearance (R (a)) was reduced following AICAR administration, while plasma glucose rate of disappearance (R (d)) was similar in the AICAR and control test. Consequently, blood glucose disposal (R (d) expressed as a percentage of R (a)) was increased following AICAR infusion (p < 0.001). Accordingly, a greater decline in plasma glucose concentration was observed following AICAR infusion (p < 0.001). Plasma NEFA R (a) and R (d) were both significantly reduced in response to AICAR infusion, and were accompanied by a significant decline in plasma NEFA concentration. Although AMPK phosphorylation in skeletal muscle was not increased, we observed a significant increase in acetyl-CoA carboxylase phosphorylation (p < 0.001).

CONCLUSIONS/INTERPRETATION

The i.v. administration of AICAR reduces hepatic glucose output, thereby lowering blood glucose concentrations in vivo in type 2 diabetic patients. Furthermore, AICAR administration stimulates hepatic fatty acid oxidation and/or inhibits whole body lipolysis, thereby reducing plasma NEFA concentration.

Substrate source use in older, trained males after decades of endurance training

PURPOSE

The purpose of this study was to compare substrate source use in older, long-term exercising, endurance-trained males with sedentary controls.

METHODS

[U-C]palmitate and [6,6-H2]glucose tracers were applied to assess plasma free fatty acid (FFA) and glucose oxidation rates, and to estimate muscle- and/or lipoprotein-derived triacylglycerol (TG) and muscle glycogen use. Subjects were 10 long-term exercising, endurance-trained males and 10 sedentary controls (age 57 +/- 1 and 60 +/- 2 yr, respectively). Muscle biopsy samples were collected before and after exercise to assess muscle fiber type-specific intramyocellular lipid and glycogen content.

RESULTS

During exercise, plasma palmitate Ra, Rd, and Rox were significantly greater in the trained subjects compared with the controls (Ra: 0.36 +/- 0.02 and 0.25 +/- 0.02; Rd: 0.36 +/- 0.03 and 0.24 +/- 0.02; Rox: 0.31 +/- 0.02 and 0.20 +/- 0.02 mmol.min, respectively, P < 0.01). This resulted in greater plasma FFA and total fat oxidation rates in the trained versus sedentary subjects (P < 0.001). Muscle- and/or lipoprotein-derived TG use contributed 10 +/- 2 and 11 +/- 3% in the trained and control groups, respectively (NS). No significant net changes in muscle fiber lipid content were observed.

CONCLUSIONS

Older, endurance-trained males oxidize more fat during moderate-intensity exercise than do sedentary controls. This greater total fat oxidation rate is attributed to a higher plasma FFA release, uptake, and oxidation rate. In contrast, intramyocellular triacylglycerol does not seem to represent a major substrate source during 1 h of moderate-intensity exercise in older trained or sedentary men.

Skeletal muscle fatty acid transporter protein expression in type 2 diabetes patients compared with overweight, sedentary men and age-matched, endurance-trained cyclists

AIM

Membrane fatty acid transporters can modulate the balance between fatty acid uptake and subsequent storage and/or oxidation in muscle tissue. As such, skeletal muscle fatty acid transporter protein expression could play an important role in the etiology of insulin resistance and/or type 2 diabetes.

METHODS

In the present study, fatty acid translocase (FAT/CD36), plasma membrane-bound fatty acid-binding protein (FABPpm) and fatty acid transport protein 1 (FATP1) mRNA and protein expression were assessed in muscle tissue obtained from 10 sedentary, overweight type 2 diabetes patients (60 +/- 2 years), 10 sedentary, weight-matched normoglycemic controls (60 +/- 2 years) and 10 age-matched, endurance trained cyclists (57 +/- 1 years).

RESULTS

Both FAT/CD36 and FATP1 mRNA and protein expression did not differ between groups. In contrast, FABPpm mRNA and protein expression were approx. 30-40% higher in the trained men compared with the diabetes patients (P < 0.01) and sedentary controls (P < 0.05).

CONCLUSIONS

Skeletal muscle FAT/CD36, FABPpm and FATP1 mRNA and protein expression are not up- or downregulated in a sedentary and/or insulin resistant state. In contrast, FABPpm expression is upregulated in the endurance trained state and likely instrumental to allow greater fatty acid oxidation rates.

Media portrayal of herbal remedies versus pharmaceutical clinical trials: impacts on decision

The use of Complementary and Alternative Medicines (CAM) in Europe and North America is increasing significantly with a concomitant growth in business interest. Users are educated and self-empowered and rely on information sources beyond mainstream medical practitioners. Not surprisingly, media coverage, much of dubious quality, has increased to meet demand for information. Here we present data from a study that explores how knowledge is translated in the socioeconomic-political context of CAM as compared to conventional pharmaceuticals. Specifically, we are interested in the nature of the information provided by clinical trials and the media and how this might impact decision-making regarding the use of CAM versus conventional pharmaceuticals and the reporting of conflicts of interest and industry funding of research. Our results suggest that, in the media, there were significant errors of omission in describing clinical trial quality and a serious under-reporting of risks of herbal remedies. Consumers, who often self-administer CAM are not being provided with information sufficient to make informed choices about treatment alternatives. The next step in the research is to determine whether these reporting dynamics in describing CAM clinical trials differ from those of reporting on pharmaceutical clinical trials.

Significant intramyocellular lipid use during prolonged cycling in endurance-trained males as assessed by three different methodologies

Intramyocellular triacylglycerol (IMTG) has been suggested to represent an important substrate source during exercise. In the present study, IMTG utilization during exercise is assessed through the use of various methodologies. In addition, we identified differences in the use of intramyocellular lipids deposited in the immediate subsarcolemmal (SS) area and those stored in the more central region of the fiber. Contemporary stable isotope technology was applied in combination with muscle tissue sampling before and immediately after 3 h of moderate-intensity cycling exercise (62 +/- 2% Vo(2 max)) in eight well-trained male cyclists. Continuous infusions with [U-13C]palmitate and [6,6-(2)H2]glucose were applied to quantify plasma free fatty acid (FFA) and glucose oxidation rates and to estimate whole body IMTG and glycogen use. Both immunohistochemical analyses of oil red O (ORO)-stained muscle cross sections and biochemical triacylglycerol (TG) extraction were performed to assess muscle lipid content. During exercise, plasma FFA, muscle (and/or lipoprotein)-derived TG, plasma glucose, and muscle glycogen oxidation contributed 24 +/- 2, 22 +/- 3, 11 +/- 1, and 43 +/- 3% to total energy expenditure, respectively. In accordance, a significant net decline in muscle lipid content was observed following exercise as assessed by ORO staining (67 +/- 8%) and biochemical TG extraction (49 +/- 8%), and a positive correlation was observed between methods (r = 0.56; P < 0.05). Lipid depots located in the SS area were utilized to a greater extent than the more centrally located depots. This is the first study to show significant use of IMTG as a substrate source during exercise in healthy males via the concurrent implementation of three major methodologies. In addition, this study shows differences in resting subcellular intramyocellular lipid deposit distribution and in the subsequent net use of these deposits during exercise.

Carbohydrate supplementation during prolonged cycling exercise spares muscle glycogen but does not affect intramyocellular lipid use

Using contemporary stable-isotope methodology and fluorescence microscopy, we assessed the impact of carbohydrate supplementation on whole-body and fiber-type-specific intramyocellular triacylglycerol (IMTG) and glycogen use during prolonged endurance exercise. Ten endurance-trained male subjects were studied twice during 3 h of cycling at 63 +/- 4% of maximal O(2) uptake with either glucose ingestion (CHO trial; 0.7 g CHO kg(-1) h(-1)) or without (CON placebo trial; water only). Continuous infusions with [U-(13)C] palmitate and [6,6-(2)H(2)] glucose were applied to quantify plasma free fatty acids (FFA) and glucose oxidation rates and to estimate intramyocellular lipid and glycogen use. Before and after exercise, muscle biopsy samples were taken to quantify fiber-type-specific IMTG and glycogen content. Plasma glucose rate of appearance (R (a)) and carbohydrate oxidation rates were substantially greater in the CHO vs CON trial. Carbohydrate supplementation resulted in a lower muscle glycogen use during the first hour of exercise in the CHO vs CON trial, resulting in a 38 +/- 19 and 57 +/- 22% decreased utilization in type I and II muscle-fiber glycogen content, respectively. In the CHO trial, both plasma FFA R (a) and subsequent plasma FFA concentrations were lower, resulting in a 34 +/- 12% reduction in plasma FFA oxidation rates during exercise (P < 0.05). Carbohydrate intake did not augment IMTG utilization, as fluorescence microscopy revealed a 76 +/- 21 and 78 +/- 22% reduction in type I muscle-fiber lipid content in the CHO and CON trial, respectively. We conclude that carbohydrate supplementation during prolonged cycling exercise does not modulate IMTG use but spares muscle glycogen use during the initial stages of exercise in endurance-trained men.

Factors associated with teachers’ implementation of HIV/AIDS education in secondary schools in Cape Town, South Africa

This study investigated the factors influencing whether high school teachers implemented HIV/AIDS education. The independent variables included constructs derived from expectancy value theories, teachers' generic dispositions, their training experience, characteristics of their interactive context and the school climate. We conducted a postal survey of 579 teachers responsible for AIDS education in all 193 public high schools in Cape Town. Questionnaires were completed and returned by 324 teachers (56% response rate) from 125 schools. Many teachers (222; 70%) had implemented HIV/AIDS education during 2003, and female teachers were more likely to have implemented than males (74% vs. 58%). The teacher characteristics associated with teaching HIV/AIDS were previous training, self-efficacy, student-centeredness, beliefs about controllability and the outcome of HIV/AIDS education, and their responsibility. The existence of a school HIV/AIDS policy, a climate of equity and fairness, and good school-community relations were the school characteristics associated with teaching HIV/AIDS. These findings demonstrate the value of teacher training and school policy formulation. They also demonstrate the value and importance of interventions that go beyond a sexual health agenda, focussing on broader school development to improve school functioning and school climate.

Substrate source utilisation in long-term diagnosed type 2 diabetes patients at rest, and during exercise and subsequent recovery

AIMS/HYPOTHESIS

Disturbances in substrate source metabolism and, more particularly, in fatty acid metabolism, play an important role in the aetiology and progression of type 2 diabetes. However, data on substrate source utilisation in type 2 diabetes are inconclusive.

METHODS

[U-(13)C]palmitate and [6,6-(2)H(2)]glucose tracers were used to assess plasma NEFA and glucose oxidation rates and to estimate the use of muscle- and/or lipoprotein-derived triacylglycerol and muscle glycogen. Subjects were ten male patients who had a long-term (7 +/- 1 years) diagnosis of type 2 diabetes and were overweight, and ten matched healthy, male control subjects. Muscle biopsy samples were collected before and after exercise to assess muscle fibre type-specific intramyocellular lipid and glycogen content.

RESULTS

At rest and during exercise, the diabetes patients had greater values than the controls for palmitate rate of appearance (Ra) (rest, 2.46 +/- 0.18 and 1.85 +/- 0.20 respectively; exercise, 3.71 +/- 0.36 and 2.84 +/- 0.20 micromol kg(-1) min(-1)) and rate of disappearance (Rd) (rest, 2.45 +/- 0.18 and 1.83 +/- 0.20; exercise, 3.64 +/- 0.35 and 2.80 +/- 0.20 micromol kg(-1) min(-1) respectively). This was accompanied by significantly higher fat oxidation rates at rest and during recovery in the diabetes patients (rest, 0.11 +/- 0.01 in diabetes patients and 0.09 +/- 0.01 in controls; recovery, 0.13 +/- 0.01 and 0.11 +/- 0.01 g/min respectively), despite significantly greater plasma glucose Ra, Rd and circulating plasma glucose concentrations. Furthermore, exercise significantly lowered plasma glucose concentrations in the diabetes patients, as a result of increased blood glucose disposal.

CONCLUSION

This study demonstrates that substrate source utilisation in long-term-diagnosed type 2 diabetes patients, in whom compensatory hyperinsulinaemia is no longer present, shifts towards an increase in whole-body fat oxidation rate and is accompanied by disturbances in fat and carbohydrate handling.

Problem-solving and decision-making preferences: no difference between complementary and alternative medicine users and non-users

The objective of this study was to determine if complementary and alternative medicine (CAM) Users are more autonomous than Non-Users with respect to their preferred role in decision-making (measured by the problem-solving decision-making or PSDM scale). A survey was mailed in spring 2001 to a random sample of 696 men (selected from the Ontario Cancer Registry), aged 18 years or older and diagnosed with prostate cancer in the preceding 2 years. Less than 5% of the 489 (72.1% response rate) men (mean age 68.6 years) who responded to the PSDM question in our survey were classified as having an autonomous role preference, while almost 1/3 of the respondents reported using CAM for their prostate cancer. The majority of respondents were classified as preferring a shared role and a substantial minority was classified as preferring a passive role. There was no statistically significant difference between CAM users and non-users with respect to their preferred role. The hypothesis that CAM Users are more autonomous problem solvers and decision makers is not supported by these findings; however, the generalizability of our results is limited by the fact that we surveyed a relatively older male population only.

Complementary and alternative groups contemplate the need for effectiveness, safety and cost-effectiveness research

OBJECTIVE

To examine the views of complementary and alternative medicine (CAM) groups on the need to demonstrate the effectiveness, safety and cost-effectiveness of their therapies and practices.

DESIGN

Qualitative interviews were conducted with 22 representatives of three CAM groups (chiropractic, homeopathy and Reiki). Qualitative content analysis was used to identify similarities and differences among and across groups.

SETTING

Ontario, Canada.

RESULTS

There were striking differences in the views of the three sets of respondents. The chiropractors agreed that it was essential for their group to provide scientific evidence that their interventions work, are safe and cost-effective. The leaders of the homeopathic group were divided on these points and the Reiki respondents showed virtually no interest in undertaking such research.

CONCLUSIONS

CAM groups that are more formally organized are most likely to recognize the importance of scientific research on their practices and therapies.

Regulation of complementary/alternative medicine: a Canadian perspective

Increased use of complementary/alternative medicine (CAM) therapies by Canadians combined with increasingly forceful lobbying from both practitioner groups and the public have made the regulation of CAM practitioners an important issue for Canadian policy makers. A variety of challenges (including regulatory structures that are difficult to change, fear of adding costs to an already under-funded healthcare system and the lack of internal cohesion of some CAM practitioner groups) are currently hindering attempts to implement new policy. However, an environment of health regulation review and renewal as well as public support for regulation may have created a window of opportunity for investigating policy options. Currently in Canada, health care providers are regulated by individual provinces. This means that although some CAM practitioners are either regulated (e.g. chiropractors) or not regulated (e.g. herbalists, homeopaths) in all provinces; others (e.g. naturopathic practitioners, acupuncture/TCM practitioners) are regulated in some provinces, but not others. Harmonization of regulations and scopes of practice for CAM practitioners across Canada is one of the biggest future challenges.

Building complementary and alternative health care research capacity: workshop report

Lack of research into the safety and efficacy of CAM has been identified as a barrier to collaboration between conventional and CAM practitioners. As an initial step to address this issue, Health Canada held an invitational roundtable discussion with researchers, practitioners and policy makers to explore specific issues related to CAM research capacity and literacy. The objectives of this workshop were to identify and prioritize CAM research infrastructure and training needs; and to identify strategies for meeting high priority needs. Eleven individuals representing three CAM groups, university-based researchers with experience in CAM research, and policy makers attended. Discussion focussed around research literacy, capacity, funding and leadership. Several recommendations were made including an advisory group, a needs assessment, support for research networks, development of learning modules, a review of existing research programmes, support for centres of excellence in CAM research, and funding for research meetings.

Use of complementary/alternative medicine by breast cancer survivors in Ontario: prevalence and perceptions

PURPOSE

To determine the prevalence of use of complementary/alternative medicine (CAM) by breast cancer survivors in Ontario, Canada, and to compare the characteristics of CAM users and CAM nonusers.

PATIENTS AND METHODS

A questionnaire was mailed to a random sample of Ontario women diagnosed with breast cancer in 1994 or 1995.

RESULTS

The response rate was 76.3%. Overall, 66.7% of the respondents reported using CAM, most often in an attempt to boost the immune system. CAM practitioners (most commonly chiropractors, herbalists, acupuncturists, traditional Chinese medicine practitioners, and/or naturopathic practitioners) were visited by 39.4% of the respondents. In addition, 62.0% reported use of CAM products (most frequently vitamins/minerals, herbal medicines, green tea, special foods, and essiac). Almost one half of the respondents informed their physicians of their use of CAM. Multiple logistic regression analysis determined that support group attendance was the only factor significantly associated with CAM use.

CONCLUSION

CAM use is common among Canadian breast cancer survivors, many of whom are discussing CAM therapy options with their physicians. Knowledge of CAM therapies is necessary for physicians and other health care practitioners to help patients make informed choices. CAM use may play a role in the positive benefits associated with support group attendance.

The community care of a patient with a fungating wound

This case study will discuss the treatment of a malignant fungating wound and the effects that it had on a patient and his family. The article also demonstrates how interprofessional working has benefits for patients, carers and staff.

Complementary/alternative medicine: comparing the view of medical students with students in other health care professions

OBJECTIVE

We compared the opinions, knowledge, and attitudes of final-year medical, physiotherapy, occupational therapy, nursing, and pharmacy students about complementary/alternative medicine (CAM).

METHODS

A cross-sectional study questionnaire (n = 442) was administered on site at the University of Western Ontario and the University of Toronto to fourth-year health professions students. Outcome measures were self-reported knowledge, attitude, and perceived usefulness of CAM therapies, the perceived importance of scientific inquiry for the acceptance of CAM, and educational exposure to the topic.

RESULTS

Educational exposure to CAM was correlated with the perceived usefulness of CAM. Medical students reported the least amount of education about CAM and viewed CAM therapies as less useful than did their health professions student peers. Medical students and pharmacy students were more likely than the other health professions students to view traditional scientific forms of evidence as necessary before accepting CAM therapies.

CONCLUSIONS

Perceptions differed among the different health professions student groups about the usefulness of CAM therapies and the kind of evidence needed before they should be incorporated into standard care. This may have important implications for multidisciplinary care.

Access all areas: wound care resources on the Internet

The World Wide Web provides access to a plethora of information on every conceivable topic. More and more, the Internet is been used to access health information, making service users better informed about their conditions and the choice of treatment. It is essential that healthcare professionals embrace this technology so that they are able to access information from around the world. Ideally, access to such technology should be as close as possible to the point of care delivery. The expansion of the NHSnet over the next 3-5 years should make this a reality for more and more practitioners.

Breast cancer survivors' perceptions of complementary/alternative medicine (CAM): making the decision to use or not to use

The study described in this article explored breast cancer survivors' perceptions and experiences as they decided whether to use a variety of complementary/alternative therapies. Six focus groups were conducted composed of women who had been diagnosed with breast cancer. Each 2-hour session was audiotaped and transcribed verbatim. In this article, the process by which the participants made the decision to use or not to use complementary/alternative therapies, including their discovery and investigation of complementary/alternative medicine (CAM) and their experiences using or not using CAM, are described. Barriers to using CAM included cost, access, and time. Family and friends generally supported the decision to use CAM; however, the participants described health care practitioners' reactions as mixed.

Evidence on patient-doctor communication

This chapter covers important and well-studied aspects of patient-doctor communication. First the paper describes the lessons learned from studies about patients' satisfactions or dissatisfactions related to patient-doctor communication, making the point that complaints about doctors are usually due to communication problems and not technical competency issues. The next section of the chapter deals with time. It is often assumed that effective communication is inefficient. While this is not necessarily the case, the research results are complex and very interesting. The third part of the chapter covers communication in relation to patient adherence with the management plan recommended by the doctor. There is strong evidence that communication affects patient adherence and that there are four key aspects of communication that can enhance the patients' co-operation with the management plan. The final topic is patients' health. Twenty-two studies indicate the generally positive effect of key dimensions of communication on actual patient health outcomes such as pain, recovery from symptom, anxiety, functional status, and physiologic measures of blood pressure and blood glucose.

Patient-physician communication assessment instruments: 1986 to 1996 in review

This paper provides a comprehensive review and comparison of instruments used to assess patient-doctor interaction over the past decade. Instruments were identified from papers indexed by MEDLINE from 1986 to 1996 using the medical subject headings 'physician-patient relations', 'physician-patient communication', and 'education, medical', as well as requests for instruments currently in use by colleagues. Each instrument was reviewed under the following categories: name of the instrument; description; number of items; reliability; validity; current use and special notes. Overall, 44 instruments were obtained and reviewed. Of these, 21 were used in only one published study each in the last decade and 15 have never been validated. While most instruments have been shown to be reliable (usually inter-rater reliability), very few instruments have been directly compared with another instrument designed to assess patient-doctor interactions. We suggest that further validation of existing instruments and incorporation of assessment of non-verbal communication between the patient and the doctor are needed.

Patient-physician communication assessment instruments: 1986 to 1996 in review

This paper provides a comprehensive review and comparison of instruments used to assess patient-doctor interaction over the past decade. Instruments were identified from papers indexed by MEDLINE from 1986 to 1996 using the medical subject headings 'physician-patient relations', 'physician-patient communication', and 'education, medical', as well as requests for instruments currently in use by colleagues. Each instrument was reviewed under the following categories: name of the instrument; description; number of items; reliability; validity; current use and special notes. Overall, 44 instruments were obtained and reviewed. Of these, 21 were used in only one published study each in the last decade and 15 have never been validated. While most instruments have been shown to be reliable (usually inter-rater reliability), very few instruments have been directly compared with another instrument designed to assess patient-doctor interactions. We suggest that further validation of existing instruments and incorporation of assessment of non-verbal communication between the patient and the doctor are needed.

Canadian naturopathic practitioners: holistic and scientific world views

This paper describes naturopathic practitioners with two different world views--holistic and scientific, and explores the relationship of practitioners' socialization experiences and practice patterns with these two world views. Data were gathered by a variety of methods including: (1) a 14-page questionnaire mailed to all 296 naturopathic practitioners licensed in Canada; (2) a participant observation study at the Canadian College of Naturopathic Medicine (CCNM); and (3) open-ended interviews with 16 students attending CCNM and 41 naturopathic practitioners which were audio-taped and transcribed verbatim. Individuals with both holistic and scientific world views entered naturopathic training and none of the practitioners who were interviewed reported a change in world view while at naturopathic college. However, practitioners reported a new-found appreciation of the "other" world view on completion of their training, indicating the occurrence of a socialization effect. Many decisions involved in setting up a practice and seeing patients were affected by the practitioners' world views. For example, there were distinct differences in the way the practitioners with different world views who were interviewed chose treatment modalities. Practitioners with scientific world views reported choosing treatments based on the available "scientific evidence", while practitioners with holistic world views included a careful exploration of the patient's spirituality and their own intuition in their treatment decisions. In addition, practitioners with holistic world views reported significantly longer patient visits than practitioners with scientific world views. The data presented here suggest that one's world view influences one's perceptions of socialization experiences and social situations, and modulates the effects of both on practice patterns.

Quality of nonstructured and structured abstracts of original research articles in the British Medical Journal, the Canadian Medical Association Journal and the Journal of the American Medical Association

OBJECTIVE

To assess and compare the quality of nonstructured and structured abstracts of original research articles in three medical journals.

DESIGN

Blind, criterion-based observational study.

SAMPLE

Random sample of 300 abstracts (25 abstracts per journal each year) of articles published in the British Medical Journal (BMJ), the Canadian Medical Association Journal and the Journal of the American Medical Association (JAMA) in 1988 and 1989 (nonstructured abstracts) and in 1991 and 1992 (structured abstracts).

MAIN OUTCOME MEASURES

The quality of abstracts was measured against 33 objective criteria, which were divided into eight categories (purpose, research design, setting, subjects, intervention, measurement of variables, results and conclusions). The quality score was determined by dividing the number of criteria present by the number applicable; the score varied from 0 to 1.

RESULTS

The overall mean quality scores for nonstructured and structured abstracts were 0.57 and 0.74 respectively (p < 0.001). The frequency in meeting the specific criteria was generally higher for the structured abstracts than for the nonstructured ones. The mean quality score was higher for nonstructured abstracts in JAMA than for those in BMJ (0.60 v. 0.54, p < 0.05). The scores for structured abstracts did not differ significantly between the three journals.

CONCLUSIONS

The findings support recommendations that promote the use of structured abstracts. Further studies should be performed to assess the effect of time on the quality of abstracts and the extent to which abstracts reflect the content of the articles.

Regional dispersion of independent professionals in primary health care in The Netherlands

One of the main objectives of Dutch Government policy on primary health care concerns equal regional dispersion of health care provisions. At this moment these provisions are geographically not equally distributed when measured in terms of the number of inhabitants per practising professional in primary health care. In this paper the current patterns of dispersion of five professional groups are described. The groups concerned are the general practitioners, dentists, physiotherapists, pharmacists and midwives. These patterns are mainly a consequence of market forces because the professionals have had the freedom to choose where to practise their profession until recently. These decisions are affected by the "place utility" of an area. In this paper place utility is conceived as being determinated by the opportunities of an area to earn a living and the amenities of an area as residential and living-environment. These concepts are operationalized by a set of independent variables. In order to understand the (differences between the) patterns of dispersion of the professional groups concerned multiple regression-analysis has been used, of which the results are compared to the hypotheses formulated.

Obstetric care in The Netherlands: regional differentiation in home delivery

In this paper attention is focused on home delivery in the Netherlands, which still accounts for 36% of the total number of births delivered. Compared to countries with a similar level of socio-economic development, home delivery plays an important role within Dutch obstetric care. To understand this unique situation, one needs to have insight into the organization and structure of Dutch obstetric care which is described in the first part of this paper. In the second part of this paper regional differentiation in the relative importance of home delivery is described. Finally regression analysis is used in order to explain the observed regional pattern. A brief abstract from the vast amount of Dutch literature on the discussion between advocates and adversaries of home delivery is included in an appendix.

Evidence for deficient 20 -cholesterol-hydroxylase activity in adrenal tissue of a patient with lipoid adrenal hyperplasia

Enzyme preparations were isolated from post-mortem adrenal tissue of a patient with lipoid adrenal hyperplasia and normal human- and bovine adrenal tissue. Cholesterol-cleaving properties were studied in incubation experiments with the addition of appropriate substrates. Cholesterol-cleaving activity of enzyme preparations of adrenal tissue from the patient was extremely low as compared with normal controls. There was no difference in 20α-hydroxycholesterol-cleaving activity. There is thus evidence for a deficient 20α-cholesterol-hydroxylase activity in the adrenal tissue of this patient with lipoid adrenal hyperplasia.