Cardiovascular determinants of exercise capacity in people with type 2 diabetes

Background

The determinants of exercise capacity in people with type 2 diabetes (T2D), a group at high risk of heart failure, are unknown.

Purpose

To assess the relationship between subclinical cardiovascular dysfunction and peak VO2 in adults with T2D.

Methods

We enrolled asymptomatic adults with T2D and no prevalent cardiovascular disease. Matched controls were recruited for comparison. Subjects underwent echocardiography, cardiopulmonary exercise testing and adenosine stress cardiac MRI. Multivariable linear regression analysis was undertaken to identify independent associations between measures of cardiovascular structure and function and peak VO2 (Figure 1).

Results

247 adults with T2D (age 52±12y, 55% males, A1c 7.4±1.1%) and 78 controls were included. Subjects with T2D had increased concentric LV remodelling (LV mass/volume 0.84±0.14 vs. 0.76±0.11g/mL, p<0.001), reduced global longitudinal strain (−16.4±2.4 vs. −17.4±1.9%, p<0.001), lower aortic distensibility (2.75 (1.74–4.03) vs. 4.92 (2.65–7.13) mmHg-1x10–3, p<0.001), reduced myocardial perfusion reserve (2.60±1.24 vs. 3.54±1.15, p<0.001), and lower peak VO2 (19.0±5.6 vs. 28.0±9.1mL/kg/min, p<0.001) than controls. In a model containing age, sex, ethnicity, smoking status and systolic blood pressure, aortic distensibility (β=−0.466, p=0.033), E/e' (β=−0.344, p=0.001) and myocardial perfusion reserve (β=0.903, p=0.005) were independently associated with peak VO2 in subjects with T2D (Table 1).

Conclusions

In asymptomatic people with T2D, aortic stiffening, diastolic filling, and myocardial perfusion reserve are key determinants of peak VO2, independent of age, sex, ethnicity, smoking status, or blood pressure.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): National Institute for Health Research - Career Development Fellowship (G P McCann, CDF-2014-07-045). British Heart Foundation - Clinical Research Training Fellowship (G S Gulsin)

Cross-disciplinary research in cancer: an opportunity to narrow the knowledge-practice gap

Health services researchers have consistently identified a gap between what is identified as "best practice" and what actually happens in clinical care. Despite nearly two decades of a growing evidence-based practice movement, narrowing the knowledge-practice gap continues to be a slow, complex, and poorly understood process. Here, we contend that cross-disciplinary research is increasingly relevant and important to reducing that gap, particularly research that encompasses the notion of transdisciplinarity, wherein multiple academic disciplines and non-academic individuals and groups are integrated into the research process. The assimilation of diverse perspectives, research approaches, and types of knowledge is potentially effective in helping research teams tackle real-world patient care issues, create more practice-based evidence, and translate the results to clinical and community care settings. The goals of this paper are to present and discuss cross-disciplinary approaches to health research and to provide two examples of how engaging in such research may optimize the use of research in cancer care.

Factors related to the implementation and use of an innovation in cancer surgery

OBJECTIVE

Nationally, efforts to implement an innovation in cancer surgery-a Web-based synoptic reporting tool-are ongoing in five provinces. The objective of the present study was to identify the key multilevel factors influencing implementation and early use of this innovation for breast and colorectal cancer surgery at two academic hospitals in Halifax, Nova Scotia.

METHODS

We used case-study methodology to examine the implementation of surgical synoptic reporting. Methods included semi-structured interviews with key informants (surgeons, implementation team members, and report end users; n = 9), nonparticipant observation, and document analysis. A thematic analysis was conducted separately for each method, followed by explanation-building to integrate the evidence and to identify the key multilevel factors influencing implementation. An audit was performed to determine use.

RESULTS

Key factors influencing implementation were these: Innovation-values fitFlexibility with the innovation and implementationThe innovation is not flawlessStrengthening the climate for implementationResource needs and availabilityPartner engagementSurgeon champions and involvementIn a 6-month period after implementation, 91.2% and 58.0% respectively of eligible breast and colorectal cancer surgeries were reported using the new tool.

CONCLUSIONS

An improved understanding of the multilevel factors influencing the implementation of innovations is critical to planning effective change interventions in health care. Further study is needed to explore differences in the use of the innovation between breast and colorectal cancer surgeons. Findings will inform the study of additional cases of synoptic reporting implementation, enabling cross-case analyses and identification of higher-level themes that may be applied in similar settings or contexts.

The methodological soundness of literature reviews addressing three potential zoonotic public health issues

Literature reviews are important information sources for multiple stakeholders in zoonotic public health with limited time to keep up with the rapid increase in primary research in this field. However, their validity depends on their methodological soundness. The study purpose was to evaluate the methodological soundness of literature reviews in zoonotic public health. Relevant reviews (n = 132) published between January 2000 and August 2006 were identified on three issues: Mycobacterium avium ssp paratuberculosis as a potential cause of Crohn's disease in humans (30 reviews); antimicrobial use in animals as a risk factor for antimicrobial resistance in human pathogens (36); and the zoonotic potential of transmissible spongiform encephalopathies (66). The zoonotic aspect of the issue was the focus of 59 reviews and a subsection of 73 reviews. Two independent reviewers evaluated reviews using 13 criteria: 10 previously validated in the medical field, and three applicable to aetiology research. No review met more than eight of 13 criteria for methodological soundness; two articles met only one criterion. Two reviews described methods for identifying relevant primary research. In only two and four reviews respectively, authors conducted quantitative syntheses of research evidence or reported summarized measures of effect for the zoonotic risk to humans. Recommendations for future research and economic impact were provided in 64 and 10 reviews respectively. In 14 reviews, conclusions exceeded evidence presented. The various review authors' position on the evidence for the zoonotic association and the zoonotic risk to public health were inconsistent for all three issues. Reviews addressing potential zoonotic public health issues lack structured and transparent methodology preventing the end user from assessing the review's validity. These reviews should adhere to structured scientific principles similar to what is used for primary research articles.

Faculty attitudes towards medical communication and their perceptions of students' communication skills training at Dalhousie University

SETTING

Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

OBJECTIVES

(1) To assess the attitudes of full-time clinical faculty members towards medical communication using the newly developed Attitudes Towards Medical Communication Scale; (2) to determine faculty members' perceptions of communications training for students and residents.

METHODS

An anonymous self-completion survey was sent to 233 full-time clinical faculty members. The questionnaire asked about faculty attitudes towards medical communication, and assessed faculty members' views of student and resident training in communication.

RESULTS

Faculty scored highly in the Attitudes Towards Medical Communication Scale, with a mean score of 51.5 (SD 4.1) out of a possible 60. In univariate analysis, rating of personal enjoyment of teaching, rating of the importance of teaching, and having attended at least one faculty communications workshop in the previous 5 years were significantly associated with higher scale scores. When these factors were assessed using linear regression, only having attended a workshop and higher rating of the importance of teaching remained significant. Faculty assessed student training in communications skills poorly overall. When assessing seven specific communications areas, more than 20% rated this training as poor for six of the areas for third- and fourth-year students and for five of the areas for residents.

CONCLUSIONS

Clinical faculty at Dalhousie have very positive attitudes towards medical communication, and more highly positive attitudes are found in those who have attended a communications workshop. Despite this evidence that faculty appreciate the importance of medical communication skills, many assessed students' training in this curriculum area as poor.

Differences in medical students' attitudes and self-efficacy regarding patient-doctor communication

To examine students' attitudes and self-efficacy regarding patient-doctor communication across levels of training, a questionnaire was administered to three classes (n = 203 students). Students' year of study, prior experience, and sex influenced their attitudes and self-efficacy regarding patient-doctor communication.

Lifelong learning in ethical practice: a challenge for continuing medical education

BACKGROUND

Formal education in the identification, analysis, and resolution of ethical issues in clinical practice is now an essential component of undergraduate and postgraduate medical education. Physicians educated before the 1980s have had little or no formal education in ethics. This article describes a project for assessing the content and format appropriate for the continuing education needs of practicing physicians.

METHODS

A questionnaire and follow-up facilitated small-group discussions with a physician ethicist around case-based problems were used to identify the ethical issues in practice where participants felt the need for continuing education.

RESULTS

The project confirmed that practitioners had very little formal ethics in medical school and less since starting practice despite encountering ethical issues. The most frequently used method of learning about ethics was informal discussion among those who have the same lack of formal education. Physicians did not feel that they needed a "very high" level of confidence and competence in handling ethical issues, even those commonly encountered. Participants indicated strongly that they lacked a systematic approach to the identification and analysis of ethical issues and suggest incorporation of the ethical component into regular CME.

FINDINGS

In spite of the small study population and the volunteer nature of the participants, the project demonstrated the identification of ethics content for CME similar to that used in medical education. Further work is needed to assess objective needs for ethics education in addition to the perceived needs of clinicians.

Prescribing exercise for cardiac patients: knowledge, practices, and needs of family physicians and specialists

PURPOSE

To determine the following about prescribing exercise for cardiac patients: physicians' present and needed knowledge; their present practices; barriers that hinder them; and perceived need for and content of a protocol for prescribing exercise.

METHODS

(1) Questionnaire mailed to 371 family physicians (FPs), 31 internists, and 25 cardiologists; and (2) four focus groups consisting of 25 FPs, 1 internist, and 3 cardiologists.

RESULTS

Questionnaire response rate was 45% (n = 192). Because responses were similar and the group was small, internists and cardiologists were combined as "specialists." Generally, questionnaire data agreed with focus group data, with the latter providing more detail. Family physicians perceived they know little about prescribing a specific exercise program while specialists perceived they know little about motivating patients to begin an exercise program. The method most frequently used by both physician groups to increase exercise is providing general advice. The main barriers to prescribing exercise were inadequate knowledge (FPs only), patient education materials, and community resources. Both groups rated highly the need for a protocol for prescribing exercise and indicated it should: (1) include identification of patient's stage of change; (2) include indications and contraindications for exercise; (3) provide guidelines for developing a specific exercise prescription; (4) contain patient education materials, and (5) be simple and short.

CONCLUSIONS

Family physicians perceive they know little about prescribing a specific exercise program for cardiac patients while specialists perceive they know little about motivating patients. Physicians rate highly the need for a protocol to help them prescribe exercise for cardiac patients.

Effects of external thermal manipulation on laminar temperature and perfusion scintigraphy of the equine digit

AIMS

To assess the effects of external thermal manipulation on the soft-tissue and vascular perfusion of the equine digit using nuclear scintigraphy and documented tissue temperatures.

METHODS

Six horses were used in a randomised crossover design. Each horse was treated with external heat (47 degrees C) or external cold (4 degrees C) applied to a digit for 30 minutes. The opposite front foot was untreated and used for control measurements. Nuclear scintigraphy was performed before, during, and after therapy to assess vascular and soft-tissue perfusion to the digit in response to therapy. Dorsal hoof wall laminar-tissue temperatures were recorded before, during, and after therapy using a thermistor.

RESULTS

Treatment with topical cold therapy significantly decreased soft-tissue perfusion of the digit to 80.5% of the pre-cooled values. Conversely, the application of external heat significantly increased soft-tissue perfusion of the digit 25.1% above the pre-heated values. Vascular perfusion showed similar, but not statistically significant trends. External cold application to the digit caused a significant mean decrease in laminar-tissue temperatures of 11.6 degrees C during therapy, while external heat application to the digit caused a significant mean increase in laminar-tissue temperatures of 3.9 degrees C.

CONCLUSION

The external application of heat and cold to the normal equine foot could effectively alter soft-tissue perfusion and laminar-tissue temperatures within 30 minutes of treatment. The application of hot water and ice water to the digit was a safe, well-tolerated, and economical therapy.

CLINICAL RELEVANCE

Cooling the foot could decrease enzymatic reactions associated with laminitis, and warming could increase local perfusion when desired.

Self-reported effects of computer workshops on physicians' computer use

BACKGROUND

The need for physicians to be proficient in the use of computers is undeniable. As computers have become easier to use and more widespread, their use in medicine is expanding. Several organizations have produced continuing medical education programs to teach physicians about the use of computers in medicine but little has been reported on the effects of such programs.

METHOD

We present the self-reported effects of a series of workshops that taught physicians about basic computer skills: information retrieval, the Internet, CD-ROMs, electronic mail, and computer-aided learning.

RESULTS

A questionnaire mailed to 65 workshop participants yielded a response rate of 46% (n = 30). Of the 30 respondents, 27% (n = 8) had bought new hardware or software because of attending the workshops, with the most common purchase being a new computer. Fifty-seven percent (n = 17) had increased their use of computers, with the most common applications being use of the Internet for information retrieval and electronic mail.

Testing a rating scale of video-taped consultations to assess performance of trainee nurse practitioners in general practice

BACKGROUND

Nurse practitioners (NPs) in the United Kingdom are taking on some of the consultation work previously done by general practitioners (GPs) without there being any established professional standards that they must achieve before doing so. There is a need to develop and test methods of assessing their consultation performance for reasons of professional accreditation and patient safety.

AIMS

1. To make independent summative assessments of trainee nurse practitioners' (TNPs) consultation performance. 2. To assess the validity and reliability of an existing video-taped assessment tool.

METHOD

Four TNPs taking part in the EROS (extended roles of staff) study video recorded seven or eight consecutive consultations with typical patients during one surgery. Each consultation was rated nine times by members of a panel comprising eight independent GP trainers, four NPs and the GPs and TNPs in the EROS practices. A rating scale developed by Cox & Mulholland was used for the purpose.

RESULTS

Eight of the 37 items and four consultations had more than 10% missing data, mean = 7.7 items per rater. Factor analysis yielded a single factor solution explaining 32.6% of the variance and indicated that items could be summed to provide a single score. Internal consistency was high, alpha coefficient = 0.92. Individual differences between raters in scoring consultations were taken into account in providing a score for each consultation. Scores obtained were found to cluster at the positive end of the distribution indicating a high level of performance. Greater differences were found between scorers than between consultations.

CONCLUSIONS

This instrument is appropriate for scoring NP consultations and this small sample was rated as showing a uniformly high standard of performance. Some items could be deleted since they do not feature in the range of consultations currently performed. If this or a similar tool was to be adopted more widely for summative rating purposes then it should be tested rigorously for validity and reliability, training should be given to raters and criteria provided by which to make judgements.