Prospective health care costs and lost work days associated with diabetes-related distress and depression symptoms among 1488 individuals with diabetes

The aim of this study was to investigating the impact of major depression symptoms and diabetes-related distress on future health care costs and lost workdays in individuals with diabetes. We linked survey data from a random sample of a German statutory health insurance (SHI) with diabetes (n = 1488, 63.0% male, mean age 66.9 years) with their SHI data one year after the survey. Within the survey data we identified major depression symptoms (Patient Health Questionnaire-9) and diabetes-related distress (Problem Areas in Diabetes Scale). We retrieved health care costs and lost workdays from SHI data. To assess the impact of major depression symptoms and diabetes-related distress on health care costs and lost workdays, we adjusted regression models for age, sex, education, employment status, and diabetes duration, type, and severity. Major depression symptoms were associated with significantly higher costs (by a factor of 1.49; 95% CI: 1.18-1.88). Lost workdays were also more likely for respondents with depression symptoms (RR1.34; 0.97-1.86). Health care costs (by a factor of 0.81; 0.66-1.01) and the risk of lost workdays (RR 0.86; 0.62-1.18) may be lower among respondents with high diabetes-related distress. While major depression and diabetes-related distress have overlapping indicators, our results indicate different impacts on health care costs.

Knowledge of HbA1c and LDL-C treatment goals, subjective level of disease-related information and information needs in patients with atherosclerotic cardiovascular disease

BACKGROUND/HYPOTHESIS

Risk factor control of diabetes mellitus (DM) and especially dyslipidemia remains unsatisfactory in patients with atherosclerotic cardiovascular disease (ASCVD). We aimed to analyze the knowledge of low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (HbA1c) treatment goals, subjective level of information, and information needs in very high-risk patients with ASCVD.

METHODS

ASCVD patients (n = 210; 75 ± 9 years; 71.4% male; 89.5% coronary disease) with DM (96.7% type 2) completed a questionnaire assessing knowledge of HbA1c and LDL-C treatment goals and subjective level of information and information needs on disease-related topics of DM and ASCVD. Serum LDL-C and HbA1c were measured.

RESULTS

HbA1c goal (<7.0% in 60.6%) was attained more frequently than LDL-C goal (<70 mg/dl in 39.9%; p < .01). Significantly more participants named the correct goal for HbA1c compared to LDL-C (52.9% vs. 2.4%; p < .01). Subjective levels of information were higher and information needs were lower for DM than for ASCVD (p < .01 for all topics). No associations of knowledge of treatment goals and level of information with the attainment of treatment goals for HbA1c and LDL-C were found. However, in multivariate regression, higher levels of education were associated with knowledge of treatment goals (HbA1c: odds ratio [OR] 1.32, 95% confidence interval [CI] 1.01-1.72, p = .04; LDL-C: OR 2.32, 95% CI 1.07-5.03; p = .03).

CONCLUSION

In very high-risk patients with ASCVD, a deficit of knowledge of treatment goals to control dyslipidemia exists when compared to DM, patients felt significantly better informed for topics of DM than for ASCVD and display higher information needs for topics of ASCVD.

The novel ageing-induced long non-coding RNA MIRIAL controls endothelial cell and mitochondrial function

 

Vascular ageing is a key risk factor for cardiovascular diseases and is characterised by a continuous decline in endothelial cell function. Despite progress in recent years, the molecular mechanisms for this deterioration remain incompletely understood. Long non-coding RNAs (lncRNAs) are a heterogeneous class of RNAs that have been shown to regulate gene expression and protein function, however, little is known about their role in the ageing-associated dysregulation of endothelial cell (EC) function. In this study, we aimed to identify and functionally characterise a novel ageing-regulated lncRNA in ECs.

Using RNA sequencing data of cardiac ECs derived from 12 weeks young and 20 months old mice, we identified Mirial as an ageing-induced lncRNA (1.32-fold, p=0.00005). Mirial is conserved between mice and humans and has no obvious coding potential. GapmeR-mediated silencing of MIRIAL in human umbilical vein ECs (HUVECs) decreased cell proliferation by 50%, migration by 24% (p=0.045) and basal angiogenic sprouting by 53% (p=0.0029), without affecting apoptosis or senescence. Additionally, silencing of MIRIAL increases mitochondrial mass (1.8-fold, p&lt;0.01) and spare respiratory capacity (1.95-fold). Preliminary data from the hearts of Mirial knockout mice confirm the elevated mitochondrial mass after Mirial ablation (1.26-fold, p=0.05). In HUVECS, MIRIAL is mainly associated with the chromatin (80%), suggesting a role in the regulation of gene expression. Pathway analysis showed an overrepresentation of p53 target genes that were upregulated upon MIRIAL knockdown, which was validated using qRT-PCR (1.8–5.2-fold increases). Interestingly, this effect is fully dependent on the presence of p53. Moreover, p53 and phospho-p53 (Ser15) were both increased (1.8-fold, p=0.01 and 2.9-fold, p=0.02, respectively) after MIRIAL silencing. Pulldown of MIRIAL identified DDX5 and MRPL41 as direct p53 interactors and RNA immunoprecipitation revealed that MIRIAL physically interacts with p53 (3.75-fold enrichment, p&lt;0.01). Gene set enrichment analysis of RNA sequencing data revealed that 10% of deregulated genes after MIRIAL knockdown have a binding site for Forkhead Box O (FoxO) transcription factors. In particular, FoxO1 is known as one of the key players in endothelial proliferation and regulation of angiogenesis as well as in mitochondrial biogenesis.

Taken together, MIRIAL is an ageing-induced lncRNA in endothelial cells acting as a key regulator of metabolic and cellular function. MIRIAL promotes cell proliferation, migration and basal angiogenic sprouting while decreasing mitochondrial function. We hypothesise that MIRIAL influences these cellular functions by affecting the p53 pathway and mitochondrial respiration through FoxO signalling. The results from the present study suggest that modulation of cellular MIRIAL expression may be a promising strategy to prevent or even reverse ageing-induced functional decline of ECs, both in vitro and in vivo.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft - Collaborative Research Centre (SFB) 834 - Project B9Deutsche Forschungsgemeinschaft - Collaborative Research Centre/Transregio (TRR) 267 - Project B4

Catering situation at Austrian schools

Background

Due to the increase in all-day compulsory schools in Austria, it is important that students receive health-promoting meals throughout the day. The aim of the analysis was a nationwide evaluation of the current situation concerning catering at schools.

Methods

Using a nationwide representative sample of schools from the 5th grade upwards, a questionnaire was conducted as a telephone interview with 331 randomly chosen schools. In addition, 56 schools in Vienna from the 5th grade onwards were randomly selected in order to analyze the current offer at school cafeterias in detail.

Results

Lunch was offered at 72% of all schools, a school cafeteria was available at 81%, a cold drink vending machine at 66%, a hot drink vending machine at 41% and a snack vending machine at 23%. With regard to the health promoting composition of the catering offer, 18% of all schools already had a certified lunch menu, 22% a certified school cafeteria, 14% a certified cold drink vending machine and 5% a certified snack vending machine. In 79% of schools there is direct competition for school catering (93% supermarkets, 45% bakeries, 33% snack stands, 8% fast food restaurants). The results of the detailed analysis in Vienna showed that only 35% of all school cafeterias are certified. All of these locations are advised externally.

Conclusions

The majority of the schools offer catering during breaks and at lunchtime. Without external advice, the majority of the offers must be classified as not health promoting.

Key messages

The food offered at schools is an important component in the nutrition of students in Austria. Cafeteria operators in schools often need external advice in order to be able to offer a healthy selection of food and beverages.

The novel ageing-induced long non-coding RNA MIRIAL controls endothelial cell and mitochondrial function

 

Vascular ageing is a key risk factor for cardiovascular diseases and is characterised by a continuous decline in endothelial function. Despite progress in recent years, the molecular mechanisms for this deterioration remain incompletely understood. Long non-coding RNAs (lncRNAs) are a heterogeneous class of RNAs that have been shown to regulate gene expression and protein function, however, little is known about their role in the ageing-associated dysregulation of endothelial cell (EC) function.

In this study, we aimed to identify and functionally characterise a novel ageing-regulated lncRNA in ECs.

Using RNA sequencing data of cardiac ECs from 12 weeks young and 20 months old mice, we identified Mirial as an ageing-induced lncRNA (1.32-fold, p=0.ehab724.33565). MIRIAL is conserved between mice and humans and has no obvious coding potential. GapmeR-mediated silencing of MIRIAL in human umbilical vein ECs (HUVECs) decreased cell proliferation by 50%, migration by 24% (p=0.045) and basal angiogenic sprouting by 53% (p=0.0029), while increasing VEGF-A-stimulated sprouting by 50% (p=0.0139) and not affecting apoptosis or senescence. Subcellular fractionation of HUVECs revealed that MIRIAL was predominantly associated with the chromatin (80%). Pathway analysis of RNA sequencing data showed an overrepresentation of upregulated p53 target genes upon MIRIAL knockdown in HUVECs which was validated using qRT-PCR (1.8–5.2-fold increased). Using siRNA against p53 we showed that this effect is fully dependent on the presence of p53. Moreover, p53 and its phosphorylated form (Ser15) were both increased (1.8-fold, p=0.01 and 2.9-fold, p=0.02) after MIRIAL silencing. Intriguingly, RNA immunoprecipitation revealed that MIRIAL physically interacts with p53 (3.75-fold enriched, p=0.0067). To further study the interactome of MIRIAL, we performed RNA pulldown assays followed by mass spectrometry analysis of bound proteins, which identified the ageing-associated prohibitin (PHB) 1 and 2 to potentially interact with MIRIAL. Similar to MIRIAL knockdown, siRNA-mediated PHB 1 or 2 silencing caused proliferative defects. Further, PHBs are known to physically interact with p53 and control mitochondrial metabolism, a key factor in cellular ageing. Interestingly, silencing of MIRIAL in HUVECs increased mitochondrial mass (1.8-fold, p=0.0008) and spare respiratory capacity (1.95-fold) with the latter being decreased in isolated aged murine ECs.

Taken together, MIRIAL is an ageing-induced lncRNA in ECs acting as a key regulator of metabolic and cellular function. MIRIAL promotes cell proliferation, migration and basal angiogenic sprouting while decreasing mitochondrial function and VEGF-A-stimulated sprouting. We hypothesise that MIRIAL influences p53 signalling and mitochondrial respiration through PHB 1 and 2. The present study suggests that modulation of MIRIAL expression may be a promising strategy to prevent or even reverse ageing-induced functional decline of ECs.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Research Council (ERC) Starting Grant: Non-coding RNA in Vascular Ageing (NOVA)

A New FXR Ligand Chemotype with Agonist/Antagonist Switch

Therapeutic modulation of the bile acid-sensing transcription factor farnesoid X receptor (FXR) is an appealing strategy to counteract hepatic and metabolic diseases. Despite the availability of several highly potent FXR agonists structural diversity of FXR modulators is limited, and new ligand scaffolds are needed. Here we report structure-activity relationship elucidation of a new FXR modulator chemotype whose activity can be tuned between agonism and antagonism by two minor structural modifications. Starting from a weak FXR/PPAR agonist, we have developed selective FXR activators and antagonists with nanomolar to low-micromolar potencies and binding affinities. The new FXR ligand chemotype modulates the FXR activity in the native cellular setting, is endowed with favorable metabolic stability, and lacks cytotoxicity. It valuably expands the collection of FXR modulators as a new scaffold for FXR-targeted drug discovery.

Different information needs in subgroups of people with diabetes mellitus: a latent class analysis

BACKGROUND

Current evidence suggests that the information needs of people with diabetes mellitus differ across patient groups. With a view to being able to provide individualized information, this study aims to identify (i) the diabetes-related information needs of people with diabetes mellitus; (ii) different subgroups of people with specific information needs; and (iii) associated characteristics of the identified subgroups, such as sociodemographic characteristics, diabetes-related comorbidities, and well-being.

METHODS

This cross-sectional study was based on data from 837 respondents with diabetes mellitus who participated in the population-based KORA (Cooperative Health Research in the Augsburg Region) Health Survey 2016 in Southern Germany (KORA GEFU 4 study) (45.6% female, mean age 71.1 years, 92.8% Type 2 diabetes). Diabetes-related information needs were assessed with a questionnaire asking about patients' information needs concerning 11 diabetes-related topics, e.g. 'long-term complications' and 'treatment/therapy'. Subgroups of people with different information needs and associated characteristics were identified using latent class analysis.

RESULTS

We identified the following four classes of people with different information needs: 'high needs on all topics', 'low needs on all topics', 'moderate needs with a focus on complications and diabetes in everyday life', and 'advanced needs with a focus on social and legal aspects and diabetes research'. The classes differed significantly in age, years of education, type of diabetes, diabetes duration, diabetes-related comorbidities, smoking behaviour, diabetes education, current level of information, and time preference.

CONCLUSIONS

Knowledge about different patient subgroups can be useful for tailored information campaigns or physician-patient interactions. Further research is needed to analyse health care needs in these groups, changes in information needs over the course of the disease, and prospective health outcomes.

Preferences of people with type 2 diabetes for telemedical lifestyle programmes in Germany: protocol of a discrete choice experiment

INTRODUCTION

Telemedical lifestyle programmes for people with type 2 diabetes mellitus (T2DM) provide an opportunity to develop a healthier lifestyle and consequently to improve health outcomes. When implementing new programmes into standard care, considering patients' preferences may increase the success of the participants. This study aims to examine the preferences of people with T2DM with respect to telemedical lifestyle programmes, to analyse whether these preferences predict programme success and to explore the changes that may occur during a telemedical lifestyle intervention.

METHODS AND ANALYSIS

We outline the protocol of the development and assessment of a discrete choice experiment (DCE) to examine patient preferences in a telemedical lifestyle programme with regard to the functions of the online portal, communication, responsibilities, group activities and time requirements. To develop the design of the DCE, we conducted pilot work involving healthcare experts and in particular people with T2DM using cognitive pretesting. The final DCE is being implemented within a randomised controlled trial for investigating whether participation in a telemedical lifestyle intervention programme sustainably improves the HbA1c values in 850 members of a large German statutory health insurance with T2DM. Preferences are being assessed before and after participants complete the programme. The DCE data will be analysed using regression and latent class analyses.

ETHICS AND DISSEMINATION

The DCE study has been approved by the ethics committee of the medical faculty of the Heinrich Heine University Duesseldorf, registration number 2018-242-ProspDEuA, registered on 6 December 2018. The TeLIPro trial is registered at the US National Library of Medicine, registration number NCT03675919, registered on 15 September 2018. We aim to disseminate our results in peer-reviewed journals, at national and international conferences and among interested patient groups and the public.

How well are Swiss French physicians prepared for future practice in primary care?

BACKGROUND

Moving from postgraduate training into independent practice represents a major transition in physicians' professional life. Little is known about how Swiss primary care graduates experience such a transition. The aim of this study was to explore the extent to which primary care physicians who recently set up private practice felt prepared to work as independent practitioners.

METHODS

We conducted 7 focus groups among recently established (≤ 5 years) primary care physicians in Switzerland. Questions focused on positive and negative aspects of setting up a practice, and degree of preparedness. Transcripts were analysed according to organisational socialisation and work role transition frameworks.

RESULTS

Participants felt relatively well prepared for most medical tasks except for some rheumatologic, minor traumatology, ENR, skin and psychiatric aspects. They felt unprepared for non clinical tasks such as office, insurance and medico-legal management issues and did not anticipate that the professional networking outside the hospital would be so important to their daily work. They faced dilemmas opposing professional values to the reality of practice which forced them to clarify their professional roles and expectations. Adjustment strategies were mainly informal.

CONCLUSION

Although the postgraduate primary care curriculum is longer in Switzerland than in most European countries, it remains insufficiently connected with the reality of transitioning into independent practice, especially regarding role development and management tasks. A greater proportion of postgraduate training, with special emphasis on these issues, should take place directly in primary care.

Best practices for the management of local-regional recurrent chordoma: a position paper by the Chordoma Global Consensus Group

Chordomas are rare, malignant bone tumors of the skull-base and axial skeleton. Until recently, there was no consensus among experts regarding appropriate clinical management of chordoma, resulting in inconsistent care and suboptimal outcomes for many patients. To address this shortcoming, the European Society of Medical Oncology (ESMO) and the Chordoma Foundation, the global chordoma patient advocacy group, convened a multi-disciplinary group of chordoma specialists to define by consensus evidence-based best practices for the optimal approach to chordoma. In January 2015, the first recommendations of this group were published, covering the management of primary and metastatic chordomas. Additional evidence and further discussion were needed to develop recommendations about the management of local-regional failures. Thus, ESMO and CF convened a second consensus group meeting in November 2015 to address the treatment of locally relapsed chordoma. This meeting involved over 60 specialists from Europe, the United States and Japan with expertise in treatment of patients with chordoma. The consensus achieved during that meeting is the subject of the present publication and complements the recommendations of the first position paper.

A population-based study of the association between dysglycaemia and hearing loss in middle age

AIMS

To investigate the independent associations between hearing loss and dysglycaemia in a sample of middle-aged adults, including separate analysis of those aged < 60 years.

METHODS

The first 2023 participants in the cross-sectional Busselton Health Ageing Survey were assessed for hearing loss ≥ 26 dB (better ear) for four-frequency average (4FA) of pure-tone thresholds at 500, 1000, 2000 and 4000 Hz, and high-frequency average (HFA) of pure-tone thresholds at 4000 and 8000 Hz.

RESULTS

Valid data from 1864 participants in the Busselton Health Ageing Survey [92.1%; mean ± sd age 56.2 ± 5.5 years, 46.0% men, 120 (7.0%) with diabetes, 274 (14.7%) with prediabetes] were analysed, of whom 103 (5.5%) had four-frequency average hearing loss and 561 (30.1%) had high-frequency average hearing loss. In multivariable analyses, glycaemic status was not independently associated with four-frequency or high-frequency average hearing loss. In the 1286 participants aged < 60 years, there was no relationship between dysglycaemia and high-frequency average hearing loss, but the prevalence of four-frequency average hearing loss increased from 2.3% (95% CI 1.5-3.4) in participants with normoglycaemia to 5.7% (95% CI 3.0-10.6) in those with prediabetes and 10.2% (4.2-21.5) in those with diabetes (trend P = 0.003). In multivariable analysis with normoglycaemia as reference, the odds ratios for four-frequency average hearing loss were 2.84 (95% CI 1.29-6.27) for prediabetes and 5.93 (95% CI 1.67-21.05) for diabetes (P ≤ 0.01) in the < 60 year age group.

CONCLUSIONS

There was progressively increasing mid-range hearing loss with worsening glucose tolerance in younger individuals, suggesting dysglycaemia-associated early-onset presbycusis.

Classic IL-6R signalling is dispensable for intestinal epithelial proliferation and repair

Inflammatory bowel disease is characterized by disturbed cytokine signalling in the mucosa. Inhibition of the proinflammatory interleukin (IL)-6 pathway is a promising new therapeutic strategy, but safety concerns arise as IL-6 signalling also contributes to epithelial repair of the intestinal mucosa. To which extent IL-6 classic or trans-signalling contributes to intestinal repair remains elusive. We tested the influence of IL-6 classic signalling on intestinal repair and proliferation. Whereas IL-6 induced STAT3 phosphorylation in the colonic cancer cell lines, primary non-malignant intestinal organoids did not respond to IL-6 classic signalling. Mice deficient in intestinal IL-6R (IL-6R^ΔIEC mice) did not display increased susceptibility to acute dextran sulfate sodium (DSS)-induced colitis. In the azoxymethane DSS model IL-6R^ΔIEC mice were not protected from inflammation-induced carcinogenesis but showed comparable tumor load to wild-type mice. These data indicate that classic signalling is not the major pathway to transduce IL-6 stimuli into the intestinal epithelium.

Neural pathways of embarrassment and their modulation by social anxiety

While being in the center of attention and exposed to other's evaluations humans are prone to experience embarrassment. To characterize the neural underpinnings of such aversive moments, we induced genuine experiences of embarrassment during person-group interactions in a functional neuroimaging study. Using a mock-up scenario with three confederates, we examined how the presence of an audience affected physiological and neural responses and the reported emotional experiences of failures and achievements. The results indicated that publicity induced activations in mentalizing areas and failures led to activations in arousal processing systems. Mentalizing activity as well as attention towards the audience were increased in socially anxious participants. The converging integration of information from mentalizing areas and arousal processing systems within the ventral anterior insula and amygdala forms the neural pathways of embarrassment. Targeting these neural markers of embarrassment in the (para-)limbic system provides new perspectives for developing treatment strategies for social anxiety disorders.

Providers Expectations on Telemedicine: A Qualitative Research in a Large Healthcare Network of Latin America

The benefits of Telemedicine make it a viable, reliable and useful discipline for dispensing health care. This qualitative study is aimed to understand the expectations, opinions and previous knowledge of the professionals about telemedicine at the Hospital Italiano de Buenos Aires.

RESULTS

Professionals realize that Telemedicine is inserted into their usual practice in an informal way. They consider telemedicine as an alternative to the traditional delivery of health care, but are afraid of their role in health care is undermined. Professionals point out very specific applications of Telemedicine such as monitoring the health of patients remotely, drug doses adjustments and sharing clinical information.

CONCLUSION

Results suggest that professionals are not familiar with telemedicine and will be necessary to develop a training plan before implementation.

Structural changes of central white matter tracts in Kennedy's disease - a diffusion tensor imaging and voxel-based morphometry study

OBJECTIVES

Spinobulbar muscular atrophy [Kennedy's disease (KD)] is a rare X-linked neurodegenerative disorder of mainly spinal and bulbar motoneurons. Recent studies suggest a multisystem character of this disease. The aim of this study was to identify and characterize structural changes of gray (GM) and white matter (WM) in the central nervous system.

MATERIAL AND METHODS

Whole-brain-based voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) analyses were applied to MRI data of eight genetically proven patients with KD and compared with 16 healthy age-matched controls.

RESULTS

Diffusion tensor imaging analysis showed not only decreased fractional anisotropy (FA) values in the brainstem, but also widespread changes in central WM tracts, whereas VBM analysis of the WM showed alterations primarily in the brainstem and cerebellum. There were no changes in GM volume. The FA value decrease in the brainstem correlated with the disease duration.

CONCLUSION

Diffusion tensor imaging analysis revealed subtle changes of central WM tract integrity, while GM and WM volume remained unaffected. In our patient sample, KD had more extended effects than previously reported. These changes could either be attributed primarily to neurodegeneration or reflect secondary plastic changes due to atrophy of lower motor neurons and reorganization of cortical structures.

Xerostomia after radiotherapy. What matters--mean total dose or dose to each parotid gland?

PURPOSE

Xerostomia is a debilitating side effect of radiotherapy in patients with head and neck cancer. We undertook a prospective study of the effect on xerostomia and outcomes of sparing one or both parotid glands during radiotherapy for patients with squamous cell carcinoma of the head and neck.

METHODS AND MATERIALS

Patients with locally advanced squamous cell carcinoma of the head and neck received definitive (70 Gy in 2 Gy fractions) or adjuvant (60-66 Gy in 2 Gy fractions) curative-intent radiotherapy using helical tomotherapy with concurrent chemotherapy if appropriate. Group A received < 26 Gy to the left and right parotids and group B received < 26 Gy to either parotid.

RESULTS

The study included 126 patients; 114 (55 in group A and 59 in group B) had follow-up data. There were no statistically significant differences between groups in disease stage. Xerostomia was significantly reduced in group A vs. group B (p = 0.0381). Patients in group A also had significantly less dysphagia. Relapse-free and overall survival were not compromised in group A: 2-year relapse-free survival was 86% vs. 72% in group B (p = 0.361); 2-year overall survival was 88% and 76%, respectively (p = 0.251).

CONCLUSION

This analysis suggests that reducing radiotherapy doses to both parotid glands to < 26 Gy can reduce xerostomia and dysphagia significantly without compromising survival. Sparing both parotids while maintaining target volume coverage and clinical outcome should be the treatment goal and reporting radiotherapy doses delivered to the individual parotids should be standard practice.

[Tomorrow's family doctor]

The profession of family doctor will undergo profound changes in the coming decade due to external, political, demographic and societal developments. Changes will also occur from within the profession affecting its content and its functioning. Other influences, in addition to generational developments (reduced working hours, feminisation, revaluation of the work-life balance), will come from collaboration with new professions, news structures as well as technical and human progress. In this transitional period it is important to uphold core values of family medicine, in particular coordination, continuity of care and the global approach to patients. In training future family doctors we must both prepare them for new skills and roles, and continue to share the core values with them.

Isolation and characterization of eight polymorphic microsatellite markers for the migratory characiform fish, Salminus brasiliensis

Eight polymorphic microsatellite loci were isolated and characterized for the migratory freshwater fish Salminus brasiliensis (Characiformes) and tested on 67 individuals from nine geographically distant locations along the Paraná Basin. The number of alleles per locus ranged from four to 14, with observed heterozygosity estimates ranging from 0·15 to 0·79.

[Teaching about practice guidelines: osteoporosis]

Family physicians need to know how to teach students practical guidelines for frequent diseases such as osteoporosis. After the age of 50 years, the risk for osteoporotic fractures is 50% for women and 20% for men. It is therefore useful to prevent and screen for osteoporosis. Family physicians need to know how to recognize the clinical and biological risk factors for osteoporosis; they must know when to request a bone densitometry, the "gold standard" for diagnosis. They must also be able to integrate these factors within the clinical context to evaluate the absolute risk of osteoporosis-related fracture that determines the need for specific treatment. Numerous treatments with proven efficacy to reduce global fractures are available but it is important to know their different indications, risk/benefits and potential harmful side-effects.

[Learning about family medicine and the doctor-patient relationship: student views]

The five university institutes/units for family medicine in Switzerland are now responsible for teaching family medicine to medical students, particularly through the introductory cleckship in primary care in the 2nd year. During four half-days, the students attend the office of a family doctor and discover the characteristics of family medicine according to the definition of the World Association of Family Doctors (WONCA). This article shows how these training sessions are a profound and enriching learning experience for students. Different skills are presented and are illustrated by extracts from the reports students write at the end of the four half-days.

[Diabetes and research in primary care: how to improve the care of our patients?]

Family practitioners are well aware of the guidelines for diabetic care yet they often find it difficult to apply them in practice. Experience from the literature as well as our own research provide guidance on ways to address this problem in Primary care: 1) collaboration with a nurse practitioner for the prevention of micro and macro-angiopathic complications, 2) the use of motivational interviewing techniques to motivate patients to lifestyle changes, 3) multidisciplinary collaboration (with specialists, nurses, colleagues, pharmacists, etc) and the support of information technology. Research within the Swiss academic institutes of Primary care should provide further, more concrete, guidance on ways to apply these different options in Switzerland to improve the quality of care for diabetic patients.

Physical activity and memory functions: an interventional study

Previous studies have suggested beneficial effects of physical activity on cognition. Here, we asked in an interventional approach if physical activity performed at different intensity levels would differentially affect episodic memory function. Additionally, we tried to identify mechanisms mediating these changes. Sixty-two healthy elderly individuals were assessed for level of physical activity, aerobic fitness, episodic memory score, neurotrophin and catecholamine levels, and received a magnetic resonance image of the brain at baseline and after a six months intervention of medium or low-intensity physical activity or control. Increase in total physical activity was positively associated with increase in memory score over the entire cohort, without significant differences between intensity groups. It was also positively associated with increases in local gray matter volume in prefrontal and cingulate cortex, and BDNF levels (trend). In conclusion, we showed that physical activity conveys the beneficial effects on memory function independently of its intensity, possibly mediated by local gray matter volume and neurotrophic factors. Our findings may carry significant implications for prevention of cognitive decline in the elderly.

Clinical supervisors' perceived needs for teaching communication skills in clinical practice

BACKGROUND

Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills.

AIMS

To explore clinical supervisors' needs and perceptions regarding their role as communication skills trainers.

METHODS

Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda software for qualitative data analysis.

RESULTS

Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere.

CONCLUSIONS

Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

Aprepitant/5HT-3 antagonist (EMEND) for the prevention of chemoradiation-induced nausea and vomiting (CRINV) in patients receiving gemcitabine/ 5-FU–based chemoradiation and concurrent upper abdominal radiation for pancreatic cancer

e20661

Background: Significant chemoradiation-induced nausea and vomiting (CRINV) occurs in patients (pts) receiving chemoradiation for pancreatic cancer. The aim of this trial was to determine if prophylactic Aprepitant/5HT-3/dexamethasone added to standard chemoradiation resulted in less CRINV when compared to historical controls. Methods: Pts with locally advanced or resected pancreatic cancer received wkly Gemcitabine (200 mg/m2) and continuous infusion 5-fluorouracil (5-FU) or oral capecitabine with concurrent radiation (50.4 Gy). Aprepitant (125 mg p.o.) was given each Monday (day 1) of each week 1 hr before the gemcitabine infusion and on days 2 and 3 (80 mg p.o.) - 1 hour prior to the radiation. A 5HT-3 antagonist was given orally 30–60 minutes prior to the chemotherapy and dexamethasone (12 mg) was given on day 1 and repeated at a dose of 8 mg on days 2 and 3 with the aprepitant. Grade III/IV nausea was assessed using NCI CTC v. 3.0. The Multinational Association of Supportive Care in Cancer Antiemesis Tool (MAT) questionnaire was completed at baseline prior to the start of all therapy, Time 1 (T#1), repeated at the end of the first week (T#2) and then repeated again at the end of the last full week of chemoradiation (T#3). Results: Of the 17 patients available for analysis, CTC grade III nausea and grade IV vomiting was observed in one patient (6%) during the entire treatment course. Utilizing the MAT at T#1, T#2 and T#3 respectively; 3/15, 4/15 and 2/13 pts reported experiencing any level of nausea. At those same time points; 0/15, 1/15 and 0/13 pts reported vomiting. The range of the average degree of nausea reported on a scale from 1–10 (worst) was 2.5 -3.67 over the study period. During treatment, 54–64% of participants reported no nausea/vomiting (N/V). For those patients who experienced N/V, it was rated as mild to moderate with only 3 of 17 requiring additional anti-emetics. Conclusions: Prophylactic Aprepitant/5HT-3/dexamethasone therapy resulted in minimal CRINV for pts receiving upper abdominal chemoradiation in this feasibility study. This regimen may be soon be integrated in to future CALGB pancreatic chemoradiation trials.

[Table: see text]

[Brief motivational interventions in primary care]

Primary care physicians see a majority of the population at least once a year and are in an ideal position to promote health and to discuss health behaviour change. Two proven methods to help people change are: brief intervention and motivational interviewing. We propose a combination of these two methods. The interview is structured following the 5 A's with an added first step: 1) agenda; 2) assess ambivalence; 3) advise; 4) agree; 5) assist and 6) arrange and is motivational in that it uses collaboration, non-judgement, and respect of the patient's autonomy. The aim is to help the patient explore and resolve his ambivalence and progress towards change.

The long-range transport of birch (Betula) pollen from Poland and Germany causes significant pre-season concentrations in Denmark

BACKGROUND

Birch pollen is highly allergic and has the potential for episodically long-range transport. Such episodes will in general occur out of the main pollen season. During this time, allergy patients are unprotected and high pollen concentrations will therefore have a full allergenic impact.

OBJECTIVE

To show that Denmark obtains significant quantities of birch pollen from Poland or Germany before the local trees start to flower.

METHODS

Simultaneous observations of pollen concentrations and phenology in the potential source area in Poland as well as in Denmark were performed in 2006. The Danish pollen records from 2000 to 2006 were analysed for possible long-range transport episodes and analysed with trajectories in combination with a birch tree source map.

RESULTS

In 2006, high pollen concentrations were observed in Denmark with bi-hourly concentrations above 500 grains/m(3) before the local trees began to flower. Poland was identified as a source region. The analysis of the historical pollen record from Copenhagen shows significant pre-seasonal pollen episodes almost every year from 2000 to 2006. In all episodes, trajectory analysis identified Germany or Poland as source regions.

CONCLUSION

Denmark obtains significant pre-seasonal quantities of birch pollen from either Poland or Germany almost every year. Forecasting of birch pollen quantities relevant to allergy patients must therefore, take into account long-range transport. This cannot be based on measured concentrations in Denmark. The most effective way to improve the current Danish pollen forecasts is to extend the current forecasts with atmospheric transport models that take into account pollen emission and transport from countries such as Germany and Poland. Unless long-range transport is taken into account, pre-seasonal pollen episodes will have a full allergic impact, as the allergy patients in general will be unprotected during that time.

Feasibility of a RARE-based sequence for quantitative diffusion-weighted MRI of the spine

The feasibility of a diffusion-weighted single-shot fast-spin-echo sequence for the diagnostic work-up of bone marrow diseases was assessed. Twenty healthy controls and 16 patients with various bone marrow pathologies of the spine (bone marrow edema, tumor and inflammation) were examined with a diffusion-weighted single-shot sequence based on a modified rapid acquisition with relaxation enhancement (mRARE) technique; four diffusion weightings (b-values: 50, 250, 500 and 750 s/mm(2)) in three orthogonal orientations were applied. Apparent diffusion coefficients (ADCs) were determined in the bone marrow and in the intervertebral discs of healthy volunteers and in diseased bone marrow. Ten of the 20 volunteers were repeatedly scanned within 30 min to examine short-time reproducibility. Spatial reproducibility was assessed by measuring ADCs in two different slices including the same lesion in 12 patients. The ADCs of the lesions exhibited significantly higher values, (1.27 +/- 0.32)x10(-3) mm(2)/s, compared with healthy bone marrow, (0.21 +/- 0.10)x10(-3) mm(2)/s. Short-time and spatial reproducibility had a mean coefficient of variation of 2.1% and 6.4%, respectively. The diffusion-weighted mRARE sequence provides a reliable tool for determining quantitative ADCs in vertebral bone marrow with adequate image quality.

[Motivational interviewing: some theoretical aspects and some practical exercises]

Heath behavior change is an important task for caregivers. Motivational Interviewing (MI) is an effective evidence-based approach to overcoming the ambivalence that keeps many people from desired changes in their lives. In a warm and empathic atmosphere and in a basic trust in the patient self efficacy for achieving the change, MI is a patient-centered approach to enhance patient motivation to commit them in the change decision. Among critical conditions of change, MI practicing emphasizes on expressing empathy, supporting self-efficacy, rolling with resistance and developing discrepancy. Regular practicing with helping and non judgmental teachers is a necessary condition of a fruitful learning.

[Every doctor is a teacher]

The doctor plays a role of a teacher so as to help the patient to understand, integrate and take care of his illness in his own socio-professional context. As patient educator, the doctor will get to know the patient in his specific environment. He will then be able to teach the needed knowledge and competencies after checking what the patient knows already (patient's knowledge and representations) and what he needs to know. It will be useful to check what the patient has acquired as knowledge or competencies to favour its memorisation. The patient and the doctor will then be able to define together a common treatment and plan through concrete and realistic objectives that will be revised during the follow-up.

The assessment of hemispheric lateralization in functional MRI--robustness and reproducibility

Various methods have been proposed to calculate a lateralization index (LI) on the basis of functional magnetic resonance imaging (fMRI) data. Most of them are either based on the extent of the activated brain region (i.e., the number of "active" voxels) or the magnitude of the fMRI signal change. The purpose of the present study was to investigate the characteristics of various variants of these approaches and to identify the one that yields the most robust and reproducible results. Robustness was assessed by evaluating the dependence on arbitrary external parameters, reproducibility was assessed by Pearson's correlation coefficient. LIs based on active voxels counts at one single fixed statistical threshold as well as LIs based on unthresholded signal intensity changes (i.e., based on all voxels in a region of interest) yielded neither robust nor reproducible laterality results. Instead, the lateralization of a cognitive function was best described by "thresholded" signal intensity changes where the activity measure was based on signal intensity changes in those voxels in a region of interest that exceeded a predefined activation level. However, not all other approaches should be discarded completely since they have their own specific application fields. First, LIs based on active voxel counts in the form of p-value-dependent lateralization plots (LI=LI(p)) can be used as a straightforward measure to describe hemispheric dominance. Second, LIs based on active voxel counts at variable thresholds (standardized by the total number of active voxels) are a good alternative for big regions of interest since LIs based on signal intensity changes are restricted to small ROIs.

Subcortical reorganization in amyotrophic lateral sclerosis

The cerebral cortex reorganizes in response to central or peripheral lesions. Although basal ganglia and cerebellum are key components of the network dedicated to movement control, their role in motor reorganization remains elusive. We therefore tested if slowly progressive neurodegenerative motor disease alters the subcortical functional anatomy of the basal ganglia-thalamo-cerebellar circuitry. Ten patients with amyotrophic lateral sclerosis (ALS) and ten healthy controls underwent functional magnetic resonance imaging (fMRI), while executing a simple finger flexion task. Cued by an acoustic trigger, they squeezed a handgrip force transducer with their right hand at 10% of their maximum voluntary contraction force. Movement frequency, amplitude, and force were controlled. Statistical parametric mapping of task-related BOLD-response revealed increased activation in ALS patients as compared to healthy controls. The main activation increases were found in the supplementary motor area, basal ganglia, brainstem, and cerebellum. These findings suggest that degeneration of cortical and spinal motor neurons in ALS leads to a recruitment of subcortical motor structures. These subcortical activation patterns strongly resemble functional activation in motor learning and might therefore represent adaptations of cortico-subcortical motor loops as a - albeit finally ineffective - mechanism to compensate for the ongoing loss of motor neurons in ALS.