Challenges faced by physicians when discussing the Type 2 diabetes diagnosis with patients: insights from a cross-national study (IntroDia® ).

AIMS: To investigate physicians' recalled experiences of their conversations with patients at diagnosis of Type 2 diabetes, because physician-patient communication at that time may influence the patient's subsequent self-care and outcomes. METHODS: As part of a large cross-national study of physician-patient communication during early treatment of Type 2 diabetes (IntroDia® ), we conducted a cross-sectional survey of physicians treating people with Type 2 diabetes in 26 countries across Africa, Asia, Europe, Latin America, the Middle East, North America and Oceania. The survey battery was designed to evaluate physician experiences during diagnosis conversations as well as physician empathy (measured using the Jefferson Scale of Physician Empathy). RESULTS: A total of 6753 of 9247 eligible physicians completed the IntroDia® survey (response rate 73.0%). Most respondents (87.5%) agreed that the conversation at diagnosis of Type 2 diabetes impacts the patient's acceptance of the condition and self-care. However, almost all physicians (98.9%) reported challenges during this conversation. Exploratory factor analysis revealed two related yet distinct types of challenges (r = 0.64, P < 0.0001) associated with either patients (eight challenges, α = 0.87) or the situation itself at diagnosis (four challenges, α = 0.72). There was a significant inverse association between physician empathy and overall challenge burden, as well as between empathy and each of the two types of challenges (all P < 0.0001). Study limitations include reliance on accurate physician recall and inability to assign causality to observed associations. CONCLUSIONS: Globally, most physicians indicated that conversations with patients at diagnosis of Type 2 diabetes strongly influence patient self-care. Higher physician empathy was associated with fewer challenges during the diagnosis conversation.

Evolution of quality at the Organ Center of the Organ Procurement and Transplantation Network/United Network for Organ Sharing.

One of the goals of the Organ Center of the Organ Procurement and Transplantation Network/United Network for Organ Sharing is to increase the efficiency of equitable organ allocation in the United States. Recognizing the ever-growing need for organ donors and transplants, leaders at the Organ Center increased its commitment to quality improvement initiatives through the development of a quality management team in 2001. The Organ Center began to focus on ways to capture data on processes and pinpoint areas for improvement. As the collection and analysis of data evolved, the Organ Center embraced formal quality standards, such as improvement cycles. Using these cycles, the Organ Center has seen significant improvement. One initiative involving lifesaving heart, lung, and liver placement showed success by doubling the Organ Center's organ placement rate. Another project involving the validation of donor information demonstrated that the accuracy of organ allocation can be improved by 5% on a consistent basis. As stewards for the gift of life and leaders in organ allocation, the Organ Center uses continuous quality improvement to achieve the goal of increasing the efficiency of equitable organ allocation.

The organ center of the United Network for Organ Sharing and twenty years of organ sharing in the United States.

The increasing size of the transplant waiting list and the increasing use of expanded criteria donors places a premium on efficient use of recovered organs. Maximal organ utilization often necessitates organ sharing between transplant organizations. Optimal organ sharing requires rapid, integrated communication of donor information combined with expedited organ transportation. For more than 20 years, the United Network for Organ Sharing's Organ Center has fulfilled this task for the United States transplant community. This overview details a brief history of United States organ sharing and the role played by the Organ Center. The current scope and modes of Organ Center operations are detailed.

Tumour size measurement in an oncology clinical trial: comparison between off-site and on-site measurements.

AIM: To evaluate the degree of variability between lesion measurements obtained by a single observer compared with multiple observers, and in selected cases evaluate which of the two measurements more accurately represented the lesion size. MATERIALS AND METHODS: In this study we compared the performance of a single off-site observer to multiple on-site observers during measurement of 300 abdominal and thoracic lesions. Lesion measurements that were larger than 1cm(2), differed by more than 50%, but by less than 100%, were compared by a single adjudicator, who was blinded to the measurement source (n=46). RESULTS: Measurements of the 300 lesions differed by an average of 109% (SD 251%). Of 266 lesions larger than 1cm(2), results of the single observer compared with multiple observers differed by more than 10% for 249 lesions, more than 30% for 169 lesions, more than 50% for 126 lesions, and more than 100% for 66 lesions. Forty-six lesions were compared by the adjudicator. The adjudicator selected the measurement of the single observer for 37 lesions (80.4%), and the measurement determined by one of the multiple observers for nine lesions (19.6%; p=0.00002). CONCLUSION: Measurement of lesion size by a single observer compared with multiple observers reveals a high degree of variability. An adjudicator selected the measurement of the single observer more frequently than that of multiple observers, with statistical significance. These findings suggest that studies designed to quantify imaging features should limit the number of observers.

The presence of a FLT3 internal tandem duplication in patients with acute myeloid leukemia (AML) adds important prognostic information to cytogenetic risk group and response to the first cycle of chemotherapy: analysis of 854 patients from the United Kingdom Medical Research Council AML 10 and 12 trials.

In acute myeloid leukemia (AML), further prognostic determinants are required in addition to cytogenetics to predict patients at increased risk of relapse. Recent studies have indicated that an internal tandem duplication (ITD) in the FLT3 gene may adversely affect clinical outcome. This study evaluated the impact of a FLT3/ITD mutation on outcome in 854 patients, mostly 60 years of age or younger, treated in the United Kingdom Medical Research Council (MRC) AML trials. An FLT3/ITD mutation was present in 27% of the patients and was associated with leukocytosis and a high percentage of bone marrow blast cells (P <.001 for both). It had a borderline association with a lower complete remission rate (P =.05) and a higher induction death rate (P =.04), and was associated with increased relapse risk (RR), adverse disease-free survival (DFS), event-free survival (EFS), and overall survival (OS) (P <.001 for all). In multivariate analysis, presence of a mutation was the most significant prognostic factor predicting RR and DFS (P <.0001) and was still significant for OS (P =.009) and EFS (P =.002). There was no evidence that the relative effect of a FLT3/ITD differed between the cytogenetic risk groups. More than one mutation was detected in 23% of FLT3/ITD(+) patients and was associated with worse OS (P =.04) and EFS (P =.07). Biallelic disease or partial/complete loss of wild-type alleles was present in 10% of FLT3/ITD(+) patients. The suggestion is made that detection of a FLT3/ITD should be included as a routine test at diagnosis and evaluated for therapeutic management.

Fatal anaphylactic reaction to hair dye.

We present the first reported case of fatal anaphylaxis resulting from the application of hair dye. A 68-year-old woman had a history of anaphylactic reaction to hair dye 2 years before her death. After using a different hair dye preparation, the patient experienced shortness of breath, collapsed, and died. Autopsy findings were consistent with anaphylaxis. Pathogenic mechanisms are reviewed.

Continuous monitoring of health status outcomes: experience with a diabetes education program.

A diabetes education program was evaluated using an outcomes management system. Data concerning health status outcomes, including glycemic control (HbA1c), diabetes-related quality of life, and general health-related quality of life, were collected over a 15-month period. This information was collected for each clinic patient at entry into the program and again at a 6-month follow-up session. Patients improved significantly in all categories of outcomes. Newly diagnosed patients showed significantly greater reduction in HbA1c than did patients with a history of diabetes. Health-related quality of life, as measured by symptoms and the SF-36, improved independent of glycemic control. Despite the difficulties of interpreting results from this one-group, pretest-posttest design, the study demonstrated the value of a multidimensional approach to outcome assessment and program evaluation.

Changes in bladder and external urethral sphincter function after spinal cord injury in the rat.

Spinal cord injury (SCI) in humans results in inappropriate contractions of the external urethral sphincter muscle (EUS) during micturition (bladder-sphincter dyssynergia), leading to urinary retention. The major goal of this study was to determine whether SCI in rats has similar detrimental effects on micturition. After chronic SCI, urethan-anesthetized rats had a significantly (15-fold) increased bladder capacity and impaired voiding (31-fold increase in residual volume) compared with control rats. Bladder contractions in SCI rats were accompanied by abnormal tonic EUS electromyographic activity, whereas the EUS electromyograms of control rats exhibited a burst pattern (4-8 Hz) during voiding. Suppression of EUS activity with neuromuscular blockade did not improve the fraction of urine voided in SCI rats and reduced the fraction voided in control rats. Therefore, both tonic activity and complete quiescence of the rat's EUS appear to be detrimental to voiding, suggesting that the normal bursting EUS activity facilitates bladder emptying. In summary, rats and humans exhibit similar micturition dysfunctions after SCI (e.g., bladder-sphincter dyssynergia and impaired voiding).

CP-82,009, a potent polyether anticoccidial related to septamycin and produced by Actinomadura sp.

A new polyether antibiotic CP-82,009 (C49H84O17) was isolated by solvent extraction from the fermentation broth of Actinomadura sp. (ATCC 53676). Following purification by column chromatography and crystallization, the structure of CP-82,009 was elucidated by spectroscopic (NMR and MS) methods. The absolute stereochemistry was determined by a single crystal X-ray analysis of the corresponding rubidium salt. CP-82,009 is among the most potent anticoccidial agents known, effectively controlling the Eimeria species that are the major causative agents of chicken coccidiosis at doses of 5 mg/kg or less in feed. It is also active in vitro against certain Gram-positive bacteria, as well as the spirochete, Serpulina (Treponema) hyodysenteriae.

CP-82,996, a novel diglycoside polyether antibiotic related to monensin and produced by Actinomadura sp.

A new polyether antibiotic CP-82,996 (C50H86O16) was isolated by solvent extraction from the fermentation broth of Actinomadura sp. (ATCC 53764). Following purification by silica gel column chromatography and crystallization, the structure of CP-82,996 was determined by a single crystal X-ray analysis. The structure is closely related to monensin, but is unique in that it contains two sugar groups, whereas monensin has none. The 1H and 13C NMR chemical shifts and assignments for CP-82,996 were elucidated, and they were compared with those determined previously for monensin. CP-82,996 is active against certain Gram-positive bacteria, and is a very potent anticoccidial agent. It effectively controlled chicken coccidiosis caused by several Eimeria species at 5-10 ppm in feed, and is 10-20 times more potent than monensin.

CP-84,657, a potent polyether anticoccidial related to portmicin and produced by Actinomadura sp.

A new polyether antibiotic CP-84,657 (C45H78O14) was isolated by solvent extraction from the fermentation broth of Actinomadura sp. (ATCC 53708). Following purification by column chromatography and crystallization, the structure of CP-84,657 was elucidated by spectroscopic (NMR and MS) methods. The absolute stereochemistry was determined by a single crystal X-ray analysis of the corresponding rubidium salt. CP-84,657 is among the most potent anticoccidal agents known, effectively controlling the Eimeria species that are the major causative agents of chicken coccidiosis at doses of 5 mg/kg or less in feed. It is also active in vitro against certain Gram-positive bacteria, as well as the spirochete, Treponema hyodysenteriae.

CP-78,545, a new monocarboxylic acid ionophore antibiotic related to zincophorin and produced by a Streptomyces.

A new monocarboxylic acid ionophore antibiotic related to zincophorin, CP-78,545 (1), was found in the culture broth of Streptomyces sp. N731-45. CP-78,545 was extracted with organic solvents and purified by column chromatography. The metabolite, which is active in vitro against certain Gram-positive bacteria, as well as the anaerobe Treponema hyodysenteriae, and a coccidium Eimeria tenella, was isolated as a water insoluble magnesium salt (2) in 2:1 (ligand/metal) stoichiometry. The structure of CP-78,545 was elucidated by spectroscopic (NMR and MS) methods, and the relative stereochemistry was determined by single-crystal X-ray analysis of the cadmium salt (3). CP-78,545, i.e., 24-dehydrozincophorin, is unique since its molecular backbone contains a terminal double bond previously not found in other polyether ionophores.

Gestational diabetes mellitus: a syndrome with phenotypic and genotypic heterogeneity.

One hundred ninety-nine gravida with gestational diabetes mellitus (GDM) defined as "carbohydrate intolerance of varying severity with onset or first recognition during pregnancy" have been stratified into subgroups on the basis of fasting plasma glucose and evaluated for further phenotypic and genotypic heterogeneity. A significantly greater proportion of the women in all our groups were older and heavier than in a "control" population of 148 consecutive gravida with documented normal oral glucose tolerance. After correction for age and weight by covariate analysis, absolute insulinopenia in response to oral glucose could be demonstrated in all GDM groups, although exceptions were present in each. The incidence of diabetes in the mothers of our patients with GDM was 8-fold greater than in controls; the incidence in fathers did not deviate from control patterns. HLA-DR3 and DR4 antigens were more frequently present in GDM and the increase was statistically significant in blacks. At the time of diagnosis, cytoplasmic islet cell antibodies (ICA) were significantly more common in GDM associated with elevated fasting plasma glucose than in controls; the frequency of ICA was 18.4% (7/38) in women with fasting plasma glucose greater than or equal to 130 mg/dl. Our findings indicate that GDM entails genotypic as well as phenotypic diversity and may include patients with slowly-evolving Type I diabetes mellitus, as well as patients with Type II diabetes mellitus, and women with asymptomatic diabetes which antedated the pregnancy (i.e. pregestational diabetes mellitus). Appreciation of this heterogeneity should be incorporated into any evaluation of intervention strategies for women with GDM or into prognoses concerning their postpartum metabolic status.

Gestational diabetes mellitus. Heterogeneity of maternal age, weight, insulin secretion, HLA antigens, and islet cell antibodies and the impact of maternal metabolism on pancreatic B-cell and somatic development in the offspring.

We have examined gravida with gestational diabetes mellitus (GDM), as defined by the National Diabetes Data Group (Diabetes 1979; 28:1039), for phenotypic and genotypic heterogeneity. Fasting plasma glucose (FPG) at diagnosis was used for further stratification of GDM according to putative metabolic severity into class A1 (FPG less than 105 mg/dl [N = 129]), class A2 (FPG 105-129 mg/dl [N = 47]), and class B1 (FPG greater than or equal to 130 mg/dl [N = 23]). All GDM classes tended to be older and heavier than consecutive gravida with documented normal glucose tolerance (controls, N = 148). Subdivision into "lean" and "obese" indicated that plasma immunoreactive insulin (IRI) was greater after overnight fast in the obese of all groups except B1. However, absolute increases in IRI above fasting levels in response to glucose during OGTT were significantly enhanced by obesity only in class A2 gravida. Adjustment for the effects of age and weight by covariate analysis indicated that the IRI response to glycemic stimulation is usually attenuated in all forms of GDM. Mean values for increases in IRI above fasting values during the first 15 min and IRI increments relative to the increases in plasma glucose throughout the 180-min OGTT were below control values in all GDM groups and progressively so, i.e., A1 less than A2 less than B1. The absolute insulinopenia was not invariable; a small number of gravida from all GDM groups displayed well-preserved IRI responses to oral glucose. Genotypic evaluation of the GDM population disclosed an increased occurrence of "markers" known to be associated with type I diabetes mellitus.(ABSTRACT TRUNCATED AT 250 WORDS)

A method of assessment during vocational training: report of a pilot study.

Problems arising from the present rate of failure of vocational trainees in the MRCGP examination are outlined; and the role of formative assessment during training in reducing this rate is considered. A study is described in which trainees in a number of centres were assessed by a method designed to measure specified cognitive abilities and areas of knowledge. The method, based on written papers, provides each candidate with a profile of performance and generates comparative standards. Reliability of marking, the distribution of candidate-scores within and between areas of assessment and techniques for monitoring the effectiveness of questions are reported. Use of the method by College as an educational service to trainees is considered, along with its potential as a Part I MRCGP examination.

Inhibition of terminal axonal sprouting by serum from patients with amyotrophic lateral sclerosis.

To investigate the pathogenesis of amyotrophic lateral sclerosis, we compared the effect of serum from patients with this disease on the regenerative sprouting of terminal axons in botulinum-treated mouse gluteus muscle with the effects of serum from controls and from patients with diabetic peripheral neuropathy. Serum from 9 of 19 patients with the sporadic form of amyotrophic lateral sclerosis and from 2 of 6 patients with the familial form caused a reduction in the proportion of sprouting terminal axons, as compared with that found in muscles treated with serum from controls or diabetic patients. Immunoglobulin from patients with amyotrophic lateral sclerosis, when tested on immunoblots, recognized a 56-kilodalton protein secreted by denervated rat diaphragm muscle; rabbit antiserum raised against this protein also suppressed terminal axonal sprouting. Thus, we have detected an antibody in the serum of patients with amyotrophic lateral sclerosis that inhibits sprouting of neurons and subsequent reinnervation of skeletal muscle. Whether this antibody is of primary pathogenic importance or represents a secondary response to neuromuscular destruction is not known. In either case, serum from patients with amyotrophic lateral sclerosis may provide reagents for studies of the trophic communications between muscle and motor neurons.