Cardiovascular MRI evidence of reduced systolic function and reduced LV mass in rheumatoid arthritis: impact of disease phenotype.

The accelerated risk of cardiovascular disease (CVD) in Rheumatoid Arthritis (RA) requires further study of the underlying pathophysiology and determination of the at-risk RA phenotype. Our objectives were to describe the cardiac structure and function and arterial stiffness, and association with disease phenotype in patients with established) RA, in comparison to healthy controls, as measured by cardiovascular magnetic resonance imaging (CMR). 76 patients with established RA and no history of CVD/diabetes mellitus were assessed for RA and cardiovascular profile and underwent a non-contrast 3T-CMR, and compared to 26 healthy controls. A univariable analysis and multivariable linear regression model determined associations between baseline variables and CMR-measures. Ten-year cardiovascular risk scores were increased in RA compared with controls. Adjusting for age, sex and traditional cardiovascular risk factors, patients with RA had reduced left ventricular ejection fraction (mean difference - 2.86% (- 5.17, - 0.55) p = 0.016), reduced absolute values of mid systolic strain rate (p < 0.001) and lower late/active diastolic strain rate (p < 0.001) compared to controls. There was evidence of reduced LV mass index (LVMI) (- 4.56 g/m2 (- 8.92, - 0.20), p = 0.041). CMR-measures predominantly associated with traditional cardiovascular risk factors; male sex and systolic blood pressure independently with increasing LVMI. Patients with established RA and no history of CVD have evidence of reduced LV systolic function and LVMI after adjustment for traditional cardiovascular risk factors; the latter suggesting cardiac pathology other than atherosclerosis in RA. Traditional cardiovascular risk factors, rather than RA disease phenotype, appear to be key determinants of subclinical CVD in RA potentially warranting more effective cardiovascular risk reduction programs.

Pharmacology and Therapeutics Education in the European Union Needs Harmonization and Modernization: A Cross-sectional Survey Among 185 Medical Schools in 27 Countries.

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real-life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU.

Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study.

OBJECTIVES: To monitor progression to inflammatory arthritis (IA) in individuals with non-specific musculoskeletal (MSK) symptoms and positive anticyclic citrullinated peptide (anti-CCP) antibodies. To develop a pragmatic model to predict development of IA in this patient group. METHODS: In this prospective observational cohort, patients with new non-specific MSK symptoms and positive anti-CCP were recruited from regional primary care and secondary care referrals. Clinical, imaging and serological parameters were assessed at baseline. Cox regression analysis was performed to identify predictors of progression to IA and develop a risk score to stratify patients at presentation. FINDINGS: 100 consecutive patients (73 women, mean age 51 years) were followed up for median 19.8 months (range 0.1-69.0); 50 developed IA after a median 7.9 months (range 0.1-52.4), 34 within 12 months. The majority (43/50) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism criteria for rheumatoid arthritis. A model for progression to IA was devised using four variables: tenderness of hand or foot joints, early morning stiffness ≥30 min, high-positive autoantibodies, and positive ultrasonographic power Doppler signal. None of the five individuals at low risk (score 0) progressed to IA, compared with 31% of 29 at moderate risk (1-2) and 62% of 66 at high risk (≥3). Adding shared epitope increased the number at low risk (score 0-1; 0/11 progressed). CONCLUSIONS: In patients presenting with non-specific MSK symptoms and anti-CCP, the risk of progression to IA could be quantified using data available in clinical practice. The proposed risk score may be used to stratify patients for early therapeutic intervention. TRIAL REGISTRATION NUMBER: NCT02012764 at ClinicalTrials.gov.

Long term outcomes following emergency intensive care readmission after elective oesophagectomy.

OBJECTIVE: The purpose of this study was to analyse the outcomes of patients readmitted to ICU following initial recovery after oesophagectomy. BACKGROUND: Surgery for oesophageal cancer has significant morbidity and poor long-term outcomes. There is limited evidence concerning the long-term outcomes of patients who require readmission to the intensive care unit (ICU) after an initial recovery following resection. METHOD: The case notes of 221 patients who underwent elective oesophagectomy over an eleven-year period were reviewed. Patients who were readmitted to ICU following initial recovery were identified and the clinical and demographic characteristics of these patients were prospectively recorded and their outcomes analysed. RESULTS: A total of 43 patients were readmitted to ICU during the study period mainly for respiratory complications or anastomotic leaks. 17 patients (40%) required a period of mechanical ventilation; 16 patients (37%) required inotropes and 2 patients (5%) required renal support. The mean ICU stay on readmission was 8 days (range 0-49 days) with an in-hospital mortality rate of 33%. In terms of long-term outcomes, the actuarial two- and five-year survival rates were 42.3 +/- 7.7% and 36.7 +/- 8.5% respectively. Multivariate analysis identified both age (Hazard ratio: 1.05 +/- 0.02; p = 0.04) and requirement for renal support (Hazard ratio: 5.63 +/- 0.8; p = 0.03) as independent adverse predictors of survival. CONCLUSIONS: Although ICU readmission following elective oesophagectomy is associated with significant mortality, the overall long-term survival rate for these patients, particularly those who do not require renal support is encouraging.

The effects of co-dependence on physicians and nurses.

To evaluate the effect on physicians and nurses of being closely involved with one or more chemical dependent persons, a sample of 67 physicians and 133 nurses with chemical dependent significant others was surveyed. The majority reported that the quality of their work was adversely affected by this association. Reduced ability to concentrate, absenteeism, errors, poor judgment, and patient neglect were reported. Most reported their professional education had not prepared them to recognize and assist people with chemical dependence and half thought their professional education negatively influenced their ability to help. About half had attempted to treat the chemical dependent person(s) themselves, sometimes giving medication and occasionally diverting drugs for this purpose. Most said their self-esteem and self-confidence were damaged by these relationships. Over one-third reported being diagnosed as depressed and 12% had attempted suicide. There were few differences between physicians and nurses on the effects of being in a co-dependent relationship(s), although nurses and women were more likely to have chemically dependent parents. Implications for professional education are identified.

Drug use and disciplinary actions among 300 nurses.

A survey of 300 U.S. nurses recovering from alcohol and other drug dependency was conducted to describe the effect of drug use on job performance and related disciplinary actions. Subjects reported experimentation with or dependence on a variety of drug categories. Many visible effects on job performance were reported but only 23% reported disciplinary action against their nursing licenses. Females and older nurses were more often dependent on alcohol, while younger nurses and males reported narcotic dependency with greater frequency. Narcotic use was significantly related to disciplinary action.

Pharmacists recovering from alcohol and other drug addictions: an interview study.

An interview study of 86 pharmacists recovering from alcohol or other drug addiction was conducted to describe their experiences during development of and recovery from the addiction. Patterned after similar studies of other recovering health-care professionals, the study permitted comparisons with these other groups. Many felt inadequately prepared to recognize or deal with warning signs of problems of addiction in themselves or others. Forty-four had been arrested; 45 had experienced unemployment because of drinking or other drug use; 16 lost their licenses. Eighteen reported suicide attempts, 13 by drug overdose. Most reported experiences that are regarded as late-stage events, although 50 had never been subject to board action because of their drinking and other drug use. The use of chemicals interfered with the pharmacists' lives long before they were consciously worried about it. For 18, recovery occurred through the assistance of mutual-help groups alone; others had a variety of treatment experiences. Fewer pharmacists reported addiction to only alcohol than did other health-care professionals. Very few reported addiction to parenteral drugs, a significant deviation from the other groups studied. Pharmacists differed from other groups also in that they were extra scrupulous in reporting acts of dishonesty associated with their addiction, which may make their behavior appear worse than that of the other groups when the opposite may be the case. The profession must begin to answer questions about how recovering pharmacists should be treated, and what the role of professional groups in their recovery is.

One hundred alcoholic women in medicine. An interview study.

To examine the patterns of diagnosis, referral, and help-seeking behaviors of alcoholic women physicians, 95 women physicians and five women medical students were interviewed. Both groups were self-described alcoholics and members of Alcoholics Anonymous and were abstinent from alcohol for at least one year. Subjects participated in one-hour interviews with a recovered alcoholic professional woman. Addictions to drugs other than alcohol were common, with only 40% reporting addiction to alcohol alone. Seventy-three reported serious suicidal ideation prior to sobriety, 26 after the drinking ended. Thirty-eight had made overt suicide attempts, 15 more than once. The presence of alcoholics in the nuclear family and marital instability were common. Treatment experiences varied from none other than Alcoholics Anonymous (21%) to long-term residential treatment of 15 weeks or more per episode (23%). Most had reached treatment through circumstances other than referral by therapists or intervention by impaired-physician committees. Their current procedures should be evaluated with the particular needs of women in mind.

Physicians in alcoholism: a study of current status and future needs.

Members of the American Medical Society on Alcoholism were studied to shed light on medical manpower needs in the alcoholism field. Findings were compared to AMA and federal survey data for all American physicians. AMSA respondents were broadly distributed among specialties: primarily psychiatrists, internists, and family practitioners. They were evenly divided between office-based and institutional practice, and most were on medical school faculties. Regarding alcoholism treatment, they generally agreed that Alcoholics Anonymous is necessary and that nonmedical counsellors are effective, although their attitudes on the etiology of alcoholism were divided. This sample of physicians in alcoholism, although not inclusive of all in the field, represents a diverse group, with differing clinical and educational needs.

Alcoholism outreach in single room occupancies.

Alcoholism flourishes in the community occupying single room occupancy (SRO) dwellings on Manhattan's west side. Individuals in this setting have few social resources and by reason of background and deprivation are inhibited from seeking help for their alcoholism. Consequently a direct in-person outreach approach is required in order to effect treatment. The milieu is rife with physical and psychological threats to occupants. These present unique challenges to the community alcoholism counselor who, as a member of an interdisciplinary community mental health treatment team, seeks to intervene. Counselor is viewed by client as an intruder in the environment. Breaking the isolation in which the client is immersed and developing a bond with him becomes the most immediate and most difficult of the several tasks facing the counselor.

The alcoholic social worker: a survey.

This paper presents data on 50 alcoholic social workers who had successfully stopped drinking for one year or more. In spite of the fact that these social workers were in many cases visibly in trouble with 63 arrests, 120 inpatient admissions, 13 suicide attempts, and a high reported incidence of addiction to other drugs, they found that collaegues and superiors as well as professionals from whom they sought individual treatment were extremely reluctant to confront the alcoholism problem directly. The authors urge social workers to consider ways of offering help to colleagues in a more systematic manner than is currently available.

Alcoholics Anonymous, alcoholism counseling, and social work treatment.

The authors suggest that the misunderstanding by many social workers of the particular values of Alcoholics Anonymous and the skills of alcoholism counselors can involve alcoholic patients themselves in the stress of reconciling different approaches to treatment. They call upon all who treat alcoholics to build mutual trust and cooperation on two assumptions basic to all forms of treatment-that alcoholism is a disease and abstinence is essential to recovery.

The alcoholic physician: a survey.

The authors conducted interviews with 98 recovered alcoholic physicians, all of whom had been entirely abstinent for a minimum of one calendar year. Psychiatry was the only specialty clearly overrepresented. A disproportionate number of subjects reported high standing in their medical school classes. Nearly half of the sample had experienced difficulty with drugs other than alcohol. While legal sanctions and admission to health care and correctional institutions were common among this group, relatively little formal response of a disciplinary nature from colleagues or medical organizations was reported.