Astrid Seeberger

Elevated cardiac troponin T in predialysis patients is associated with inflammation and predicts mortality

Abstract.  Löwbeer C, Stenvinkel P, Pecoits‐Filho R, Heimbürger O, Lindholm B, Gustafsson SA, Seeberger A (Karolinska Institutet at Huddinge University Hospital; Capio Diagnostik, St Görans Hospital, Stockholm, Sweden). Elevated cardiac troponin T in predialysis patients is associated with inflammation and predicts mortality. J Intern Med 2003; 253: 153–160.

Serum cardiac troponin T in patients hospitalized with heart failure is associated with left ventricular hypertrophy and systolic dysfunction

Background: Cardiac troponin T (cTnT) is a highly sensitive and specific marker of acute myocardial infarction. Serum cTnT is also slightly elevated in patients with severe heart failure and is associated with left ventricular hypertrophy (LVH) in patients treated with haemodialysis. In this study serum cTnT concentrations and echocardiographic findings were investigated in heart failure patients without acute coronary syndrome. cTnT was also compared with other cardiac markers and plasma levels of brain natriuretic peptide (BNP). Methods: Twenty-six patients hospitalized with heart failure were included in the study. Echocardiographic measurements and blood sampling were carried out 12-36 h after admission. Serum cTnT (3rd generation assay), cardiac troponin I (cTnI), creatine kinase MB (CKMB) and CK were measured. Plasma BNP was analysed using the Shionoria assay. LVH was defined as left ventricular mass index (LVMI)>125 g/m<formula>2</formula> for males and>110 g/m<formula>2</formula> for females. Left ventricular systolic function was estimated from the mitral annulus motion (AV-mean LV). Results: Median cTnT was 0.012 (<0.010-0.032) μg/L. Sixty-two percent of the patients (16 of 26) had elevated serum cTnT≥0.010 μg/L. cTnT was positively correlated with CKMB (ρ=0.40, p=0.04) and BNP (ρ=0.43, p=0.03), but not with cTnI and CK. A negative correlation was found between cTnT and AV-mean LV (ρ=−0.58, p=0.007), and there was a positive correlation between cTnT and LVMI (ρ=0.44, p=0.03). No other analyte was correlated to LVMI. Conclusions: Serum cTnT but not cTnI was associated with left ventricular dysfunction and LVH in patients hospitalized with heart failure. This explains why cTnT tends to be slightly elevated in patients with heart failure without symptoms of acute myocardial ischaemia.

To be and to have a critical friend in medical teaching

Background  In order to stimulate reflection and continuous professional development, a model of critical friends evaluating each other was introduced in medical education.

Serum cystatin C: A useful marker of kidney function in very old people

Abstract Background: Serum creatinine-based estimates of GFR may be inaccurate in the elderly and there is need for improvement. Serum Cystatin C, not being influenced by muscle volume, may be more accurate. Material and methods: GFR was measured with plasma clearance of iohexol in 50 elderly persons aged >70 years. Blood tests were drawn for analysis of creatinine, albumin and urea. Cystatin C was analysed on frozen specimens using the Dade Behring method. GFR estimates based on cystatin C were compared to estimates based on serum creatinine, using earlier published equations. Results: Significant increase with age was found with cystatin C (rs=0.62, p<0.0001) and urea (rs=0.43, p=0.0018) but no correlation with creatinine (rs=0.05, p=0.7502). All equations underestimated GFR with a bias ranging from −2.2 to −31%. The equation with the greatest accuracy was the Hoek equation (Cystatin C based) with 98% of estimates within 30% of mGFR and confidence interval 89–100%. Estimated GFR using the MDRD Study equations (creatinine based) showed accuracy of 94% with 4 or 6 factors used. There was a gender difference with an accuracy higher among males (p<0.002). The Cockcroft Gault equation was not found useful with high bias and a low accuracy. Conclusion: S-cystatin C seems a useful marker for kidney function in the elderly. Two equations based on serum cystatin C as well as the two MDRD equations seem adequate for estimating kidney function.

A single session of haemodialysis improves left ventricular synchronicity in patients with end-stage renal disease: a pilot tissue synchronization imaging study

BACKGROUND Mechanical left ventricular (LV) dyssynchrony impairs cardiac function in patients with heart failure and LV hypertrophy (LVH) and may be a factor contributing to the high incidence of cardiac deaths in patients with end-stage renal disease (ESRD). Objectives. To evaluate the possible presence of LV dyssynchrony in ESRD patients, and acute effect of haemodialysis (HD) on LV synchronicity using a tailored echocardiographic modality, tissue synchronization imaging (TSI). METHODS In 13 clinically stable ESRD patients (7 men; 65 +/- 10 years) with LVH, echocardiography data were acquired before and after a single HD session for subsequent off-line TSI analysis enabling the retrieval of regional intraventricular systolic delay data. Six basal and six midventricular LV segments were evaluated. Dyssynchrony was defined as a regional difference in time to peak systolic velocity >105 ms. RESULTS Before HD, all patients had at least one dyssynchronous LV segment. The percentage of delayed segments correlated positively to LV end-diastolic diameter (r = 0.68, P < 0.05). HD induced a substantial decrease in the percentage of delayed segments from 36 +/- 25% to 19 +/- 14% (P < 0.01), reduced average maximal mechanical systolic LV delay from 300 +/- 89 to 225 +/- 116 ms (P < 0.05) and completely normalized LV synchronicity in three patients (23%). CONCLUSIONS LV dyssynchrony appears to be present frequently in ESRD patients with LVH. The severity of LV dyssynchrony correlates with LV end-diastolic diameter and decreases after a single session of HD suggesting a mechanistic relevance of volume overload and possibly other toxins accumulating in HD patients.

Subclinical Atherosclerosis, Endothelial Function, and Serum Inflammatory Markers in Chronic Kidney Disease Stages 3 to 4

Different inflammatory markers, brachial artery flow-mediated dilatation (FMD), and brachial intima-media thickness (bIMT) were measured in 50 patients with chronic kidney disease (CKD) stages 3 to 4 with estimated glomerular filtration rate (eGFR) and 35 age- and gender-matched controls. The bIMT was significantly increased in the patients with CKD compared with controls (0.43 mm [0.42, 0.45] vs 0.34 mm [0.32, 0.36]; P < .001). There was no significant difference in FMD between the study groups (4.7% vs 5.3%; P = .56). There were significant correlations between bIMT and high-sensitive C-reactive protein, vascular cellular adhesion molecule 1, tumor necrosis factor, and interleukin 6 (P < .05). However, eGFR adjusted for age and gender was the best predictor of bIMT. In conclusion, bIMT and inflammatory markers were increased in patients with CKD compared with the controls. Furthermore, significant correlations between bIMT and inflammatory activity in patients with CKD were observed. The eGFR adjusted for age and gender was the best predictor of bIMT.

Left ventricular mechanical dyssynchrony in patients with different stages of chronic kidney disease and the effects of hemodialysis

Left ventricular (LV) dyssynchrony is a known cause of mortality in patients with heart failure and may possibly play a similar role in patients with chronic kidney disease (CKD) in whom sudden death is one of the most common and as yet not fully explained cause of death. LV synchronicity and its relationship with increased volume load and various biomarkers was analyzed in 145 patients including 53 patients with CKD stages 3 and 4 and in 92 CKD stage 5 patients undergoing hemodialysis (HD) or peritoneal dialysis (PD) using color tissue Doppler imaging and tissue synchronization imaging. The HD patients were evaluated both before and after a single HD session. LV dyssynchrony was defined as a regional difference in time to peak systolic myocardial velocity, between 12 LV segments > 105 milliseconds. LV dyssynchrony was present in 54% of the patients with no difference between CKD 3 and 4 (58%), HD (48%), and PD (51%). LV dyssynchrony was independently associated with LV mass index and increased estimation of LV end‐diastolic pressure. A single HD session resulted in significant changes in LV synchronicity variables—with improvement in 50% of the patients—especially in patients with higher myocardial systolic velocities and lower LV mass index. Abnormalities in LV synchronicity are highly prevalent in CKD patients already prior to dialysis treatment and are associated with LV hypertrophy, LV dysfunction and load conditions, underlining the importance of volume status for LV synchronicity in CKD patients.

Longitudinal mentorship to support the development of medical students’ future professional role: a qualitative study

BackgroundMentoring has been employed in medical education in recent years, but there is extensive variation in the published literature concerning the goals of mentoring and the role of the mentor. Therefore, there is still a need for a deeper understanding of the meaning of mentoring for medical students’ learning and development. The aim of this qualitative study is to explore how formal and longitudinal mentoring can contribute to medical students’ professional development.MethodsSixteen medical students at a Swedish university were interviewed individually about their experiences of combined group and one-to-one mentoring that is given throughout their studies. The mentoring programme was focused on the non-medical skills of the profession and used CanMEDS roles of a physician for students’ self-assessment. Data were analysed using a latent, interpretive approach to content analysis.ResultsThe results comprise three themes: Integrating oneself with one’s future role as a physician, Experiencing clinical reality with the mentor creates incentives to learn and Towards understanding the professional competence of a physician. The mentorship enabled the students to create a view of their future professional role and to integrate it with their own personalities. The students’ understanding of professional competence and behaviour evolved during the mentorship and they made advances towards understanding the wholeness of the profession. This approach to mentorship supported different components of the students’ professional development; the themes Integrating oneself with one’s future role and Towards understanding the professional competence of a physician can be regarded as two parallel processes, while the third theme, Experiencing clinical reality with the mentor creates incentives to learn, promotes these processes.ConclusionsFormalized and longitudinal mentoring focusing on the non-medical skills can be recommended to help medical students to integrate their professional role with themselves as individuals and promote understanding of professional competence in the process of becoming a physician.

How do medical and nursing students experience emotional challenges during clinical placements

Objectives To investigate which kinds of situations medical and nursing students found emotionally challenging during their undergraduate education, and how they managed their experiences. Methods This study used an exploratory research design. We gathered qualitative data using an open-ended questionnaire distributed to students in the middle and at the end of their education. In total, 49 nursing and 65 medical students participated. Also, five students were interviewed individually to acquire richer data. Data were analysed using narrative thematic analysis. Results Medical and nursing students experienced a range of situations during their undergraduate education that they found emotionally challenging, mainly during clinical placements. The students’ narratives concerned confronting patients’ illness and death, unprofessional behaviour among healthcare professionals, dilemmas regarding patient treatment, students relating to patients as individuals and not diagnoses, and using patients for their own learning. The narratives concerned both the formal and the hidden curriculum, i.e., what is included in the profession (confronting illness and death), and what is not (unprofessional behaviour among healthcare professionals). Students managed their experiences by talking to trusted peers or supervisors, and by getting used to these situations. Conclusions Despite the different knowledge, experiences, and conditions for medical and nursing students, our findings suggest that their experiences of emotional challenges are similar. Support and opportunities to talk about these experiences are important. Teachers, supervisors, and students need to be aware that students might experience emotionally difficult situations, and that the students need time for reflection and support.