Deborah R. Erlich

Association of elevated lipoprotein(a) levels and coronary heart disease in NIDDM patients. Relationship with apolipoprotein(a) phenotypes

SummaryNon-insulin-dependent diabetes mellitus (NIDDM) is a strong and independent risk factor for coronary heart disease. We assessed the potential relationship between plasma Lp(a) levels, apo(a) phenotypes and coronary heart disease in a population of NIDDM patients. Seventy-one patients with coronary heart disease, who previously have had transmural myocardial infarction, or significant stenosis on coronary angiography, or positive myocardial thallium scintigraphy, or in combination, were compared with 67 patients without coronary heart disease, who tested negatively upon either coronary angiography, myocardial thallium scintigraphy or a maximal exercise test. The prevalence of plasma Lp(a) levels elevated above the threshold for increased cardiovascular risk (>0.30 g/l) was significantly higher (p=0.005) in patients with coronary heart disease (33.8%) compared to the control group (13.4%). The relative risk (odds ratio) of coronary heart disease among patients with high Lp(a) concentrations was 3.1 (95% confidence interval, 1.31–7.34;p=0.01). The overall frequency distribution of apo(a) phenotypes differed significantly between the two groups (p=0.043). However, the frequency of apo(a) isoforms of low apparent molecular mass (≤700 kDa) was of borderline significance (p=0.067) between patients with or without coronary heart disease (29.6% and 16.4%, respectively). In this Caucasian population of NIDDM patients, elevated Lp(a) levels were associated with coronary heart disease, an association which was partially accounted for by the higher frequency of apo(a) isoforms of small size. In multivariate analyses, elevated levels of Lp(a) were independently associated with coronary heart disease (odds ratio 3.48, p=0.0233).

Exercise training-induced triglyceride lowering negatively correlates with DHEA levels in men with type 2 diabetes

OBJECTIVE: To investigate the effect of an exercise training program on lipid profile in correlation with DHEA level and body weight and body composition in type 2 diabetic men.DESIGN: Longitudinal, controlled clinical intervention study with exercise training consisting of an 8 week supervised program of aerobic exercise (75% VO2 peak, 45 min), twice a week and intermittent exercise, once a week, on a bicyle ergometer.SUBJECTS: Sixteen men (age 45.4±7.2 y (mean±s.d.), HbA1c 8.15±1.7%, body mass index (BMI) 29.6±4.6 kg/m2) were randomly divided into two groups: trained group (n=8) and control group (n=8).MEASUREMENTS: Lipid, apo- and lipoprotein and DHEA concentrations. Cross-sectional areas of subcutaneous and visceral adipose tissue and mid-thigh muscle by magnetic resonance imaging.RESULTS: Training decreased visceral (153.25±38.55 vs 84.20±21.30 cm2, P<0.001), subcutaneous (241.55±49.55 vs 198.00±39.99 cm2, P<0.001) adipose tissue area and triglyceride levels (2.59±1.90 vs 1.79±1.08 nmol/l, P<0.05) and increased mid-thigh muscle cross-sectional area (148.30±36.10 vs 184.35±35.85 cm2, P<0.001), and DHEA levels (11.00±3.10 vs 14.25±4.10 nmol/l, P<0.05) with no modification in body weight. Changes in triglycerides were negatively correlated with changes in DHEA (r=−0.81, P=0.03). This correlation was independent of changes in abdominal fat distribution.CONCLUSION: Training decreases abdominal fat depots, improves muscular mass and affects favourably triglyceride and DHEA levels. Changes in triglycerides and DHEA were inversely related.

Student–teacher education programme (STEP) by step: Transforming medical students into competent, confident teachers

Abstract Background: While most medical schools have students teach other students, few offer formal education in teaching skills, and fewer provide teaching theory together with experiential teaching practice. Furthermore, curriculum evaluation of teaching education is lacking. Aim: This study aimed to examine effects of a novel didactic teaching curriculum for students embedded in a practical teaching experience. Methods: A longitudinal 12-week curriculum with complementary didactic and practical components for final-year students learning how to teach was developed, implemented and evaluated using a multi-level evaluation based on the Kirkpatrick approach with qualitative and quantitative methods. Results: Thirteen student–teachers acquired measureable knowledge, skills and attitudes necessary for teaching excellence. Confidence in teaching increased (p < 0.001), particularly in four key areas: oral feedback, written feedback, mentoring, and the difficult learner. Student–teachers demonstrated teaching competence as determined by self-assessment, student feedback, and faculty observation. Top teachers impacted their first-year students’ performance in patient interviewing as measured by Objective Structured Clinical Examination (OSCE). Conclusions: Reinforcing educational theory with practical teaching experience under direct faculty supervision promotes teaching competency for graduating medical students. The intertwined didactic plus practical model can be applied to various teaching contexts to fulfil the mandate that medical schools train graduates in core teaching knowledge, skills and attitudes in preparation for their future roles as clinical teachers.

Developing a Clinician Friendly Tool to Identify Useful Clinical Practice Guidelines: G-TRUST

BACKGROUND Clinicians are faced with a plethora of guidelines. To rate guidelines, they can select from a number of evaluation tools, most of which are long and difficult to apply. The goal of this project was to develop a simple, easy-to-use checklist for clinicians to use to identify trustworthy, relevant, and useful practice guidelines, the Guideline Trustworthiness, Relevance, and Utility Scoring Tool (G-TRUST). METHODS A modified Delphi process was used to obtain consensus of experts and guideline developers regarding a checklist of items and their relative impact on guideline quality. We conducted 4 rounds of sampling to refine wording, add and subtract items, and develop a scoring system. Multiple attribute utility analysis was used to develop a weighted utility score for each item to determine scoring. RESULTS Twenty-two experts in evidence-based medicine, 17 developers of high-quality guidelines, and 1 consumer representative participated. In rounds 1 and 2, items were rewritten or dropped, and 2 items were added. In round 3, weighted scores were calculated from rankings and relative weights assigned by the expert panel. In the last round, more than 75% of experts indicated 3 of the 8 checklist items to be major indicators of guideline usefulness and, using the AGREE tool as a reference standard, a scoring system was developed to identify guidelines as useful, may not be useful, and not useful. CONCLUSION The 8-item G-TRUST is potentially helpful as a tool for clinicians to identify useful guidelines. Further research will focus on its reliability when used by clinicians.

‘We rise by lifting others’: peer support and professional development for women in academic medicine*

Mentors have been defined as ‘influential people who help you reach major life goals’ [1]. Although each mentor– protégé relationship is individualised, generally a mentoring relationship is ‘enabling and cultivating, a relationship that assists in empowering an individual with the working environment’ [2]. It is not only the protégé who stands to gain from having a mentor; both parties in a successful mentoring relationship should benefit from participation [3]. Contemporary issues in medicine, such as increasing workloads, threats to retention and reduced opportunities for informal support, make the need for active mentoring more critical than ever [4]. Mentors are often thought of as wiser, more experienced coaches. A potential alternative to this senior– junior dynamic, however, is mentorship rendered by peers, who are, according to one definition, ‘people from similar social groupings ... helping each other to learn and learning themselves by teaching’ [5]. Just as medical student peers can facilitate learning during formal curricular study [6–14], so too can peers cultivate professional development for one another beyond the training years. In fact, peer mentors can be even more effective than senior mentors [15,16]. Proposed reasons include higher perceived candour, comfort, empathy, and safety[17−18]. While peer mentoring likely enhances anyone’s professional growth, it may especially benefit women. Because of women’s under-representation in senior academic roles [19], emerging leaders have few women senior to them available. Because of the especially diverse range of possible careers within academic family medicine, female family physicians in particular stand to gain from active career management guided by peer coaches. Several models for peer mentorship in medicine and other domains are manifest in the literature (see Table 1). These previous models were largely institutionally developed, organised or sponsored for the purpose of furthering participants’ careers. Outcomes included enhanced knowledge, interpersonal skills development, increased scholarship, and facilitated job transitioning [20−23]. Unlike prior literature on institutionally supported mentorship models, this paper describes an independently convened peer support and professional development (PSPD) group. Explicit goals were to meet the evolving professional development needs of the participants; to offer a formal but safe environment for discussing challenges, successes and strategy; and to provide peer support during periods of professional transition and growth.