Healthcare professional’s guide to cardiopulmonary exercise testing

Cardiopulmonary exercise testing (CPEX) is a valuable clinical tool that has proven indications within the fields of cardiovascular, respiratory and pre-operative medical care. Validated uses include investigation of the underlying mechanism in patients with breathlessness, monitoring functional status in patients with known cardiovascular disease and pre-operative functional state assessment. An understanding of the underlying physiology of exercise, and the perturbations associated with pathological states, is essential for healthcare professionals to provide optimal patient care. Healthcare professionals may find performing CPEX to be daunting, yet this is often due to a lack of local expertise and guidance with testing. We outline the indications for CPEX within the clinical setting, present a typical protocol that is easy to implement, explain the key underlying physiological changes assessed by CPEX, and review the evidence behind its use in routine clinical practice. There is mounting evidence for the use of CPEX clinically, and an ever-growing utilisation of the test within research fields; a sound knowledge of CPEX is essential for healthcare professionals involved in routine patient care

Determinants of Length of Stay Following Total Anterior Circulatory Stroke

Identification of factors that determine length of stay (LOS) in total anterior circulatory stroke (TACS) has potential for targeted intervention to reduce the associated health care burden. This study aimed to determine which factors predict LOS following either ischaemic or haemorrhagic TACS. The study sample population was drawn from the Norfolk and Norwich Stroke and Transient Ischemic Attack (TIA) Register (1996 – 2012), a prospective registry. 2965 patients admitted with TACS verified by a stroke specialist team were included. Primary analysis identified predictors of length of stay (LOS) in either haemorrhagic or ischaemic TACS. Secondary analyses identified predictors of LOS in patients who were discharged alive or who died during admission separately. Moderate (p=0.014) to severe disability (p=0.015) and history of congestive heart failure (p=0.027) in the primary analysis and pre-stroke residence in a care facility among patients who survived to discharge (p=0.013) were associated with a shorter length of stay. Factors associated with increased length of stay included presence of neurological lateralisation in the primary analysis (p=0.004) and amongst patients who died (p=0.003 and p=0.014 for ischaemic and haemorrhagic stroke, respectively). Patients with advanced age (≥85 years) with haemorrhagic stroke had longer LOS regardless of mortality outcome. Patients with low pre-morbid disability (modified Rankin score ≤2 who died following haemorrhagic TACS also had longer LOS. Our study found predictors of LOS following TACS include neurological lateralisation, pre-stroke disability status, congestive heart failure, pre-morbid residence and age. The identification of such factors would assist in resource allocation and discharge planning

The epidemiology and natural history of Crohn’s disease in population-based patient cohorts from North America: a systematic review

To quantify, through systematic review, the epidemiology and natural history of Crohn’s disease in North America. Methods:  The selected articles contained: (i) population-based samples of patients followed from the time of diagnosis; and (ii) objective diagnostic criteria for disease. Studies on the natural history of Crohn’s disease also contained sufficient follow-up. Data collection and analysis:  For prevalence studies, data on the incidence, prevalence, gender and age at diagnosis were extracted. For natural history studies, data on the disease activity, use of medications and surgery were extracted. Main results:  The prevalence of Crohn’s disease in North America ranges from 26.0 to 198.5 cases per 100 000 persons. The incidence rates range from 3.1 to 14.6 cases per 100 000 person-years. Most patients have a chronic intermittent disease course, while 13% have an unremitting disease course and 10% have a prolonged remission. Less than half require corticosteroids at any point. During any given year, approximately 10% are treated with corticosteroids and 30% are treated with 5-aminosalicylates. Up to 57% of patients require at least one surgical resection. Conclusions:  Between 400 000 and 600 000 patients in North America have Crohn’s disease, and the natural history is marked by frequent exacerbations requiring treatment with corticosteroids, 5-aminosalicylate products and surgery.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72031/1/j.1365-2036.2002.01140.x.pd

Prescribing in type 2 diabetes patients with and without cardiovascular disease history: A descriptive analysis in the UK CPRD

PURPOSE: Some classes of glucose-lowering medications, including sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1-receptor agonists (GLP1-RAs) have cardio-protective benefit, but it is unclear whether this influences prescribing in the United Kingdom (UK). This study aims to describe class-level prescribing in adults with type 2 diabetes mellitus (T2DM) by cardiovascular disease (CVD) history using the Clinical Practice Research Datalink (CPRD). METHODS: Four cross-sections of people with T2DM aged 18-90 and registered with their general practice for >1 year on 1st January 2017 (n = 166,012), 1st January 2018 (n = 155,290), 1st January 2019 (n = 152,602) and 31st December 2019 (n = 143,373) were identified. Age-standardised proportions for class use through time were calculated separately in those with and without CVD history and by total number of medications prescribed (one, two, three, four+). An analysis by UK country was also performed. FINDINGS: Around 31% of patients had CVD history at each cross-section. Metformin was the most common treatment (>70% of those with and without CVD had prescriptions across all treatment lines). Overall use of SGLT2is and GLP1-RAs was low, with slightly less use in patients with CVD (SGLT2i: 9.8% and 13.8% in those with and without CVD respectively; GLP1-RA: 4.3% and 4.9%, December 2019). Use of SGLT2is as part of dual therapy was low but rose throughout the study. In January 2017, estimated use was 8.0% (95% CI 6.9-9.1%) and 8.9% (8.6-9.3%) in those with and without CVD. By December 2019 this reached 18.3% (17.0-19.5%) and 21.2% (20.6-21.7%) for those with and without CVD respectively. SGLT2i use as triple therapy increased: 22.7% (21.0-24.4%) and 25.9% (25.2-26.6%) in January 2017 to 41.3% (39.5-43.0%) and 45.5% (44.7-46.3%) in December 2019. GLP1-RA use also increased, but observed usage remained lower than SGLT2 inhibitors. Insulin use remained stable throughout, with higher use observed in those with CVD (16% vs 9.7% Dec 2019). Time trends in England, Wales, Scotland and Northern Ireland were similar, although class prevalence varied. IMPLICATIONS: Although use of SGLT2is and GLP1-RAs has increased, overall usage remains low with slightly lower use in those with CVD history, suggesting there is opportunity to optimise use of these medicines in T2DM patients to manage CVD risk. Insulin use was substantially more prevalent in those with CVD despite no evidence of CVD benefit. Further investigation of factors influencing this finding may highlight strategies to improve patient access to the most appropriate treatments, including those with evidence of cardiovascular benefit

Feasibility and marketing studies of health sciences librarianship education programs.

The University of North Carolina at Chapel Hill evaluated five curricular models designed to improve education for health sciences librarianship. Three of the models enhanced existing degree and certificate programs, and two were new programs for working information professionals. Models were developed with input from experts and a Delphi study; the marketability of the models was tested through surveys of potential students and employers; and recommendations were made as a guide to implementation. The results demonstrated a demand for more specialized curricula and for retraining opportunities. Marketing data showed a strong interest from potential students in a specialized master's degree, and mid-career professionals indicated an interest in post-master's programs that provided the ability to maintain employment. The study pointed to the opportunity for a center of excellence in health sciences information education to enable health sciences librarians to respond to their evolving roles

Increasing the source/sink ratio in Vitis vinifera (cv Sangiovese) induces extensive transcriptome reprogramming and modifies berry ripening

<p>Abstract</p> <p>Background</p> <p>Cluster thinning is an agronomic practice in which a proportion of berry clusters are removed from the vine to increase the source/sink ratio and improve the quality of the remaining berries. Until now no transcriptomic data have been reported describing the mechanisms that underlie the agronomic and biochemical effects of thinning.</p> <p>Results</p> <p>We profiled the transcriptome of <it>Vitis vinifera </it>cv. Sangiovese berries before and after thinning at veraison using a genome-wide microarray representing all grapevine genes listed in the latest V1 gene prediction. Thinning increased the source/sink ratio from 0.6 to 1.2 m²leaf area per kg of berries and boosted the sugar and anthocyanin content at harvest. Extensive transcriptome remodeling was observed in thinned vines 2 weeks after thinning and at ripening. This included the enhanced modulation of genes that are normally regulated during berry development and the induction of a large set of genes that are not usually expressed.</p> <p>Conclusion</p> <p>Cluster thinning has a profound effect on several important cellular processes and metabolic pathways including carbohydrate metabolism and the synthesis and transport of secondary products. The integrated agronomic, biochemical and transcriptomic data revealed that the positive impact of cluster thinning on final berry composition reflects a much more complex outcome than simply enhancing the normal ripening process.</p

The silent majority: Pico- and nanoplankton as ecosystem health indicators for marine policy

A healthy marine ecosystem is a fully functioning system, able to supply ecosystem services whilst still maintaining resilience to human-induced environmental change. Monitoring and managing the health of resilient marine ecosystems requires indicators that can assess their biodiversity state and food web functioning. Plankton are crucial components of pelagic habitats, occupying the base of the pelagic food web. Larger plankton have long been used to monitor ecosystem productivity and biodiversity due to their identification via traditional light microscopy. In contrast, the regular monitoring of pico- and nanoplankton (<20 µm; hereafter called “tiny plankton”) only started with the development of flow cytometry techniques, which has limited their inclusion as ecosystem health indicators. Four UK plankton surveys have sampled and identified these tiny plankton for up to 14 years, providing an opportunity to test their suitability as indicators of ecosystem state. We investigated six groups of tiny plankton, including heterotrophic nanoeukaryotes, photosynthetic nanoeukaryotes, photosynthetic picoeukaryotes, and Synechococcus cyanobacteria, and two groups of heterotrophic bacteria. Flow cytometry and light microscopy data from an inshore Western English Channel station revealed that 99.98 % of plankton abundance and 71 % of plankton biomass was derived from tiny plankton cells too small to be quantified accurately under a light microscope and thus not adequately considered in assessments of pelagic habitats. Different UK marine and coastal regions showed consistency in peak abundances of these tiny plankton. We used a novel wavelet coherence method to identify time-based relationships between tiny plankton and environmental variables linked to human pressures. Relationships were found between nitrogenous nutrients and all tiny plankton groups, most commonly at sub-annual to annual time scales. Photosynthetic picoeukaryotes, heterotrophic nanoeukaryotes, and HNA-bacteria were associated with high sea surface temperatures. Given the here established relationship between tiny plankton and environmental variables, and their importance in the full plankton assemblage, we recommend that, alongside existing microplankton lifeforms, tiny plankton groups can be used as plankton lifeforms, either individually or in combination, to inform biodiversity indicators that meet policy obligations under the EU Marine Strategy Framework Directive (MSFD), (Oslo-Paris Convention) OSPAR strategies, and the UK Marine Strategy