Lipid Management in Diabetes with a Focus on Emerging Therapies.

We reviewed the current and potential future management of dyslipidemia in patients with diabetes, with a focus on reduction of risk for macrovascular disease. We considered novel dyslipidemia therapies, in particular, inhibitors of proprotein convertase subtilisin kexin 9 (PCSK9), which have been approved in Canada for reducing low-density lipoprotein (LDL) cholesterol in certain patient groups. We searched for English-language randomized clinical trials (RCTs) of lipid-lowering modalities, mainly since 2012, that included patients with diabetes. The results from some RCTs may have future impacts on the approach to patients with diabetes. In particular, ezetimibe added to statins in the context of acute coronary syndromes seems to have particular benefits in patients with diabetes. Also, patients with diabetes show no differences, so far, from patients without diabetes with respect to efficacy of PCSK9 inhibitors in LDL cholesterol reduction and also in the frequency of adverse effects. RCTs of clinical outcomes with PCSK9 inhibitors performed exclusively in patients with diabetes are desirable, but approval of these agents for use in Canada has occurred before the availability of such results. Clinicians will have to gauge whether certain subjects with diabetes might benefit from this therapy, such as those with superimposed familial dyslipidemia, those with recurrent cardiovascular events and recalcitrant LDL cholesterol levels despite maximally tolerated statin therapy and those with high cardiovascular risk who cannot tolerate any dose of statins.

Excelling in the role of advocate: a qualitative study exploring advocacy as an essential physiotherapy competency.

PURPOSE: To explore the perspectives of leading advocates regarding the attributes required for excelling in the advocate role as described within the Essential Competency Profile for Physiotherapists in Canada (2009). METHODS: We used a descriptive qualitative design involving in-depth, semi-structured interviews conducted with leading Canadian advocates within the physiotherapy profession. Transcribed interviews were coded and analyzed using thematic analysis. RESULTS: The 17 participants identified eight attributes necessary for excelling in the role of advocate: collaboration, communication, scholarly practice, management, professionalism, passion, perseverance, and humility. The first five attributes correspond to roles within the Essential Competency Profile for Physiotherapists in Canada. Participants identified the attributes of collaboration, communication, and scholarly practice as the most important for successful advocacy. Participants also noted that the eight identified attributes must be used together and tailored to meet the needs of the advocacy setting. CONCLUSIONS: Identifying these eight attributes is an important first step in understanding how competence in the advocate role can be developed among physiotherapy students and practitioners. Most importantly, this study contributes to the knowledge base that helps physiotherapists to excel in advocating for their clients and the profession.

Objectif: Étudier les points de vue des principaux défenseurs au sujet des qualités requises pour exceller dans le rôle de défenseur décrit dans le Profil des compétences essentielles des physiothérapeutes au Canada (2009). Méthodes: Nous avons utilisé un contexte qualitatif descriptif comportant des entrevues semi-structurées détaillées réalisées auprès de défenseurs canadiens de premier plan de la profession. Nous avons codé les entrevues transcrites et les avons analysées en appliquant une analyse thématique. Résultats: Les 17 participants ont défini huit qualités nécessaires pour exceller dans le rôle de défenseur: collaboration, communication, pratique savante, gestion, professionnalisme, passion, persévérance et humilité. Les cinq premières qualités correspondent aux rôles décrits dans le Profil des compétences essentielles des physiothérapeutes au Canada. Les participants ont considéré la collaboration, la communication et la pratique savante comme les qualités les plus importantes pour réussir comme défenseur. Ils ont aussi signalé que les huit qualités définies doivent servir ensemble et être personnalisées de façon à répondre aux besoins du contexte de défense. Conclusion: La détermination de ces huit qualités constitue une première étape importante pour comprendre comment les étudiants en physiothérapie et les praticiens peuvent devenir défenseurs compétents. Le plus important: cette étude contribue à la base de savoir qui aide les physiothérapeutes à exceller dans la défense de leurs clients et de la profession.

Hand-held tools with complex kinematics are efficiently incorporated into movement planning and online control.

Certain hand-held tools alter the mapping between hand motion and motion of the tool end point that must be controlled in order to perform a task. For example, when using a pool cue, the motion of the cue tip is reversed relative to the hand. Previous studies have shown that the time required to initiate a reaching movement (Fernandez-Ruiz J, Wong W, Armstrong IT, Flanagan JR. Behav Brain Res 219: 8-14, 2011), or correct an ongoing reaching movement (Gritsenko V, Kalaska JF. J Neurophysiol 104: 3084-3104, 2010), is prolonged when the mapping between hand motion and motion of a cursor controlled by the hand is reversed. Here we show that these time costs can be significantly reduced when the reversal is instantiated by a virtual hand-held tool. Participants grasped the near end of a virtual tool, consisting of a rod connecting two circles, and moved the end point to displayed targets. In the reversal condition, the rod translated through, and rotated about, a pivot point such that there was a left-right reversal between hand and end point motion. In the nonreversal control, the tool translated with the hand. As expected, when only the two circles were presented, movement initiation and correction times were much longer in the reversal condition. However, when full vision of the tool was provided, the reaction time cost was almost eliminated. These results indicate that tools with complex kinematics can be efficiently incorporated into sensorimotor control mechanisms used in movement planning and online control.

Informed consent documents do not encourage good-quality decision making.

OBJECTIVE: Informed consent for research has emphasized information provision over support to people making a difficult decision. We assessed the extent to which existing informed consent documents (ICDs) conform to the International Patient Decision Aid Standards for supporting decision making. STUDY DESIGN AND SETTING: One hundred thirty-nine ICDs for trials registered with ClinicalTrials.gov were obtained from study investigators. Using a four-point scale, two raters assessed each ICD on 32 items. RESULTS: Overall agreement between raters was 95.1% (linear weighted kappa-0.745). For 12 items focused on providing enough information, conformity was above 50% for three, and 0% for another four. For all eight items focused on how to present outcome probabilities, conformity was below 20%. For two items focused on clarifying and expressing values, conformity was below 10%. For two items focused on improving structured guidance, conformity was below 5%. For four items focused on using evidence, one item showed conformity of 74%; all others showed conformity below 5%. For four items focused on transparency, conformity was high (above 60% for two, above 80% for the others). CONCLUSIONS: Existing ICDs do not meet most validated standards for encouraging good decision making. These standards make clear predictions about how one might improve ICDs ensure that research participants are fully informed.

Acceptance of a pandemic influenza vaccine: a systematic review of surveys of the general public.

INTRODUCTION: The effectiveness of pandemic vaccine campaigns such as the H1N1 vaccine rollout is dependent on both the vaccines' effectiveness and the general public's willingness to be vaccinated. It is therefore critical to understand the factors that influence the decision of members of the public whether to get vaccinated with new, emergently released vaccines. METHODS: A systematic review of English language quantitative surveys was conducted to identify consistent predictors of the decision to accept or decline any (pre)pandemic vaccine, including the H1N1 influenza A vaccine. A total of ten studies were included in this review and all pertained to the 2009 H1N1 influenza A pandemic. Respondents' willingness to receive a pandemic vaccine ranged from 8%-67% across the ten studies. The factors reported to be consistent predictors of the intention to vaccinate were: risk of infection, proximity or severity of the public health event, severity of personal consequences resulting from the illness, harm or adverse events from the vaccine, acceptance of previous vaccination, and ethnicity. Age and sex were the demographic variables examined most frequently across the ten studies and there was no consistent association between these variables and the intention to accept or reject a pandemic vaccine. CONCLUSION: Some predictors of the intention to accept or decline a (pre)pandemic vaccine or the H1N1 influenza A vaccine are consistently identified by surveys. Understanding the important factors influencing the acceptance of a pandemic vaccine by individual members of the public may help inform strategies to improve vaccine uptake during future pandemics.