Development and validation of the physician self-efficacy to manage emotional challenges Scale (PSMEC).

BACKGROUND: Medical students experience emotional challenges during their undergraduate education, often related to work-based learning. Consequently, they may experience feelings of uncertainty and self-doubt, which can negatively affect their well-being. Therefore, it is crucial to support students' development of their ability to manage distressful situations. Self-efficacy beliefs may be a central aspect of supporting them in this development, and have been shown to relate to resilient factors such as students' motivation, learning, and well-being. METHODS: We constructed a scale to measure medical students' physician self-efficacy to manage emotional challenges during work-based learning, the PSMEC scale. The aim of the present study was to evaluate some of the psychometric properties of the PSMEC scale. The scale consists of 17 items covering five subscales: (1) medical knowledge and competence, (2) communication with difficult patients and delivering bad news, (3) being questioned and challenged, (4) educative competence in patient encounters, and (5) ability to establish and maintain relationships with healthcare professionals. Data were collected from 655 medical students from all seven medical schools in Sweden. To investigate the scale's dimensionality and measurement invariance with regard to gender and time in education, single and multiple group confirmatory factor models were estimated using techniques suitable for ordered categorical data. Measures of Cronbach's alpha were calculated to evaluate internal consistency. RESULTS: The scale showed good internal consistency on both the global dimension and the five subdimensions of self-efficacy. In addition, the scale was shown to be measurement invariant across genders and times in education, indicating that the scale means of male and female medical students and the scale means of students at the middle and end of their education can be compared. CONCLUSIONS: The physician self-efficacy to manage emotional challenges scale demonstrated satisfactory psychometric properties, with regards to dimensionality, internal consistency, and measurement invariance relating to gender and time in education, and this study supports the usefulness of this scale when measuring self-efficacy in relation to emotional challenges.

The impact of emotionally challenging situations on medical students' professional identity formation.

In their interactions with patients and health care professionals during work-based learning, medical students are known to experience emotionally challenging situations that can evoke negative feelings. Students have to manage these emotions. Students learn and develop their professional identity formation through interactions with patients and members of the healthcare teams. Earlier studies have highlighted the issues involved with processing emotionally challenging situations, although studies concerning learning and professional identity formation in response to these experiences are rare. In this study, we explored medical students' experiences of emotionally challenging situations in work-based learning, and the impact these experiences had on forming medical students' professional identities. We conducted an analysis of narrative data (n = 85), using a constructivist grounded theory approach. The narratives were made up of medical students' reflective essays at the end of their education (tenth term). The analysis showed that students' main concern when facing emotionally challenging situations during their work-based education was the struggle to achieve and maintain a professional approach. They reported different strategies for managing their feelings and how these strategies led to diverse consequences. In the process, students also described arriving at insights into their own personal needs and shortcomings. We consider this development of self-awareness and resulting self-knowledge to be an important part of the continuously ongoing socialization process of forming a professional identity. Thus, experiencing emotionally challenging situations can be considered a unique and invaluable opportunity, as well as a catalyst for students' development. We believe that highlighting the impact of emotions in medical education can constitute an important contribution to knowledge about the process of professional identity formation. This knowledge can enable faculty to provide students with more effective and sufficient support, facilitating their journey in becoming physicians.

Emotional challenges of medical students generate feelings of uncertainty.

OBJECTIVES: Health care students face many situations during their education that might be emotionally challenging. Students are confronted with illness, suffering, death, patient treatment dilemmas, and witnessing unprofessional behaviour on the part of health care professionals. Few studies have focused on what these experiences lead to in relation to the process of becoming a professional. The purpose of the study was to explore medical students' main concerns relating to emotionally challenging situations during their medical education. METHODS: A constructivist grounded theory approach was used to explore and analyse medical students' experiences. Data were gathered by means of focus group interviews, including two interviews in the middle and two interviews at the end of the students' undergraduate programme. A total of 14 medical students participated. RESULTS: Students' main concerns relating to emotionally challenging situations were feelings of uncertainty. These feelings of uncertainty concerned: (i) insufficient knowledge and skills; (ii) the struggle to manage emotions in patient encounters; (iii) perceived negative culture and values amongst health care professionals and in the health care system, and (iv) lacking a self-evident position on the health care team. The first two aspects relate to uncertainties concerning their own capabilities and the other two aspects relate to uncertainties regarding the detached medical culture and the unclear expectations of them as students in the health care team. CONCLUSIONS: In the process of becoming a physician, students develop their professional identity in constant negotiation with their own perceptions, values and norms and what they experience in the local clinical context in which they participate during workplace education. The two dimensions that students have to resolve during this process concern the questions: Do I have what it takes? Do I want to belong to this medical culture? Until these struggles are resolved, students are likely to experience worry about their future professional role.

Is low pre-transplant parathyroid hormone a risk marker for cardiovascular disease in long-term follow-up of renal transplant recipients?

BACKGROUND: Secondary hyperparathyroidism and altered levels of parathyroid hormone (PTH) are associated with vascular events in chronic kidney disease. After renal transplantation, this association is not clear. Pre-transplant parathyroidectomy (PTX) is common, but post-transplant data are scarce. We aimed to study the effect of PTH at the time of transplantation on risk of post-transplant vascular events in renal transplant recipients with and without pre-transplant PTX. METHODS: 258 patients from two Swedish transplant units were followed for 6 years. Separate analyses were made for patients with or without pre-transplant PTX. Patients with no pre-transplant PTX were stratified by quartiles of PTH at time of transplantation and patients with pre-transplant PTX were stratified by above and below median levels of PTH at time of transplantation. Hazard ratios for vascular events, mortality, and graft failure were calculated in adjusted Cox regression models. RESULTS: In patients with no pre-transplant PTX, the lowest quartile of PTH at transplantation had a higher risk of cardiovascular events compared to quartile 3 with an adjusted hazard ratio (95% CI) of 2.63 (1.04-6.67). In patients with pre-transplant PTX, the group below median of PTH had a higher risk of cardiovascular events with an adjusted hazard ratio (95% CI) of 18.15 (1.62-203.82) compared to patients above median of PTH. CONCLUSION: Low levels of parathyroid hormone before transplantation were associated with increased risk of post-transplant vascular events both in patients with and without pre-transplant parathyroidectomy. Any conclusions on causal or direct effect of PTH on outcome cannot be drawn from this observational study.

Initiation of erythropoiesis-stimulating agents and outcomes: a nationwide observational cohort study in anaemic chronic kidney disease patients.

BACKGROUND: In 2012, new clinical guidelines were introduced for use of erythropoiesis-stimulating agents (ESA) in chronic kidney disease (CKD) patients, recommending lower haemoglobin (Hb) target levels and thresholds for ESA initiation. These changes resulted in lower blood levels in these patients. However, there is limited evidence on just when ESA should be initiated and the safety of a low Hb initiation policy. METHODS: In this observational inception cohort study, Swedish, nephology-referred, ESA-naïve CKD patients (n = 6348) were enrolled when their Hb dropped below 12.0 g/L, and they were followed for mortality and cardiovascular events. Four different ESA treatments were evaluated applying dynamic marginal structural models: (i) begin ESA immediately, (ii) begin ESA when Hb <11.0 g/dL, (iii) begin ESA when Hb <10.0 g/dL and (iv) never begin ESA in comparison with 'current practice' [the observed (factual) survival of the entire study cohort]. The adjusted 3-year survival following ESA begun over a range of Hb (from <9.0 to 12.0 g/dL) was evaluated, after adjustment for covariates at baseline and during follow-up. RESULTS: Overall, 36% were treated with ESA. Mortality during follow-up was 33.4% of the ESA-treated and 27.9% of the non-treated subjects. The adjusted 3-year survival associated with ESA initiation improved for subjects with initial Hb <9.0 to 11 g/dL and then decreased again for those with Hb above 11.5 g/dL. Initiating ESA at Hb <11.0 g/dL and <10.0 g/dL was associated with improved survival compared with 'current practice' [hazard ratio (HR) 0.83; 95% confidence interval (CI) 0.79-0.89 and 0.90; 95% CI 0.86-0.94, respectively] and did not increase the risk of a cardiovascular event (HR 0.93; 95% CI 0.87-1.00). CONCLUSION: In non-dialysis patients with CKD, ESA initiation at Hb < 10.0-11.0 g/dL is associated with improved survival in patients otherwise treated according to guidelines.

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

BACKGROUND: Mentoring 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. METHODS: Sixteen 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. RESULTS: The 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. CONCLUSIONS: Formalized 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.

Effects of hemodialysis on the cardiovascular system: quantitative analysis using wave intensity wall analysis and tissue velocity imaging.

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease (ESRD). The aim of this study was to investigate the changes in cardiovascular function induced by a single session of hemodialysis (HD) by the analysis of cardiovascular dynamics using wave intensity wall analysis (WIWA) and of systolic and diastolic myocardial function using tissue velocity imaging (TVI). Gray-scale cine loops of the left common carotid artery, conventional echocardiography, and TVI images of the left ventricle were acquired before and after HD in 45 patients (17 women, mean age 54 years) with ESRD. The WIWA indexes, W(1) and preload-adjusted W(1), W(2) and preload-adjusted W(2), and the TVI variables, isovolumic contraction velocity (IVCV), isovolumic contraction time (IVCT), peak systolic velocity (PSV), displacement, isovolumic relaxation velocity (IVRV), isovolumic relaxation time (IVRT), peak early diastolic velocity (E'), and peak late diastolic velocity (A'), were compared before and after HD. The WIWA measurements showed significant increases in W(1) (P < 0.05) and preload-adjusted W(1) (P < 0.01) after HD. W(2) was significantly decreased (P < 0.05) after HD, whereas the change in preload-adjusted W(2) was not significant. Systolic velocities, IVCV (P < 0.001) and PSV (P < 0.01), were increased after HD, whereas the AV-plane displacement was decreased (P < 0.01). For the measured diastolic variables, E' was significantly decreased (P < 0.01) and IVRT was significantly prolonged (P < 0.05), after HD. A few correlations were found between WIWA and TVI variables. The WIWA and TVI measurements indicate that a single session of HD improves systolic function. The load dependency of the diastolic variables seems to be more pronounced than for the systolic variables. Preload-adjusted wave intensity indexes may contribute in the assessment of true LV contractility and relaxation.

Can empathy be preserved in medical education?

OBJECTIVES: The aim of this study was to investigate changes in empathy during medical education, as well as to identify promoters and inhibitors of empathy and analyse their roles. METHODS: We used qualitative content analysis to examine 69 critically reflective essays written by medical students as a part of their final examination at the end of the medical program. The essays were based on previous self-evaluations performed each term and represented retrospective reflections on their professional development. RESULTS: A majority of the students felt that their empathy did not decrease during medical education. On the contrary, many felt that their empathy had increased, especially the cognitive part of empathy, without loss of affective empathy. Many of them described a professionalisation process resulting in an ability to meet patients with preserved empathy but without being overwhelmed by emotions. They identified several factors that promoted the development of empathy: a multiplicity of patients, positive role models, and educational activities focusing on reflection and self-awareness. They also identified inhibitors of empathy: lack of professional competence and a stressful and empathy-hostile medical culture. CONCLUSIONS: Our analysis of these retrospective reflections by students suggests that empathy can be preserved during medical education, despite the presence of important inhibitors of empathy. This finding might be due to the presence of more potent promoters and/or to the fact that educational activities might result in a decreased susceptibility to empathy-decreasing circumstances.

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

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.

Acute effects of low and high intravenous doses of furosemide on myocardial function in anuric haemodialysis patients: a tissue Doppler study.

BACKGROUND: In patients with pulmonary oedema and preserved renal function, furosemide has not only a renal, but also a vascular effect, causing a rapid fall in left ventricular filling pressure accompanied by an increase in venous compliance. Previous studies have shown conflicting findings regarding the vascular effects of furosemide in patients with end-stage renal disease (ESRD). The objective of our study was to investigate whether furosemide induces changes in central cardiac haemodynamics in anuric ESRD patients, using conventional echocardiography and colour tissue Doppler velocity imaging (TVI), a new quantitative and sensitive method. METHODS: Repeated low doses (40 mg followed by an additional dose of 40 mg after 30 min) of i.v. furosemide were administered to 12 (61.6 +/- 16 years, 7 men) and a high dose (250 mg) of i.v. furosemide to 6 (64.1 +/- 3.6 years, 5 men) clinically stable anuric haemodialysis (HD) patients. Conventional two-dimensional echocardiography and colour TVI images were recorded immediately before (0 min) the furosemide infusion in both groups, and in the group receiving the repeated low-dose infusion (at 0 and 30 min), 10, 20, 30, 40, 50 and 70 min after the administration of the first infusion. In the group receiving the single high dose of furosemide the ultrasound investigation was repeated 10, 20, 30 and 40 min after the infusion. The myocardial tissue velocities (v; cm/s) for isovolumetric contraction (IVC), peak systole (PS), early (E') and late (A') myocardial diastolic filling velocities were measured in the left ventricle (LV) at six sites (infero-septal, antero-lateral, inferior, anterior, infero-lateral and antero-septal walls) at the basal region. IVC time (IVCT), IV relaxation time (IVRT), PS time (PSt), RR interval, mitral annulus motion (MAM), strain rate (SR), left ventricular filling pressure (E/E') and cardiac output were also measured. The average of the different walls was used to evaluate global function. Right ventricle (RV) dynamics was evaluated from measurements of IVC velocity (IVCv), peak systolic velocity (PSv), E' and A' from the RV free wall. RESULTS: No significant changes in cardiac output, IVCv, PSv, SR, MAM, E', A', E'/A', IVRT and LV filling pressure were observed, indicating that neither 40 mg (plus additional 40 mg after 30 min) nor 250 mg of furosemide had any measurable effects on LV filling pressure and LV and RV systolic and diastolic function. CONCLUSIONS: In anuric HD patients, low and high doses of furosemide had no significant effects on central cardiac haemodynamics. Therefore, the use of furosemide infusion in anuric ESRD patients with acute pulmonary oedema is not supported by the results of this study.

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.

Serum cardiac troponin T, troponin I, plasma BNP and left ventricular mass index in professional football players.

UNLABELLED: Concentrations of cardiac troponins (cTn) in serum or plasma may be elevated in several disease states other than acute coronary syndromes. In heart failure and end stage renal disease, cardiac troponin T (cTnT) correlates positively with left ventricular mass index (LVMI). Exercise-induced elevation of cardiac troponins in well-trained athletes has been confirmed by several reports but the aetiology and clinical significance is unclear. In the present study, we measured baseline concentrations of cardiac markers and investigated whether or not serum cTnT is associated with left ventricular hypertrophy (LVH) in professional football players. METHODS: Twenty-three male professional football players with a mean age of 23 years (range 18-32) were studied. Echocardiography and blood sampling were carried out approx 24h after a training session. Serum cTnT, other cardiac markers and plasma brain natriuretic peptide (BNP) were compared with LVMI. RESULTS: cTnT was only detectable in one subject. The prevalence of elevated cardiac troponin I (cTnI), creatine kinase MB (CKMB) and creatine kinase was higher than for cTnT. cTnI concentrations were higher in football players than in controls. LVMI did not correlate with any of the cardiac markers. Plasma BNP concentrations were normal in all subjects. CONCLUSION: Serum cTnT concentrations were not elevated in healthy professional football players with LVH. This argues against the hypothesis that LVH per se may cause increased cTnT. The finding of higher cTnI in football players than in non-athletic controls should be confirmed and the aetiology elucidated.

Elevated serum 8-oxo-dG in hemodialysis patients: a marker of systemic inflammation?

Does inflammation, as assessed by high sensitivity C-reactive protein (hs-CRP), in patients with end-stage renal disease (ESRD) tightly associate with increased serum levels of 8-oxo-7,8-dihydro-2'-deoxyguanosine (8- oxo-dG)? Increased oxidative stress and inflammation have both been highlighted among several nontraditional risk factors for cardiovascular disease, which is the main cause of mortality in ESRD patients. In contrast to oxidative stress effects on proteins and lipids, DNA base damage has not been well demonstrated in ESRD. Two groups of hemodialysis patients were studied, one group with persistent inflammation (n = 13, with constant elevation of CRP > 10 mg/L for 6 months) and one group of noninflamed patients (n = 19, with constant CRP < 10 mg/L for 6 months). Serum 8-oxo-dG was significantly elevated in persistent inflammation in comparison to noninflamed patients. At an individual level, a significant correlation was found between serum 8-oxo-dG and hsCRP. Extracellular 8-oxo-dG leads to intracellular oxidative damage on the nucleotide pool, thus providing a sensitive marker for inflammatory response. Serum levels of 8-oxo-dG, in combination with other inflammatory markers, serve as useful diagnostic tools for identification of patients in risk for inflammatory complications.

Enhanced RAGE-mediated NFkappaB stimulation in inflamed hemodialysis patients.

Advanced glycation end-products (AGEs), a group of carbohydrate-derived compounds formed by non-enzymatic glycation and oxidation, are markedly elevated in end-stage renal disease (ESRD) and may be related to both inflammation and oxidative stress. The cellular effects of AGE are largely mediated by their interaction with specific surface receptors, such as RAGE. Measurements of biomarkers of inflammation and oxidative stress were conducted in 7 hemodialysis (HD) patients (5 males) with persistent high-grade inflammation (C-reactive protein [CRP]>10 mg/L) and 11 HD-patients (6 males) with low-grade inflammation (CRP<10 mg/L) for at least 6 months. Measured biomarkers for inflammation included hs-CRP, interleukin (IL)-6, white blood cells, neutrophils, S-albumin, peroxisome proliferator-activated receptors (PPAR alpha, beta, gamma) and nuclear factor kappaB (NFkappaB) activity. Markers for oxidative stress were advanced oxidation products (AOPP), myeloperoxidase (MPO)-activity, pentosidine and carboxymethyl lysine (CML). In addition, the effect of increasing doses of CML-modified human serum albumin on NFkappaB activity was tested in mononuclear cells isolated from each patient. As expected, HD-patients with high-grade inflammation had significantly elevated levels of IL-6 (median 9.2 pg/mL versus 2.5 pg/mL; p<0.01), MPO-activity (134.5+/-14.6 DeltaOD(630)/(min mg protein) versus 80.5+/-12.9 DeltaOD(630)/(min mg protein); p<0.05), PPAR-gamma (0.65+/-0.01 OD(655) versus 0.56+/-0.01 OD(655); p<0.01), and AOPP (269+/-54 microM versus 163+/-15 microM; p<0.05) compared with low-grade inflamed patients. Significant associations were demonstrated between hs-CRP and NFkappaB (rho=0.58; p<0.05), AOPP (rho=0.49; p<0.05) and PPAR-gamma (rho=0.62; p<0.05), respectively. In the patient group with high-grade inflammation, stimulation of mononuclear cells with CML-modified human serum albumin caused a rapid dose-dependent rise (p<0.0001) in NFkappaB activity that could be completely blocked by an anti-RAGE antibody. Inflammation and oxidative stress biomarkers are interrelated in ESRD. Inflammatory cell signal pathways, such as NFkappaB, are activated by CML-modification of proteins via RAGE.

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.

Changes in circulating biomarkers during a single hemodialysis session.

The hemodialysis (HD) procedure induces an inflammatory response potentially contributing to cardiovascular disease. Here we investigated the acute impact of HD on circulating biomarkers. Circulating biomarkers (small solutes, middle molecular-sized peptides, and proteins) related to inflammation, oxidative stress, and vascular calcification (VC) were measured before and after a single session of HD in 45 clinically stable patients. Concentrations were corrected for ultrafiltration-induced hemoconcentration. Among vascular calcification-related biomarkers, osteoprotegerin and fetuin-A remained unchanged while fibroblast growth factor-23 (FGF23) decreased by -19%. Changes of FGF23 and changes of phosphate correlated (ρ = 0.61, P < 0.001). While C-reactive protein did not change, interleukin-6 (IL-6) increased by 14% and pentraxin 3 (PTX3) increased by 45%. IL-6 and PTX3 appear to be valid biomarkers of the intradialytic inflammatory response. VC-related markers were in general not affected by the single HD session; however, the observed correlation between acute changes of FGF-23 and phosphate during HD warrants further studies.

Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging.

BACKGROUND: Cardiovascular disease is the leading cause of death in chronic kidney disease (CKD) patients. Tissue Doppler velocity imaging (TVI) is a new objective method that accurately quantifies myocardial tissue velocities, deformation, time intervals and left ventricular (LV) filling pressure. In this study, TVI was compared with conventional echocardiography for the assessment of left ventricular (LV) function in pre-dialysis patients with different stages of CKD. The results obtained by TVI were used to analyse possible relationships between LV function and clinical factors such as hyperparathyroidism and hypertension that could influence LV function. METHODS: Conventional echocardiography and TVI images were recorded in 40 patients (36 men and 4 women, mean age 60+/-14 years, range 28-80 years) and in 27 healthy controls (21 men and 6 women, mean age 58+/-17 years, range 28-82 years). Twenty-two patients had mild/moderate CKD (CCr>29 ml/min; Group 1) and 18 patients had severe CKD (CCr

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. OBJECTIVE: To investigate whether the critical friend concept can serve as a pragmatic model for evaluation of medical teachers and as a fruitful tool for enhancing self-knowledge and professional development among medical educators. METHODS: Three pairs of critical friends were formed, consisting of experienced medical teachers (n = 6) at the Karolinska Institutet. Each teacher was assigned to give 1 lecture and 1 seminar in his or her specific research or clinical field. The critical friend evaluated the performance in class, acting as an observer using a pre-formed protocol. The evaluation was communicated to the teacher during a 45-minute session within 48 hours after the teaching session. Each of the 6 teachers was criticised and gave criticism within the pair configurance. The outcome of the process was evaluated by an experimenter, not participating in the process, who performed a semistructured interview with each of the 6 teachers. RESULTS: Each teacher had a different way of reflecting on teaching after the project than before and made changes in his or her way of teaching. We also noted that being a critical friend may be even more effective than having one. The majority of the feedback provided was positive and valuable. CONCLUSION: To be and to have a critical friend is worth the extra workload. Therefore, the critical friend concept should be made part of regular teaching practice.