Adherence to medication: A nation-wide study from the Children's Cancer Hospital, Egypt

AIM: To investigate adherence to medical regimen and predictors for non-adherence among children with cancer in Egypt. METHODS: We administered two study specific questionnaires to 304 parents of children diagnosed with cancer at the Children's Cancer Hospital in Cairo, Egypt, one before the first chemotherapy treatment and the other before the third. The questionnaires were translated to colloquial Egyptian Arabic, and due, to the high illiteracy level in Egypt an interviewer read thequestions in Arabic to each parent and registered the answers. Both questionnaires consisted of almost 90 questions each. In addition, a Case Report Form was filled in from the child's medical journal. The study period consisted of 7 mo(February until September 2008) and we had a participation rate of 97%. Descriptive statistics are presented and Fisher's exact test was used to check for possible differences between the adherent and non-adherent groups. A P-value below 0.05 was considered significant. Software used was SAS version 9.3 for Windows(SAS Institute Inc., Cary, NC, United States).RESULTS: Two hundred and eighty-one(90%) parents answered the second questionnaire, regarding their child's adherence behaviour. Approximately two thirds of the children admitted to their third chemotherapy treatment had received medical recommendations upon discharge from the first or second chemotherapy treatment(181/281, 64%). Sixty-eight percent(123/181) of the parents who were given medical recommendations reported that their child did not follow the recommendations. Two main predictors were found for non-adherence: child resistance(111/123, 90%) and inadequate information(100/123, 81%). In the adherent group, 20% of the parents(n = 12/58) reported trust in their child's doctor while 14 percent 8/58 reported trust in the other health-care professionals. Corresponding numbers for the non-adherent group are 8/123(7%) for both their child's doctor and other health-care professionals. Almost all of the parents expressed a lack of optimism towards the treatment(116/121, 96%), yet they reported an intention to continue with the treatment for two main reasons, for the sake of their child's life(70%)(P = 0.005) and worry that their child would die if they discontinued the treatment(81%)(P < 0.0001).CONCLUSION: Non-adherence to medical regimen is common among children diagnosed with cancer inEgypt, the main reasons being child resistance and inadequate information.

Stage and size using magnetic resonance imaging and endosonography in neoadjuvantly-treated rectal cancer

AIM: To assess the stage and size of rectal tumours using 1.5 Tesla (1.5T) magnetic resonance imaging (MRI) and three-dimensional (3D) endosonography (ERUS). METHODS: In this study, patients were recruited in a phaseⅠ/Ⅱ trial of neoadjuvant chemotherapy for biopsy-proven rectal cancer planned for surgical resection with or without preoperative radiotherapy. The feasibility and accuracy of 1.5T MRI and 3D ERUS were compared with the histopathology of the fixed surgical specimen (pathology) to determine the stage and size of the rectal cancer before and after neoadjuvant chemotherapy. A Philips Intera 1.5T with a cardiac 5-channel synergy surface coil was used for the MRI, and a B-K Medical Falcon 2101 EXL 3D-Probe was used at 13 MHz for the ERUS. Our hypothesis was that the staging accuracy would be the same when using MRI, ERUS and a combination of MRI and ERUS. For the combination, MRI was chosen for the assessment of the lymph nodes, and ERUS was chosen for the assessment of perirectal tissue penetration. The stage was dichotomised into stageⅠ and stage Ⅱ or greater. The size was measured as the supero-inferior length and the maximal transaxial area of the tumour. RESULTS: The staging feasibility was 37 of 37 for the MRI and 29 of 36 for the ERUS, with stenosis as a limiting factor. Complete sets of investigations were available in 18 patients for size and 23 patients for stage. The stage accuracy by MRI, ERUS and the combination of MRI and ERUS was 0.65, 0.70 and 0.74, respectively, before chemotherapy and 0.65, 0.78 and 0.83, respectively, after chemotherapy. The improvement of the post-chemotherapy staging using the combination of MRI and ERUS compared with the staging using MRI alone was significant (P = 0.046). The post-chemotherapy understaging frequency by MRI, ERUS and the combination of MRI and ERUS was 0.18, 0.14 and 0.045, respectively, and these differences were non-significant. The measurements of the supero-inferior length by ERUS compared with MRI were within 1.96 standard deviations of the difference between the methods (18 mm) for tumours smaller than 50 mm. The agreement with pathology was within 1.96 standard deviations of the difference between imaging and pathology for all tumours with MRI (15 mm) and for tumours that did not exceed 50 mm with ERUS (22 mm). Tumours exceeding 50 mm in length could not be reliably measured by ERUS due to the limit in the length of each recording. CONCLUSION: MRI is preferable to use when assessing the size of large or stenotic rectal tumours. However, staging accuracy is improved by combining MRI with ERUS.

Portal vein thrombosis:Prevalence,patient characteristics and lifetime risk:A population study based on 23796 consecutive autopsies

瞄准：估计一生在一般人口的门静脉血栓形成(PVT ) 的累积发生。方法：在 1970 和 1982 之间， 23,796 具尸体，在马尔摩城市人口代表 84% 所有在里面医院死亡，被执行，用包括门静脉的检查的一个 standardised 协议。PVT 病人被描述并且在尸体的 PVT 流行，一生的表情累积发生，在高风险的疾病范畴估计了并且以机会比率和 95% CI 表示了。结果：PVT 的人口流行是 1.0% 。有 PVT 28% 的 254 个病人有肝硬化， 23% 主要并且 44% 第二等的肝胆管恶意， 10% 主要腹的传染或煽动性的疾病并且 3% 有 myeloproliferative 混乱。有肝硬化和肝的癌的病人有最高的 PVT 风险，或 17.1 (95% CI 11.1-26.4 ) 。在 14% ，没有原因被发现；仅仅，少数他们开发了 portal-hypertension-related 复杂并发症。结论：在这基于人口的研究， PVT 比由以前的临床的系列显示被发现更普通。显著地，在肝硬化和肝的癌的过量风险应该在指导干预的未来的研究可能为被考虑的这些病人保证增加的了解。

Diagnosis and treatment of pancreatic exocrine insufficiency

Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis.Normal digestion requires adequate stimulation of pancreatic secretion,sufficient production of digestive enzymes by pancreatic acinar cells,a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food.Failure in any of these steps may result in pancreatic exocrine insufficiency,which leads to steatorrhea,weight loss and malnutrition-related complications,such as osteoporosis.Methods evaluating digestion,such as fecal fat quantification and the13C-mixed triglycerides test,are the most accurate tests for pancreatic exocrine insufficiency,but the probability of the diagnosis can also be estimated based on symptoms,signs of malnutrition in blood tests,fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging.Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption,dietary consultation,enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment.Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicro-spheres during meals.The dose should be in proportion to the fat content of the meal,usually 40-50000 lipase units per main meal,and half the dose is required for a snack.In cases that do not respond to initial treatment,the doses can be doubled,and proton inhibitors can be added to the treatment.This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.

Functional findings in irritable bowel syndrome

IBS 的病理生理学复杂、仍然不完全地知道。中央、外部的因素，包括的精神分析聚会因素，反常官方补给的活动性和分泌物，和内脏的超敏性，被认为贡献 IBS 的症状。几研究在 IBS 病人表明了改变的官方补给的运动机能，模式基于占优势的肠模式在 IBS 亚群之间不同。很少研究到目前为止在 IBS 探讨了官方补给的分泌物，但是有一些证据，在 IBS 病人的小肠支持改变的分泌物。内脏的超敏性当前被认为也许是在 IBS 的最重要的 pathophysiological 因素。重要地，几个外部、内部的因素能调制内脏的敏感，以及官方补给的活动性，并且在官方补给的道以内提高应答的海角到例如，应力和营养素在 IBS 病人被表明了。今天 IBS 被看在之上，包含在伤寒的反常功能是所谓的大脑勇气轴的 dysregulation 的混乱，自治或中枢神经系统，与可能在一些病人并且在其它的从圆周的信号的扰乱的中央处理统治的外部改变。

Aspects of the non-pharmacological treatment of irritable bowel syndrome

Irritable bowel syndrome(IBS) is one of the most commonly diagnosed gastrointestinal conditions. It represents a significant healthcare burden and remains a clinical challenge. Over the years IBS has been described from a variety of different perspectives; from a strict illness of the gastrointestinal tract(medical model) to a more complex multi-symptomatic disorder of the brain-gut axis(biopsychosocial/psychosomatic model). In this article we present aspects of the pathophysiology and the non-pharmacological treatment of IBS based on current knowledge. Effects of conditioned stress and/or traumatic influences on the emotional system(top-down) as well as effects on the intestine through stressors,infection,inflammation,food and dysbiosis(bottom-up) can affect braingut communication and result in dysregulation of the autonomic nervous system(ANS),playing an important role in the pathophysiology of IBS. Conditioned stress together with dysregulation of the autonomic nervous system and the emotional system may involve reactions in which the distress inside the body is not recognized due to low body awareness. This may explain why patients have difficulty identifying their symptoms despite dysfunction in muscle tension,movement patterns,and posture and biochemical functions in addition to gastrointestinal symptoms. IBS shares many features with other idiopathic conditions,such as fibromyalgia,chronic fatigue syndrome and somatoform disorders. The key to effective treatment is a thorough examination,including a gastroenterological examination to exclude other diseases along with an assessment of body awareness by a body-mind therapist. The literature suggests that early interdisciplinary diagnostic cooperation between gastroenterologists and body-mind therapists is necessary. Re-establishing balance in the ANS is an important component of IBS treatment. This article discusses the current knowledge of body-mind treatment,addressing the topic from a practical point of view.

Irritable bowel syndrome subtypes differ in body awareness, psychological symptoms and biochemical stress markers

AIM: To elucidate the differences in somatic, psycho-logical and biochemical pattern between the subtypes of irritable bowel syndrome (IBS). METHODS: Eighty IBS patients, 30 diarrhoea pre-dominant (D-IBS), 16 constipation predominant (C-IBS) and 34 alternating IBS (A-IBS) underwent physi-otherapeutic examinations for dysfunctions in body movements and awareness and were compared to an apparently healthy control group (AHC). All groups an-swered questionnaires for gastrointestinal and psycho-logical symptoms. Biochemical variables were analysed in blood. RESULTS: The D-IBS group showed less body aware-ness, less psychological symptoms, a more normal sense of coherence and psychosocial rating as well as higher C-peptide values. C-IBS had a higher degree of body dysfunction and psychological symptoms, as well as the lowest sense of coherence compared to controls and D-IBS. They also demonstrated the most elevated prolactin levels. A-IBS had the lowest degree of body disturbance, deteriorated quality of life and affected bi-ochemical pattern. All subtypes had higher pain scores compared to controls. In addition they all had signifi -cantly increased triglycerides and elevated morning cortisol levels, however, without statistical signifi cance compared with the controls.CONCLUSION: IBS subtypes showed different pro-files in body awareness, somatic and psychological symptoms and in biochemical variables. D-IBS differed compared to the other groups by lowered body aware-ness, less psychological symptoms and a higher sense of coherence and elevated C-peptide values. C-IBS and A-IBS subtypes suffered more from depression and anxiety, associated with a lower quality of life. These differences may be important and will be taken into account in our treatment of these patients.

Hepatic encephalopathy in patients with liver cirrhosis:Is there a role of malnutrition?

Hepatic encephalopathy(HE) is a common complica-tion in patients with liver cirrhosis but its pathogenesis remains incompletely understood.Malnutrition is com-monly encountered in patients with liver cirrhosis and it has been reported to affect the quality of life of this group of patients.Experimental studies suggest that low energy intake and poor nutritional status may facil-itate the development of HE but there are scarce data on the potential role of malnutrition in HE in patients with liver cirrhosis.Two recently published studies have evaluated the potential role of malnutrition in the development of HE in cirrhotic patients with conflicting results.In this letter to the editor we briefly present the results of the two studies as well as potential rea-sons for the conflicting results reported.

Physiological and pharmacological basis for the ergogenic effects of growth hormone in elite sports

Growth Hormone （GH） is an important and powerful metabolic hormone that is secreted in a pulsatile pattern from cells in the anterior pituitary, influenced by several normal and pathophysiological conditions. Human GH was first isolated in the 1950s and human derived cadaveric GH was initially used to treat patients with GH deficiency. However, synthetic recombinant GH has been widely available since the mid-1980s and the advent of this recombi- nant GH boosted the abuse of GH as a doping agent. Doping with GH is a well-known problem among elite athletes and among people training at gyms, but is forbidden for both medical and ethical reasons. It is mainly the anabolic and, to some extent, the lipolytic effects of GH that is valued by its users. Even though GH＇ s rumour as an effective ergogenic drug among athletes, the effectiveness of GH as a single doping agent has been questioned during the last few years. There is a lack of scientific evidence that GH in supraphysiological doses has additional effects on muscle exercise performance other than those obtained from optimised training and diet itself. However, there might be synergistic effects if GH is combined with, for example, anabolic steroids, and GH seems to have positive effect on collagen synthesis. Regardless of whether or not GH doping is effective, there is a need for a reliable test method to detect GH doping. Several issues have made the development of a method for detecting GH doping complicated but a method has been presented and used in the Olympics in Athens and Turin. A problem with the method used, is the short time span （24-36 hours） from the last GH administration during which the test effectively can reveal doping. Therefore, out-of-competition testing will be crucial. However, work with different approaches to develop an alternative, reliable test is ongoing.

Takotsubo triggered by acute myocardial infarction：a common but overlooked syndrome？

Takotsubo 心肌症(TCM ) 是描绘由的急性心脏的症候群广泛，却潜在地可逆，当解释冠的阻塞不在时的左室的机能障碍。因此， TCM 从冠的动脉疾病(CAD ) 和尖锐心肌的梗塞(AMI ) 是不同的。然而，为在一些 TCM 病人的共存的 CAD 的实质的证据存在。此处，我们拿这个协会进一步、在场的一个步骤病人同时在，并且在我们在哪个相信一个主要冠的事件触发了 TCM 受不了 AMI 和 TCM，并且在哪个的一个盒子。胸疼痛地介绍的 88 岁的女性。Echocardiography 与 hypercontractile 底揭示了顶端的 akinesia。有怀疑的尖锐的匾破裂的一个堵塞斜分支在 angiogram 上被识别，但是不能解释 akinesia 的程度。心脏的功能完全恢复了。因此，这个病人为 TCM 遵守了当前的诊断标准。TCM 是为与体的应力联系的另外的条件的著名复杂并发症。假设 AMI，也与体的应力和提高的 catecholamine 联系，能引起 TCM 因此是直觉的。我们的盒子说明那 TCM 和 AMI 可以同时发生。尽管诱发性不能决定性地从这个协会被推断，与 AMI 联系的体的压力可能在这个病人引起了 TCM。

Addition of senna improves quality of colonoscopy preparation with magnesium citrate

AIM: To prospectively investigate the effectiveness and patient’s tolerance of two low-cost bowel cleansing preparation protocols based on magnesium citrate only or the combination of magnesium citrate and senna. METHODS: A total of 342 patients who were referred for colonoscopy underwent a colon cleansing protocol with magnesium citrate alone (n = 160) or magnesium citrate and senna granules (n = 182). The colonoscopist rated the overall efficacy of colon cleansing using an established score on a 4-point scale. Patients were questioned before undergoing colonoscopy for side effects and symptoms during bowel preparation. RESULTS: The percentage of procedures rescheduled because ofinsufficient colon cleansing was 7% in the magnesium citrate group and 4% in the magnesium citrate/senna group (P = 0.44). Adequate visualization of the colonic mucosa was rated superior under the citramag/senna regimen (P = 0.004). Both regimens were well tolerated, and did not significantly differ in the occurrence of nausea, bloating or headache.However, abdominal cramps were observed more often under the senna protocol (29.2%) compared to the magnesium citrate only protocol (9.9%, P < 0.0003). CONCLUSION: The addition of senna to the bowel preparation protocol with magnesium citrate significantly improves the cleansing outcome.

Intraductal papillary mucinous neoplasm in chronic calcifying pancreatitis:Egg or hen?

Intraductal papillary mucinous neoplasm(IPMN)is an increasingly reported entity.Extensive pancreatic calcification is generally thought to be a sign of chronic pancreatitis,but it may occur simultaneously with IPMN leading to diagnostic difficulties.We report a case of a patient initially diagnosed with chronic calcifying pancreatitis who was later shown to have a malignant IPMN.This case illustrates potential pitfalls in the diagnosis of IPMN in the case of extensive pancreatic calcification as well as clues that may lead the clinician to suspecting the diagnosis.The possible mechanisms of the relation between pancreatic calcification and IPMN are also reviewed.

Body awareness therapy: A new strategy for relief of symptoms in irritable bowel syndrome patients

AIM: To compare irritable bowel syndrome (IBS) pa- tients with apparently healthy persons and to evaluate body awareness therapy, which is a physiotherapeutic remedy focusing on normalising tensions in the body, for the treatment of IBS with the hypothesis that altered body tension is associated with the syndrome. METHODS: Twenty-one IBS patients received body awareness therapy two hours weekly for 24 wk. At base- line as well as after 12 and 24 wk, they underwent ex- aminations including resource oriented body examination in combination with body awareness scale evaluation and f illed in gastrointestinal and psychological symptom questionnaires. Saliva cortisol was analysed. A group of 21 apparently healthy persons underwent the same ex- aminations once. RESULTS: Compared to the apparently healthy group, IBS patients scored higher at baseline for gastrointestinal and psychological symptoms. They showed more often alterations in normal body tension patterns, as well as deviating cortisol slopes in saliva. After 24 wk of body awareness therapy, their gastrointestinal and psychologi- cal symptoms were reduced overall. Somatic symptoms decreased in parallel with depressive symptoms. Whole body pain score decreased, coping ability as well as bio- chemical stress markers improved. CONCLUSION: IBS patients scored higher for gastroin- testinal and psychological symptoms, and presented with altered biochemical stress markers. Their body tension deviated compared to healthy controls. Furthermore,body awareness therapy gave relief of both somatic com- plaints, psychological symptoms and normalised body tension. These findings indicate that distorted tension constitutes an important part of the symptoms in IBS.

A Comparative Study of Automated Segmentation Methods for Use in a Microwave Tomography System for Imaging Intracerebral Hemorrhage in Stroke Patients

Microwave technology offers the possibility for pre-hospital stroke detection as we have previously demonstrated using non-imaging diagnostics. The focus in this paper is on image-based diagnostics wherein the technical and computational complexities of image reconstruction are a challenge for clinical realization. Herein we investigate whether information about a patient’s brain anatomy obtained prior to a stroke event can be used to facilitate image-based stroke diagnostics. A priori information can be obtained by segmenting the patient’s head tissues from magnetic resonance images. Expert manual segmentation is presently the gold standard, but it is laborious and subjective. A fully automatic method is thus desirable. This paper presents an evaluation of several such methods using both synthetic magnetic resonance imaging (MRI) data and real data from four healthy subjects. The segmentation was performed on the full 3D MRI data, whereas the electromagnetic evaluation was performed using a 2D slice. The methods were evaluated in terms of: i) tissue classification accuracy over all tissues with respect to ground truth, ii) the accuracy of the simulated electromagnetic wave propagation through the head, and iii) the accuracy of the image reconstruction of the hemorrhage. The segmentation accuracy was measured in terms of the degree of overlap (Dice score) with the ground truth. The electromagnetic simulation accuracy was measured in terms of signal deviation relative to the simulation based on the ground truth. Finally, the image reconstruction accuracy was measured in terms of the Dice score, relative error of dielectric properties, and visual comparison between the true and reconstructed intracerebral hemorrhage. The results show that accurate segmentation of tissues (Dice score = 0.97) from the MRI data can lead to accurate image reconstruction (relative error = 0.24) for the intracerebral hemorrhage in the subject’s brain. They also suggest that accurate automated segmentation can be used as a surrogate for manual segmentation and can facilitate the rapid diagnosis of intracerebral hemorrhage in stroke patients using a microwave imaging system.

Transplanting embryonic stem cells onto damaged human corneal endothelium

AIM To investigate whether human embryonic stem cells(hESCs) could be made to attach, grow and differentiate on a human Descemet's membrane(DM).METHODS Spontaneously differentiated hESCs were transferred onto a human corneal button with the endothelial layer removed using ocular sticks. The cells were cultured on a DM for up to 15 d. The genetically engineered hESC line expressed green fluorescent protein, which facilitated identification during the culture experiments, tissue preparation, and analysis. To detect any differentiation into human corneal endothelial-like cells, we analysed the transplanted cells by immunohistochemistry using specific antibodies.RESULTS We found transplanted cells form a single layer of cells with a hexagonal shape in the periphery of the DM. The majority of the cells were negative for octamer-binding transcription factor 4 but positive for paired box 6 protein, sodium potassium adenosine triphosphatase(NaKATPase), and Zona Occludens protein 1. In four of the 18 trials, the transplanted cells were found to express CK3, which indicates that the stem cells differentiated into corneal epithelial cells in these cases. CONCLUSION It is possible to get cells originating from hESCs to become established on a human DM, where they grow and differentiate into corneal endothelial-like cells in vitro.

Intrapartum application of the continuous glucose monitoring system in pregnancies complicated with diabetes: A review and feasibility study

Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system(CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specifi c period of time. The resulting profi le provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus(DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.

Hemorrhagic colitis induced by trientine in a 51-year-old patient with Wilson's disease waiting for liver transplantation:A case report

BACKGROUND Wilson's disease(WD)is a rare inherited disorder of copper metabolism.Treatment consists of chelating agents,but side effects are common.We describe a patient who developed colitis during trientine treatment leading to decompensation of liver cirrhosis.CASE SUMMARY A healthy 51-year-old woman was diagnosed with liver cirrhosis due to decompensation with ascites.Etiologic evaluation raised suspicion of hereditary hemochromatosis because of compound heterozygosity HFE p.C282Y/p.H63D,and phlebotomy was started.Re-evaluation showed low ceruloplasmin,increased urinary copper excretion and the presence of Kayser-Fleischer rings.WD was confirmed by genetic analysis.Because of decompensated cirrhosis,she was referred for liver transplant evaluation.Simultaneously,treatment with trientine was initiated.Liver function initially stabilized,and the patient was not accepted for a liver transplant.Shortly after this,she developed severe hemorrhagic colitis,most probably a side effect of trientine.During that episode,she decompensated with hepatic encephalopathy.Because of a second decompensating event,she was accepted for liver transplantation,and an uneventful transplantation was carried out after clinical improvement of colitis.CONCLUSION Despite WD being a rare disorder,it is important to consider because it can present with a plethora of symptoms from childhood to an elderly age.Colitis should be recognized as a serious adverse drug reaction to trientine treatment that can result in decompensated liver disease.

Psychometric Properties of the Swedish Version of the Fear of Complications Questionnaire

Objectives: To translate and evaluate the psychometric properties of the Swedish version of the Fear of Complications Questionnaire. Design: Cross-sectional study design and scale development. Settings: Totally, 469 adults (response rate 63.5%) with Type 1 diabetes completed the questionnaires. Participants were recruited from two university hospitals in Sweden. Participants: Eligible patients were those who met the following inclusion criteria: diagnosed with Type 1 diabetes, diabetes duration of at least 1 year and aged at least 18 years. Methods: The Fear of Complications Questionnaire was translated using the forward-backward translation method. Factor analyses of the questionnaire were performed in two steps using both exploratory and confirmatory factor analysis. Convergent validity was examined using the Hospital Anxiety and Depression Scale and the Fear of Hypoglycaemia Fear Survey. Internal consistency was estimated using Cronbach’s alpha. Results: Exploratory factor analysis supported a two-factor solution. One factor contained three items having to do with fear of kidney-related complications and one factor included the rest of items concerning fear of other diabetes-related complications, as well as fear of complications in general. Internal consistency was high Cronbach’s alpha 0.96. The findings also gave support for convergent validity, with significant positive correlations between measures (r = 0.51 to 0.54). Conclusion: The clinical relevance of the identified two-factor model with a structure of one dominant subdomain may be considered. We suggest, however a one-factor model covering all the items as a relevant basis to assess fear of complications among people with Type 1 diabetes.

The assessment of endosonographers in training

Endosonography(EUS) has an estimated long learning curve including the acquisition of both technical and cognitive skills. Trainees in EUS must learn to master intraprocedural steps such as echoendoscope handling and ultrasonographic imaging with the interpretation of normal anatomy and any pathology. In addition, there is a need to understand the periprocedural parts of the EUS-examination such as the indications and contraindications for EUS and potential adverse events that could occur post-EUS. However, the learning process and progress vary widely among endosonographers in training. Consequently, the performance of a certain number of supervised procedures during training does not automatically guarantee adequate competence in EUS. Instead, the assessment of EUScompetence should preferably be performed by the use of an assessment tool developed specifically for the evaluation of endosonographers in training. Such a tool, covering all the different steps of the EUSprocedure, would better depict the individual learning curve and better reflect the true competence of each trainee. This mini-review will address the issue of clinical education in EUS with respect to the evaluation of endosonographers in training. The aim of the article is to provide an informative overview of the topic. The relevant literature of the field will be reviewed and discussed. The current knowledge on how to assess the skills and competence of endosonographers in training is presented in detail.

Clinical features and determinants of VO_(2peak) in de novo heart transplant recipients

AIM To study exercise capacity and determinants of early peak oxygen consumption(VO_(2peak)) in a cohort of de novo heart transplant(HTx) recipients. METHODS To determine possible central(chronotropic responses, cardiopulmonary and hemodynamic function) and peripheral factors(muscular exercise capacity and body composition) predictive of VO_(2peak), a number of different measurements and tests were performed, as follows: Cardiopulmonary exercise testing(CPET) was performed mean 11 wk after surgery in 81 HTx recipients > 18 years and was measured with breath by breath gas exchange on a treadmill or bicycle ergometer. Metabolic/respiratory measures include VO_(2peak) and VE/VCO2 slope. Additional measures included muscle strength testing, bioelectrical impedance analysis, echocardiography, blood sampling and health-related quality of life. Based on the VO_(2peak)(mL/kg per minute) median value, the study population was divided into two groups defined as a low-capacity group and a high-capacity group. Potential predictors were analyzed using multiple regression analysis with VO_(2peak)(L/min) as the dependent variable.RESULTS The mean ± standard deviation(SD) age of the total study population was 49 ± 13 years, and 73% were men. This de novo HTx cohort demonstrated a median VO_(2peak) level of 19.4 mL/kg per min at 11 ± 1.8 wk postHTx. As compared with the high-capacity group, the low-capacity group exercised for a shorter time, had lower maximal ventilation, O_2 pulse, peak heart rate and heart rate reserve, while the VE/VCO_2 slope was higher. The low-capacity group had less muscle strength and muscular exercise capacity in comparison with the highcapacity group. In order of importance, O_2 pulse, heart rate reserve, muscular exercise capacity, body mass index, gender and age accounted for 84% of the variance in VO_(2peak)(L/min). There were no minor or major serious adverse events during the CPET. CONCLUSION Although there is great individual variance among de novo HTx recipients, early VO_(2peak) measures appear to be influenced by both central and peripheral factors.