Modification of the National Inpatient Medication Chart improves venous thromboembolism prophylaxis rates in high-risk medical patients.

BACKGROUND: Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality in Australia. While there is well-established evidence for the use of VTE prophylaxis in hospital inpatients, adherence to such guidelines is poor. AIM: The aim of the present study is to assess the impact of education and system change on improving rates of VTE prophylaxis in hospital inpatients. METHODS: We performed four consecutive audits of inpatient medical records of a regional hospital service over 2 years. The audits aimed to test the impact of serial interventions at increasing the appropriate use of VTE prophylaxis (based on risk assessment). The interventions were (i) staff education and (ii) a process change that mandated a prophylaxis decision by modifying the National Inpatient Medication Chart with 'VTE avoidance' preprinted in the first medication box. RESULTS: Our results from the baseline study showed that of the 236 medical inpatients reviewed, 80% were at high risk of VTE. Of this high-risk cohort, 34.9% (confidence interval (CI) 28-42%) had appropriate prophylaxis decisions. Post the education intervention, 43.2% (CI 37-49%) of the high-risk cohort received appropriate VTE prophylaxis, an improvement of 8.3% (CI -1% to 18%) from baseline. With the subsequent introduction of a process change, 82.1% (CI 66-92%) of the high-risk cohort received appropriate prophylaxis, an improvement of 47.2% and 38.8% (CI 24-54%) when compared with baseline and education respectively. Retention rates at 11 months postsystem change were 73% (CI 55-86%). CONCLUSIONS: This study therefore concluded that while education has an impact on rates of appropriate VTE prophylaxis, it is system change that has the most marked and sustained effect.

Mothers' negative affectivity during pregnancy and food choices for their infants.

OBJECTIVE: The objective of this study was to analyze whether maternal negative affectivity assessed in pregnancy is related with subsequent infant food choices. DESIGN: The study design was a cohort study. SUBJECTS: The subjects were mothers (N=37 919) and their infants participating in the Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health. MEASUREMENTS: Maternal negative affectivity assessed prepartum (Hopkins Symptom Checklist 5 (SCL-5) at weeks 17 and 30 of pregnancy), introduction of solid foods by month 3 and feeding of sweet drinks by month 6 (by the reports of the mothers) were analyzed. RESULTS: Mothers with higher negative affectivity were 64% more likely (95% confidence interval 1.5-1.8) to feed sweet drinks by month 6, and 79% more likely (95% confidence interval 1.6-2.0) to introduce solid foods by month 3. These odds decreased to 41 and 30%, respectively, after adjusting for mother's age, body mass index (BMI) and education. CONCLUSION: The maternal trait of negative affectivity is an independent predictor of infant feeding practices that may be related with childhood weight gain, overweight and obesity.

Phenotypic heterogeneity and genetic modification of P102L inherited prion disease in an international series.

The largest kindred with inherited prion disease P102L, historically Gerstmann-Sträussler-Scheinker syndrome, originates from central England, with émigrés now resident in various parts of the English-speaking world. We have collected data from 84 patients in the large UK kindred and numerous small unrelated pedigrees to investigate phenotypic heterogeneity and modifying factors. This collection represents by far the largest series of P102L patients so far reported. Microsatellite and genealogical analyses of eight separate European kindreds support multiple distinct mutational events at a cytosine-phosphate diester-guanidine dinucleotide mutation hot spot. All of the smaller P102L kindreds were linked to polymorphic human prion protein gene codon 129M and were not connected by genealogy or microsatellite haplotype background to the large kindred or each other. While many present with classical Gerstmann-Sträussler-Scheinker syndrome, a slowly progressive cerebellar ataxia with later onset cognitive impairment, there is remarkable heterogeneity. A subset of patients present with prominent cognitive and psychiatric features and some have met diagnostic criteria for sporadic Creutzfeldt-Jakob disease. We show that polymorphic human prion protein gene codon 129 modifies age at onset: the earliest eight clinical onsets were all MM homozygotes and overall age at onset was 7 years earlier for MM compared with MV heterozygotes (P = 0.02). Unexpectedly, apolipoprotein E4 carriers have a delayed age of onset by 10 years (P = 0.02). We found a preponderance of female patients compared with males (54 females versus 30 males, P = 0.01), which probably relates to ascertainment bias. However, these modifiers had no impact on a semi-quantitative pathological phenotype in 10 autopsied patients. These data allow an appreciation of the range of clinical phenotype, modern imaging and molecular investigation and should inform genetic counselling of at-risk individuals, with the identification of two genetic modifiers.

Personal models of diabetes in relation to self-care, well-being, and glycemic control. A prospective study in adolescence.

OBJECTIVE: Personal models of diabetes have been shown to be proximal determinants of self-care behavior in adults with diabetes, both cross-sectionally and prospectively. This study set out to test the predictive utility of this approach in adolescents with diabetes. RESEARCH DESIGN AND METHODS: Participants were recruited from four regional hospitals in southern England (n = 54). They completed questionnaires assessing diabetes self-care, well-being, and personal models of diabetes (perceived impact, perceived seriousness, and short- and long-term treatment effectiveness) at baseline and 1-year follow-up. GHb assays performed as part of the patients' usual diabetes care were used to assess glycemic control. RESULTS: After controlling for baseline anxiety, change in perceived impact of diabetes prospectively predicted adolescents' anxiety (beta = -0.21; t = -2.65; P < 0.01). After controlling for baseline dietary self-care, change in perceived effectiveness of the diabetes treatment regimen to control diabetes predicted dietary self-care (beta = -0.39; t = -3.28; P < 0.0005). Poorer dietary self-care and being female were predictive of poorer glycemic control (r2 = 0.29; F = 2.74; P < 0.005). CONCLUSIONS: This study provides further support for the role of personal models of illness in determining responses to illness. As adolescents take responsibility for the management of their diabetes, parents, clinicians, educators, and interventionists should consider these adolescents' beliefs about their diabetes and its treatment as key factors influencing self-care, emotional well-being. and glycemic control.

Personal-model beliefs and social-environmental barriers related to diabetes self-management.

OBJECTIVE: The specific aims of the present study were to report on the level of personal beliefs and social and environmental barriers across different regimen areas and patient subgroups and on the relationship of personal models and perceived barriers to the level of self-management. RESEARCH DESIGN AND METHODS: This study focused on several issues related to personal models (representations of illness) and perceived barriers to diabetes self-management among a large heterogeneous survey sample of 2,056 adults throughout the U.S. RESULTS: Respondents felt that diabetes was a serious disease and that their self-management activities will control their diabetes and reduce the likelihood of long-term complications. Most frequently reported barriers were related to dietary adherence, followed by exercise and glucose testing barriers. Both personal models and barriers significantly predicted level of self-management in all three regimen areas studied (diet, exercise, and glucose testing) after controlling for the influence of demographic and medical history factors. Regimen-specific models and barriers proved to be stronger predictors than more global measures. Differences on personal models and barriers were observed among different patient groups (e.g., age, health insurance, and insulin-taking status). Possible reasons for these differences and implications for intervention and future research are discussed. CONCLUSIONS: Both the personal-model and barriers scales had good internal consistency and predicted variance in each of the self-management variables after controlling for demographic and medical history factors. These brief self-report personal-model scales demonstrated good internal reliability and were as predictive of self-management as the lengthier interview-based measures in previous studies. The assessment of the treatment effectiveness component of personal models may be sufficient for most clinical purposes.

Effects of a brief office-based intervention to facilitate diabetes dietary self-management.

OBJECTIVE: There is a pressing need for brief practical interventions that address diabetes management. Using a randomized design, we evaluated a medical office-based intervention focused on behavioral issues relevant to dietary self-management. RESEARCH DESIGN AND METHODS: There were 206 adult diabetes patients randomized to usual care or brief intervention, which consisted of touchscreen computer-assisted assessment to provide immediate feedback on key barriers to dietary self-management, and goal setting and problem-solving counseling for patients. Follow-up components to the single session intervention included phone calls and interactive video or videotape instruction as needed. RESULTS: Multivariate analyses of covariance revealed that the brief intervention produced greater improvements than usual care on a number of measures of dietary behavior (e.g., fewer calories from saturated fat, fewer high-fat eating habits and behaviors) at the 3-month follow-up. There were also significant differences favoring intervention on changes in serum cholesterol levels and patient satisfaction but not on glycosylated hemoglobin. The intervention effects were relatively robust across a variety of patient characteristics, the two participating physicians, and intervention staff members. CONCLUSIONS: If the long-term results are equally positive and generalize to other setting, this intervention could provide a prototype for a feasible cost-effective way to integrate patient views and behavioral management into office-based care for diabetes.

The summary of diabetes self-care activities measure: results from 7 studies and a revised scale.

OBJECTIVE: To review reliability, validity, and normative data from 7 different studies, involving a total of 1,988 people with diabetes, and provide a revised version of the Summary of Diabetes Self-Care Activities (SDSCA) measure. RESEARCH DESIGN AND METHODS: The SDSCA measure is a brief self-report questionnaire of diabetes self-management that includes items assessing the following aspects of the diabetes regimen: general diet, specific diet, exercise, blood-glucose testing, foot care, and smoking. Normative data (means and SD), inter-item and test-retest reliability, correlations between the SDSCA subscales and a range of criterion measures, and sensitivity to change scores are presented for the 7 different studies (5 randomized interventions and 2 observational studies). RESULTS: Participants were typically older patients, having type 2 diabetes for a number of years, with a slight preponderance of women. The average inter-item correlations within scales were high (mean = 0.47), with the exception of specific diet; test-retest correlations were moderate (mean = 0.40). Correlations with other measures of diet and exercise generally supported the validity of the SDSCA subscales (mean = 0.23). CONCLUSIONS: There are numerous benefits from standardization of measures across studies. The SDSCA questionnaire is a brief yet reliable and valid self-report measure of diabetes self-management that is useful both for research and practice. The revised version and its scoring are presented, and the inclusion of this measure in studies of diabetes self-management is recommended when appropriate.

Behavioral interventions for adolescents with type 1 diabetes: how effective are they?

OBJECTIVE: To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature. RESEARCH DESIGN AND METHODS: The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated. RESULTS: The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small- to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P<0.05, 1-tailed). CONCLUSIONS: Research to date indicates that these interventions are moderately effective. Several methodological weaknesses to be avoided in future studies are noted. It is also recommended that investigators use the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework to guide the design of future studies, which should result in more disseminable interventions. RE-AIM assesses the intervention's reach, or percent or representativeness of patients willing to participate; efficacy across a range of outcomes; adoption, or the percent and representativeness of settings willing to implement the intervention; implementation, or the consistency of the delivery of the intervention as intended; and maintenance, or the extent to which delivery of the intervention becomes a routine part of health care in the medical setting.

Personality and overweight in 6-12-year-old children.

BACKGROUND: Personality may be an important yet understudied influence on childhood obesity. OBJECTIVE: We investigated the association between children's personality traits and weight status in a sample of 1533 6-12 year olds. METHODS: Mothers rated their child's personality using the Norwegian Hierarchical Personality Inventory for Children, and reported on their child's height and weight. RESULTS: Relative to their normal weight peers, overweight children were rated lower on energy, optimism, compliance, concentration, perseverance, and self-confidence, and higher on egocentricity, irritability, and anxiety. CONCLUSIONS: These findings suggest possible mechanisms to investigate in future research relating personality to childhood obesity.

Pharmacological profile of duodenal alkaline secretion.

Stimulation of mucosal alkaline secretion represents an opportunity for discovering novel drugs of potential benefit in maintenance therapy of duodenal ulcer disease. We screened over 200 agents representing the full spectrum of pharmacological categories in order to characterize stimulatory pathways and identify mechanistic leads. A variety of eicosanoids, phospho-diesterase inhibitors and adrenoreceptor agonists together with forskolin, 6-hydroxy-dopamine, 2-chloroadenosine, diazepam, testosterone, dipyridamole and dihydropyridazinone caused a reproducible increase in the metabolism-dependent component of alkaline secretion in bullfrog proximal duodenum. PGE2 (ED50 0.02 microgram/ml) was the most potent agent in vitro and was also the most effective stimulant of duodenal alkalinization in vivo in an anaesthetized cat preparation. Agents without effect on spontaneous alkaline secretion by amphibian duodenum included agonists and antagonists of histamine, 5-hydroxy-tryptamine, gamma-aminobutyric acid, dopamine, muscarinic and nicotinic receptors, inhibitors of amine uptake, monoamine oxidase and cholinesterase, plus various corticoids, diuretics, oestrogens, chemotherapeutic (anticancer) and antimicrobial agents. The major mechanism of stimulating alkaline secretion in the isolated duodenum is by increasing intracellular cyclic AMP levels. This may occur by either inhibiting metabolism of the nucleotide or by stimulating its formation. Additionally, many stimulants appear to act indirectly via liberation of endogenous prostaglandins as judged from the marked attenuation of responses in the presence of indomethacin to all agonists apart from exogenous PGE2, forskolin, ICI 63197 (PDE inhibitor), 2-chloroadenosine and diazepam. Whether purinergic agonists and benzodiazepines act directly on the enterocyte or by releasing other paracrine mediators is unknown.

Quadruple antimycobacterial chemotherapy in Crohn's disease: results at 9 months of a pilot study in 20 patients.

Twenty patients with active Crohn's disease, the majority refractory to conventional therapy, were treated with rifampicin, ethambutol, isoniazid, and pyrazinamide or clofazamine for 9 months. After this period, 10 were in remission (Crohn's disease activity index less than 150). Of the 10 not in remission, three had been at 6 months, but had relapsed on treatment. Nine of 10 patients on steroids at the beginning were off steroids at 9 months. Six patients came to surgery during the period, five for stricture formation without evidence of florid Crohn's disease outside the strictured segment. Three young patients with severe Crohn's disease facing total colectomy were spared surgery. No serious drug-related side-effects were encountered. The results of this pilot study suggest that controlled trials of antimycobacterial chemotherapy, using four or more of the best agents available, are worthy of assessment in Crohn's disease.

Extensive reorganization of the somatosensory cortex in adult humans after nervous system injury.

Magnetic source imaging revealed that the topographic representation in the somatosensory cortex of the face area in upper extremity amputees was shifted an average of 1.5 cm toward the area that would normally receive input from the now absent nerves supplying the hand and fingers. Observed alterations provide evidence for extensive plastic reorganization in the adult human cortex following nervous system injury, but they are not a sufficient cause of the phantom phenomenon termed 'facial remapping'.

Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review.

BACKGROUND: Insulin-dependent diabetes mellitus, also known as type 1 diabetes, is a life-threatening condition and is the third most common chronic illness among young people. As a result of minimal or non-existent insulin production, people with diabetes must take over the normally automatic task of regulation of blood glucose levels. This is achieved by a complex regimen involving multiple, daily administrations of insulin coordinated with dietary intake and energy expenditure and monitored by blood glucose testing. OBJECTIVES: To examine the effectiveness of educational and psychosocial interventions for adolescents with type 1 diabetes designed to improve their diabetes management. Specifically, it addressed the following research questions: (1) Do educational and psychosocial interventions for adolescents with type 1 diabetes have beneficial effects on biological and psychosocial outcomes? (2) Are there types or features of interventions that have been shown to be more effective than others? (3) What evidence is there of the cost-effectiveness of interventions? METHODS: A search strategy was formulated, piloted and refined. Three journals were handsearched, 11 electronic databases were searched and personal contacts, flyers, conferences and websites were used to notify the research community of the review to access further literature. This process generated 10,535 abstracts, which, after screening, resulted in 367 articles identified for retrieval. This number was augmented by hand-searching, personal contact and exploding references, and a final total of 457 articles were scrutinised. Of these, 64 reports describing 62 studies were identified as empirical papers evaluating educational or psychosocial interventions. The relevant data were extracted from the papers and summary tables for each study were prepared. Where possible, effect sizes were computed for outcomes from studies that included a randomised control group (CG) and other relevant information. RESULTS: A descriptive analysis of the 62 studies was undertaken. Most studies (67.7%) were conducted in the USA and 41% were randomised controlled trials (RCTs), none of which were UK-based. Only 48% of the reports provided an explicit theoretical rationale for the intervention. The mean number of participants was 53.8. The studies took place in various settings, evaluated a variety of interventions, involved various interventionists, addressed various components and assessed the effects by a range of outcomes, including measures of metabolic control and psychological and behavioural outcomes. Follow-up assessments were relatively rare. RESULTS - THE EFFECTIVENESS OF INTERVENTIONS: The 25 RCTs were examined in more detail and three of the most effective were described in depth. Effect sizes could be calculated for 14 studies. The mean (pooled) effect size for psychosocial outcomes was 0.37 and 0.33 for glycated haemoglobin with outliers (0.08 without outliers), indicating that these interventions have small to medium beneficial effects on diabetes management outcomes. A narrative review of the 21 pre-post studies with no CG was performed, including evaluations of interventions conducted at summer camps, interventions for poorly controlled patients and educational interventions. All studies reported beneficial effects. RESULTS - COST-EFFECTIVENESS: Few studies addressed economic considerations associated with interventions, and the lack of information on costs and the diversity of outcomes included by investigators impeded cost- effectiveness comparisons. Shorter hospitalisation at diagnosis is at least as effective in achieving control and avoiding complications in adolescence as longer stays. Home care may result in improved outcomes but may not be cheaper than hospital care at diagnosis. Targeting poorly controlled subjects may reduce adverse events and hospitalisations and may be more cost-effective than generic interventions. There is a need for rigorous cost-effectiveness studies of educational and psychosocial interventions for adolescents with type 1 diabetes that include longer-term considerations. CONCLUSIONS: The following conclusions were drawn from this review: (1) Educational and psychosocial interventions have small to medium beneficial effects on various diabetes management outcomes. (2) Well-designed trials of such interventions are needed in the UK (no completed RCTs of educational or psychosocial interventions for adolescents with type 1 diabetes conducted in the UK were found). (3) The evidence, arising primarily from studies in the USA, provides a starting point for the design of interventions in the UK. (4) Quantitative and narrative analysis of the evidence suggested that interventions are more likely to be effective if they demonstrate the inter-relatedness of the various aspects of diabetes management. (ABSTRACT TRUNCATED)

Coping with osteoarthritis by older adults.

OBJECTIVE: To extend to patients with osteoarthritis (OA) the coping model developed for patients with rheumatoid arthritis. METHODS: Relationship among appraisal, coping, and impact of OA were examined in a prospective study. Older men and women with OA (n = 82) were recruited from the community and were assessed at baseline, 1 month, and 4 months. Appraisal at baseline was measured by an interview addressing patients' beliefs about the intensity of their OA. Active, passive, and behavioral coping were assessed at 1 month, and the impact on OA pain, affective status, and mood was assessed at 4 months. RESULTS: Appraisal of OA as more intense was related to the use of more passive coping at 1 month, and was also related to more negative mood at 4 months. Active coping was predictive of less depressed affective status, whereas passive coping was predictive of subsequent worsening of negative mood. These relationships remained significant after controlling for demographic and medical history variables and functional status measures associated with dependent variables. No relation of either appraisal or coping to pain or positive mood was observed. CONCLUSIONS: The findings suggests that as patients' appraisals of the intensity of their OA decrease, less use of passive coping strategies, which are associated with poorer outcomes, should result. It is recommended that interventions to reduce OA impact should include both modification of appraisals of OA and modification of patients' coping strategies.

Self-management of osteoarthritis.

Osteoarthritis is the most prevalent activity-limiting condition among older persons. In addition to, or instead of, taking nonsteroidal anti-inflammatory drugs, people use a variety of activities to manage their osteoarthritis. This study describes the self-management methods reported by 61 participants aged 60 years or older assessed on two occasions 8 months apart. A questionnaire was developed to assess levels of use of 10 self-management methods including low-impact activity, rest, range-of-motion exercises, relaxation, heat (or cold), taking medication, joint protection, massage, splints, and any other activity. On a typical day, participants used about four of these activities to manage osteoarthritis symptoms, and significantly more on a day that their arthritis was worse than usual. Three self-management scales were formed from groups of activities suggested by factor analysis (medication taking, typical management, and worse-day passive management) that demonstrated adequate internal consistency and stability across the two assessments. The findings are discussed in terms of the importance of developing a brief measure of osteoarthritis self-management, and the substantial individual variation in subsets of methods used.

Personal models of diabetes and their relations to self-care activities.

Investigated the personal models of diabetes held by 46 female outpatients with non-insulin-dependent diabetes mellitus. The subjects' mean age was 64 years (range = 46 to 79 years), and 24 subjects were taking insulin. Their personal models were explored by using a comprehensive interview including questions on beliefs and emotions about cause, symptoms, course, treatment, and consequences of their diabetes. Two weeks after their interview, patients provided information about their levels of self-care activities, including exercise, diet, and glucose testing. The interview provided multiple indicators of the personal-model constructs from which four composites were formed assessing cause, symptoms, treatment, and seriousness (a combination of course and consequences). In hierarchical multiple-regression analyses, these dimensions significantly improved the prediction of diet level and marginally improved the prediction of exercise after accounting for the effects of age and insulin taking. The results are discussed in terms of variations in personal models across different patient groups and diseases and the role of personal models in determining self-care behaviors.

Radon and cigarette smoking: perceptions of this synergistic health risk.

Past approaches to the measurement of the perceived risk of combined hazards have failed to demonstrate awareness of synergy (S. E. Hampson et al., 1998; D. Hermand, E. Mullet, & B. Coutelle, 1995; D. Hermand, E. Mullet, & S. Lavieville, 1997). Respondents (N = 650) were provided with information about the synergistic risk of lung cancer from the combination of smoking and radon, and their risk perceptions were assessed on two occasions. At Time 1, using Likert-type scales, there was no evidence of synergistic risk perception. At Time 2, using a scale based on the appraisal of relative risk with anchors allowing for the expression of synergy, the combined hazard of radon and smoking was rated as significantly more of a health risk than the single hazards. The findings are discussed in terms of methodological issues in assessing synergistic risk.

Conscientiousness, perceived risk, and risk-reduction behaviors: a preliminary study.

Participants (N = 343) from an Oregon community completed surveys at baseline, 3 months, and 12 months to assess personality, the perceived health risk of radon in combination with smoking, and changes in smoking behavior. Conscientiousness predicted instituting a more restrictive household smoking rule (p < .01), and perceived risk predicted reduction in cigarettes smoked per day for men (p < .001). Perceived risk predicted a reduction in the proportion of cigarettes smoked in the home for those who had high (p < .05) but not low or moderate levels of Conscientiousness, a dimension in one personality model. The results demonstrate the importance of Conscientiousness in the prediction of health behavior, particularly behavior that affects others as well as oneself.

Somatosensory evoked potential monitoring of spinal cord ischemia during aortic operations.

Somatosensory evoked potentials were monitored in 22 consecutive patients undergoing surgical correction of an aortic coarctation. Induction of spinal cord ischemia by cross clamping of the aorta elicited a change in the evoked potential in 9 patients (41%). These alterations occurred within 5 minutes of aortic clamping in 3 cases and after 18 to 21 minutes in the remaining 6 cases. Loss of the somatosensory evoked potential for more than 14 minutes was associated with postoperative neurological deficit. Alteration of the evoked potential within 5 minutes of aortic cross clamping was significantly related to poor collateral circulation shown on the preoperative aortogram. The pathophysiology of evoked potential changes in spinal ischemia is discussed in detail.