Medical and Psychosocial Factors Associated With Low Physical Activity and Increasing Exercise Level After a Coronary Event.

PURPOSE: The reasons why many coronary patients are inactive or have a low level of physical activity (PA) are not completely understood. We identified medical and psychosocial factors associated with PA status and increasing exercise level after a coronary event. METHODS: A cross-sectional study investigated the factors associated with PA in 1101 patients hospitalized with myocardial infarction (MI) and/or a revascularization procedure. Data were collected from hospital records, a self-report questionnaire, and a clinical examination. PA was categorized as inactivity, low activity, and adequate activity (≥ moderate intensity of 30 min ≥2-3 times/wk), an overall summary PA-index was measured as a continuous variable, and self-reported PA increase since the index event was measured on a 0- to 10-point Likert Scale. RESULTS: In all, 18% reported inactivity, 42% low, and 40% adequate activity at follow-up after median 16 mo. In multiadjusted linear regression analyses, low PA-index was significantly associated with smoking, obesity, unhealthy diet, depression, female, low education, MI as index diagnosis, and ≥1 previous coronary event. Motivation, risk and illness perceptions, and low reported need of help to increase PA were significantly associated with self-reported increasing PA level in adjusted continuous analyses. CONCLUSIONS: Daily smoking, obesity, unhealthy diet, and depression were the major potentially modifiable factors associated with insufficient PA, whereas high motivation and risk and illness perceptions were associated with increasing PA level. Further research on the effect of interventions tailored to the reported significant factors of failure is needed to improve PA level in CHD patients.

Managing patients with prediabetes and type 2 diabetes after coronary events: individual tailoring needed - a cross-sectional study.

BACKGROUND: Understanding the determinants associated with prediabetes and type 2 diabetes in coronary patients may help to individualize treatment and modelling interventions. We sought to identify sociodemographic, medical and psychosocial factors associated with normal blood glucose (HbA1c < 5.7%), prediabetes (HbA1c 5.7-6.4%), and type 2 diabetes. METHODS: A cross-sectional explorative study applied regression analyses to investigate the factors associated with glycaemic status and control (HbA1c level) in 1083 patients with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records at the index event and from a self-report questionnaire and clinical examination with blood samples at 2-36 months follow-up. RESULTS: In all, 23% had type 2 diabetes, 44% had prediabetes, and 33% had normal blood glucose at follow-up. In adjusted analyses, type 2 diabetes was associated with larger waist circumference (Odds Ratio 1.03 per 1.0 cm, p = 0.001), hypertension (Odds Ratio 2.7, p < 0.001), lower high-density lipoprotein cholesterol (Odds Ratio 0.3 per1.0 mmol/L, p = 0.002) and insomnia (Odds Ratio 2.0, p = 0.002). In adjusted analyses, prediabetes was associated with smoking (Odds Ratio 3.3, p = 0.001), hypertension (Odds Ratio 1.5, p = 0.03), and non-participation in cardiac rehabilitation (Odds Ratio 1.7, p = 0.003). In patients with type 2 diabetes, a higher HbA1c level was associated with ethnic minority background (standardized beta [ß] 0.19, p = 0.005) and low drug adherence (ß 0.17, p = 0.01). In patients with prediabetes or normal blood glucose, a higher HbA1c was associated with larger waist circumference (ß 0.13, p < 0.001), smoking (ß 0.18, p < 0.001), hypertension (ß 0.08, p = 0.04), older age (ß 0.16, p < 0.001), and non-participation in cardiac rehabilitation (ß 0.11, p = 0.005). CONCLUSIONS: Along with obesity and hypertension, insomnia and low drug adherence were the major modifiable factors associated with type 2 diabetes, whereas smoking and non-participation in cardiac rehabilitation were the factors associated with prediabetes. Further research on the effect of individual tailoring, addressing the reported significant predictors of failure, is needed to improve glycaemic control. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov: NCT02309255 , December 5th 2014.

The prevalence and predictors of elevated C-reactive protein after a coronary heart disease event.

Objective An interleukin-beta antagonist reduces the risk of subsequent cardiovascular events in coronary patients with high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L. It remains to be defined how large the coronary population at inflammatory risk is, and what the predictors of elevated risk are. Methods A cross-sectional study investigated the proportion of patients with elevated hs-CRP (i.e. ≥2 mg/L) and the respective demographic and clinical predictors in 971 patients without concomitant inflammatory diseases who had been hospitalized with myocardial infarction (80%) and/or a revascularization procedure. Data were collected from hospital records, a self-report questionnaire and a clinical examination with blood samples. Results After 2-36 month follow-up, 39% ( n = 378) had hs-CRP ≥ 2 mg/L, among whom 64% ( n = 243) had low-density lipoprotein cholesterol (LDL-C) ≥1.8 mmol/L and 47% ( n = 176) used a low-intensity statin regime. Only 24% had both LDL and hs-CRP at target range, 27% had elevation of both, whereas 12% had hs-CRP ≥ 2 mg/L and LDL-C < 1.8 mmol/L. Somatic comorbidity (odds ratio (OR) 1.3/1.0 point on the Charlson score), ≥1 previous coronary event (OR 2.4), smoking (OR 2.2), higher body mass index (OR 1.2/1.0 kg/m2), high LDL-C (OR 1.4/1.0 mmol/L) and higher anxiety scores (OR 1.1/1.0 point increase on the Hospital Anxiety and Depression Scale-Anxiety subscale score) were significantly associated with hs-CRP ≥2 mg/L in adjusted analyses. Conclusions Elevated hs-CRP was frequently observed after a coronary event and associated with unfavourable LDL-C and unhealthy lifestyles and psychosocial distress. Intensified statin therapy and strategies to target these modifiable factors are the encouraged first steps to reduce inflammation and improve LDL-C in these patients.

Medical and sociodemographic factors predict persistent smoking after coronary events.

BACKGROUND: Understanding the determinants of persistent smoking after a coronary event constitutes the basis of modelling interventions of smoking cessation in secondary prevention programs. We aim to identify the potentially modifiable medical, sociodemographic and psychosocial factors, comprising the study factors, associated with unfavourable risk factor control after CHD events. METHODS: A cross-sectional explorative study used logistic regression analysis to investigate the association between study factors and smoking status in 1083 patients hospitalized with myocardial infarction and/or coronary revascularization. Hospital record data, a self-report questionnaire, clinical examination and blood samples were applied. RESULTS: At the index hospitalization, 390 patients were smoking and at follow-up after 2-36 months 167 (43%) of these had quit, while 230 reported persistent smoking. In adjusted analyses, unemployed or disability benefits (Odds ratio (OR) 4.1), low education (OR 3.5), longer smoking duration (OR 2.3) and not having ST-elevation myocardial infarction (STEMI) as index event (OR 2.3) were significantly associated with persistent smoking. Psychosocial factors at follow-up were not associated with persistent smoking. Smokers reported high motivation for cessation, with 68% wanting help to quit. Only 42% had been offered nicotine replacement therapy or other cessation aids. Smokers rated use of tobacco as the most important cause of their coronary disease (6.8 on a 1-10 Likert scale). CONCLUSIONS: Low socioeconomic status, prior duration of smoking, and not having STEMI as index event were associated with persisting smoking. Persistent smokers in this study seem to have an acceptable risk perception and were motivated to cease smoking, but needed assistance through cessation programs including prescription of pharmacological aids. TRIAL REGISTRATION: Registered at ClinicalTrials.gov: NCT02309255 , registered retrospectively.

Depression-A Major Contributor to Poor Quality of Life in Patients With Advanced Cancer.

CONTEXT: Quality of life (QoL) and depression are important patient-reported outcomes in cancer care. However, the relative importance of depression severity in predicting QoL remains unclear because of few methodologically sound studies. OBJECTIVES: To examine whether depression contributes to impairment of QoL irrespective of prognostic factors and symptom burden. METHODS: A total of 563 patients were included from the European Palliative Care Research Collaborative-Computerized Symptom Assessment Study, an international, multi-center, cross-sectional study. The relative importance of prognostic factors (systemic inflammation [modified Glasgow Prognostic Score-mGPS]), co-morbidities and physical performance (Karnofsky Performance Status), symptom burden (loss of appetite, breathlessness, nausea [Edmonton Symptom Assessment Scale], and pain [Brief Pain Inventory]), and depression severity (Patient Health Questionnaire 9) in predicting Global Health/QoL (European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire [EORTC-QLQ-C30]) were assessed using hierarchical multiple regression models. RESULTS: Fifty-five percent were women, median age was 64 years, 87% had metastatic disease, median Karnofsky Performance Status was 70, and mean global QoL was 50.5 (SD = 23.3). Worse QoL was associated with increased systemic inflammation (mGPS = 1 ß = -0.12, P = 0.003; mGPS = 2 ß = -0.09, P = 0.023), lower physical performance (ß = 0.17, P < 0.001), reduced appetite (ß = -0.15, P < 0.001), breathlessness (ß = -0.11, P = 0.004), pain (ß = -0.14, P = 0.002), and higher depression severity (ß = -0.27, P < 0.001). The full model accounted for 29% of the observed variance in QoL scores. The strongest predictor was depression severity, accounting for 5.8% of the variance. CONCLUSION: Depression severity was the strongest single predictor of poorer QoL in this sample of patients with advanced cancer, after accounting for a wide range of clinically relevant variables. Future studies should investigate the contribution of psychosocial variables on QoL. Our findings emphasize the importance of managing depression to achieve the best possible QoL for these patients.

The role of cardiac rehabilitation in secondary prevention after coronary events.

Background Coronary risk factor control in Europe is suboptimal and there are large variations in the nature of cardiac rehabilitation (CR) programmes offered to coronary heart disease patients. We aim to explore characteristics and risk factor control in patients recruited from two neighbouring hospitals offering CR with different content. Methods In a cross-sectional study, 1127 Norwegian patients hospitalized with acute myocardial infarction and/or a revascularization procedure attended a clinical visit and completed a questionnaire at 2-36 months' follow-up. The hospital of Vestfold provides comprehensive CR, while the hospital of Drammen provides mainly exercise-based CR. Results At follow-up, patients in Vestfold performed more physical activity ( p = 0.02), were less obese ( p = 0.02) and reported better medication adherence ( p = 0.02) than patients in Drammen. The perceived need for information and follow-up was higher in Drammen than Vestfold ( p < 0.001). The CR participation rate in Vestfold was 75% compared with 18% in Drammen. CR participation in Vestfold was associated with higher prevalence of smoking cessation ( p = 0.001), lower low-density lipoprotein cholesterol ( p = 0.01) and better medication adherence ( p = 0.02) compared with non-CR, in adjusted analyses. No differences in diet, body weight, or blood pressure control were found between CR and non-CR. Conclusions Vestfold, with comprehensive CR, had a higher participation rate and more risk factors on target than Drammen. Participation in CR in Vestfold was associated with higher levels of smoking cessation and medication adherence, and lower low-density lipoprotein cholesterol, but overall risk factor control is still deficient, underlining the need for improved understanding of barriers to optimal risk factor control.

Medical and psychosocial factors and unfavourable low-density lipoprotein cholesterol control in coronary patients.

Objective Understanding the determinants of low-density lipoprotein cholesterol (LDL-C) control constitutes the basis of modelling interventions for optimal lipid control and prognosis. We aim to identify medical and psychosocial (study) factors associated with unfavourable LDL-C control in coronary patients. Methods A cross-sectional explorative study used logistic and linear regression analysis to investigate the association between study factors and LDL-C in 1095 patients, hospitalized with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records, a comprehensive self-report questionnaire, clinical examination and blood samples after 2-36 months follow-up. Results Fifty-seven per cent did not reach the LDL-C target of 1.8 mmol/l at follow-up. Low socioeconomic status and psychosocial factors were not associated with failure to reach the LDL-C target. Statin specific side-effects (odds ratio 3.23), low statin adherence (odds ratio 3.07), coronary artery by-pass graft operation as index treatment (odds ratio 1.95), ≥ 1 coronary event prior to the index event (odds ratio 1.81), female gender (odds ratio 1.80), moderate- or low-intensity statin therapy (odds ratio 1.62) and eating fish < 3 times/week (odds ratio 1.56) were statistically significantly associated with failure to reach the LDL-C target, in adjusted analyses. Only side-effects (standardized ß 0.180), low statin adherence ( ß 0.209) and moderate- or low-intensity statin therapy ( ß 0.228) were associated with LDL-C in continuous analyses. Conclusions Statin specific side-effects, low statin adherence and moderate- or low-intensity statin therapy were the major factors associated with unfavourable LDL-C control. Interventions to improve LDL-C should ensure adherence and prescription of sufficiently potent statins, and address side-effects appropriately.

Reproducibility of an extensive self-report questionnaire used in secondary coronary prevention.

AIMS: Self-reported information from questionnaires is frequently used in clinical epidemiological studies, but few provide information on the reproducibility of instruments applied in secondary coronary prevention studies. This study aims to assess the test-retest reproducibility of the questionnaire applied in the cross-sectional NORwegian CORonary (NOR-COR) Prevention Study. METHODS: In the NOR-COR study 1127 coronary heart disease (CHD) patients completed a self-report questionnaire consisting of 249 questions, of which there are both validated instruments and de novo questions. Test-retest reliability of the instrument was estimated after four weeks in 99 consecutive coronary patients. Intraclass Correlation Coefficient (ICC) and Kappa (κ) were calculated. RESULTS: The mean interval between test and retest was 33 (±6.4) days. Reproducibility values for questions in the first part of the questionnaire did not differ from those in the latter. A good to very good reproducibility was found for lifestyle factors (smoking: κ = 1.0; exercise: ICC = 0.90), medical factors (drug adherence: ICC = 0.74; sleep apnoea: ICC = 0.87), and psychosocial factors (anxiety and depression: ICC = 0.95; quality of life 12-Item Short-Form Health Survey (SF12): ICC = 0.89), as well as for the majority of de-novo-created variables covering the patient's perceptions, motivation, needs, and preferences. CONCLUSIONS: The present questionnaire demonstrates a highly acceptable reproducibility for all key items and instruments. It thus emerges as a valuable tool for evaluating patient factors associated with coronary risk factor control in CHD patients.

Unfavourable risk factor control after coronary events in routine clinical practice.

BACKGROUND: Risk factor control after a coronary event in a recent European multi-centre study was inadequate. Patient selection from academic centres and low participation rate, however, may underscore failing risk factor control in routine clinical practice. Improved understanding of the patient factors that influence risk factor control is needed to improve secondary preventive strategies. The objective of the present paper was to determine control of the major risk factors in a coronary population from routine clinical practice, and how risk factor control was influenced by the study factors age, gender, number of coronary events, and time since the index event. METHODS: A cross-sectional study determined risk factor control and its association with study factors in 1127 patients (83% participated) aged 18-80 years with acute myocardial infarction and/or revascularization identified from medical records. Study data were collected from a self-report questionnaire, clinical examination, and blood samples after 2-36 months (median 16) follow-up. RESULTS: Twenty-one percent were current smokers at follow-up. Of those smoking at the index event 56% continued smoking. Obesity was found in 34%, and 60% were physically inactive. Although 93% were taking blood-pressure lowering agents and statins, 46% were still hypertensive and 57% had LDL cholesterol >1.8 mmol/L at follow-up. Suboptimal control of diabetes was found in 59%. The patients failed on average to control three of the six major risk factors, and patients with >1 coronary events (p < 0.001) showed the poorest overall control. A linear increase in smoking (p < 0.01) and obesity (p < 0.05) with increasing time since the event was observed. CONCLUSIONS: The majority of coronary patients in a representative Norwegian population did not achieve risk factor control, and the poorest overall control was found in patients with several coronary events. New strategies for secondary prevention are clearly needed to improve risk factor control. Even modest advances will provide major health benefits. TRIAL REGISTRATION: Registered at ClinicalTrials.gov (ID NCT02309255 ).

Increased prevalence of chronic fatigue among survivors of childhood cancers: a population-based study.

BACKGROUND: Fatigue is prevalent in adult cancer survivors but less studied in childhood cancer survivors. Aims were to assess fatigue levels, prevalence of chronic fatigue (CF) and the association of CF with health-related quality of life (HRQoL) in survivors of acute myeloid leukemia (AML), infratentorial astrocytoma (IA), and Wilms tumor (WT) in childhood. PROCEDURE: Seventy percent (398/567) of Nordic patients treated for AML, IA, and WT between 1985 and 2001 at age >1 year responded to a postal survey, encompassing the Fatigue Questionnaire and the Short Form 36 (SF-36). Participants were divided into two groups at time of study; younger (YG, 13-18 years) and older (OG, 19-34 years). Respondents (19-34 years, n = 763) from a Norwegian general population (GP) survey served as controls for the OG. RESULTS: The OG [mean age was 24 years (SD 3.3)] had higher fatigue levels compared to the YG and the GP, especially the females (P < 0.05). There was also a higher prevalence of CF in the OG than in the GP (14 vs. 6%, P < 0.001). Regardless of diagnosis, the OG with CF had poorer physical health (P < 0.05) on the SF-36 but better mental health (P < 0.05 and P = 0.001) relative to controls with CF. CONCLUSIONS: The prevalence of CF is higher among Nordic survivors of AML, IA, and WT than GP controls of similar age. CF is associated with impaired HRQoL in survivors. However, they reported better mental health than CF GP controls. This might indicate different underlying mechanisms of CF in the two populations.

Pain and quality of life with chronic obstructive pulmonary disease.

BACKGROUND: Pain as a symptom may be underrecognized in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: The aim of this study is to explore the prevalence and intensity of pain, its location, how demographic and clinical variables may be related to pain, and how pain is associated with quality of life (QOL). METHODS: In this cross-sectional study, 154 patients with COPD answered the Brief Pain Inventory, Respiratory Quality of Life Questionnaire, and Quality of Life Scale, and performed spirometry. RESULTS: Seventy-two percent of the patients indicated the location of pain on a body diagram. Lower lung function, higher score of pain intensity, and pain interference were associated with lower disease QOL. A higher score of pain interference was associated with lower global QOL. When controlling for disease QOL in the equation of global QOL, pain interference was no longer significant. CONCLUSION: The experience of pain is related to disease QOL in patients with COPD.

Emotional Functioning and School Contentment in Adolescent Survivors of Acute Myeloid Leukemia, Infratentorial Astrocytoma, and Wilms Tumor.

Purpose: Cancer in childhood may disrupt normal developmental processes and cause psychosocial problems in adolescent survivors of childhood cancers (ACCSs). Previous studies report inconsistent findings. Study aims were to assess subjective well-being (SWB), psychological distress, and school contentment in survivors of three dissimilar childhood cancers. Patients and methods: Nordic patients treated for acute myeloid leukemia (AML), infratentorial astrocytoma (IA), and Wilms tumor (WT) in childhood from 1985 to 2001, aged ≥1 year at diagnosis, and aged 13-18 years at the time of study were eligible for this questionnaire-based survey that included items on SWB, psychological distress, school contentment, self-esteem, and personality traits; 65% (151/231) responded. An age-equivalent group from a Norwegian health survey (n=7910) served as controls. Results: The median age of ACCSs was 16 years; 52% were males. ACCSs reported better SWB (p=0.004) and self-esteem (p<0.001). They had fewer social problems in school (p=0.004) and their school contentment tended to be higher than controls. SWB and school contentment were positively influenced by self-esteem. However, ACCSs reported higher levels of psychological distress (p=0.002), mostly attributable to general worrying. No significant differences in outcomes were found across diagnoses, and time since diagnosis did not significantly affect the results. Conclusion: The overall emotional functioning of ACCSs was good, possibly due to changes in their perception of well-being after having survived a life-threatening disease. However, they seemed more worried than their peers. This may cause an additional strain at a vulnerable period in life.

Association of breathlessness with multiple symptoms in chronic obstructive pulmonary disease.

AIM: This paper is a report of an exploration of relationships between demographic and clinical variables and the symptoms of breathlessness, depression, anxiety, fatigue, sleeping difficulties and pain for patients with chronic obstructive pulmonary disease. BACKGROUND: Research into chronic obstructive pulmonary disease has focused on single symptoms and we lack knowledge about possible associations between several symptoms. METHODS: A total of 154 patients with chronic obstructive pulmonary disease participated in a cross-sectional study from June 2006 to December 2007 (response rate 40%). All underwent pulmonary lung function tests and completed questionnaires including demographic variables, the Brief Pain Inventory, Hospital Anxiety and Depression Scale, Lee Fatigue Scale, General Sleep Disturbance Scale and the Respiratory Quality of Life Questionnaire. Bivariate correlation and multiple regression analyses were performed. RESULTS: Breathlessness was statistically significantly positively associated with the other symptoms, after controlling for demographic and clinical variables. Younger age was statistically significantly related to more breathlessness, anxiety and sleeping difficulties and lower levels of education was statistically significantly related to more breathlessness, depression and anxiety. In relation to clinical variables, smoking was statistically significantly related to more depression, whereas more co-morbidity was statistically significantly related to more breathlessness and pain. Poorer lung function was statistically significantly related to more breathlessness. However, higher lung function was related to more sleeping difficulties. CONCLUSION: Breathlessness is associated with symptoms such as depression, anxiety, fatigue, sleeping difficulties and pain, suggesting the need for an expanded focus on symptoms in chronic obstructive pulmonary disease guidelines, health care and research.

Social outcomes in young adult survivors of low incidence childhood cancers.

INTRODUCTION: The intensity and duration of childhood cancer treatment may disrupt psychosocial development and thereby cause difficulties in transition into adulthood. The study objective was to assess social outcomes in early adulthood after successful treatment for childhood acute myeloid leukemia (AML), Wilms tumor (WT) and infratentorial astrocytoma (IA). METHODS: Nordic patients treated for AML, WT and IA from 1985 to 2001 identified from a database administered by NOPHO (Nordic Society of Paediatric Haematology and Oncology) were invited to participate in a postal survey. All cancer-free survivors treated at age >1 year who were >19 years at time of study were eligible. Seventy-four percent; 247/335 responded. An age-equivalent group (N = 1,814) from a Norwegian Census Study served as controls. RESULTS: Mean age of survivors was 23 years (range 19-34), 55% females. The proportion with academic education (>/=4 years) was similar in survivors and controls (28 vs. 32%). Fifty-nine percent of survivors were employed compared to 77% among controls (p < .01). More survivors were recipients of social benefits (6.7 vs. 3.1%, p < .01). There were no differences in marital status but parenthood was more common among controls (37 vs. 27%, p = .01). Controls lived longer in their parental homes (p = .01). Cancer type or treatment intensity had no statistically significant impact on results, except for parenthood. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: The study revealed important differences in social outcomes between survivors and controls early in adult life. Specific difficulties pertain to studying social status in early adulthood because of the natural transition characteristics for this age group. Therefore, longer follow-up is warranted.

Screening for anxiety and depression after stroke: comparison of the hospital anxiety and depression scale and the Montgomery and Asberg depression rating scale.

OBJECTIVE: Anxiety and depression after stroke are frequent, but are often overlooked and not assessed. The aims of the study were to (1) assess the prevalence of anxiety and depression and (2) compare the performance of the Hospital Anxiety and Depression Scale (HADS) and Montgomery and Asberg Depression Rating Scale (MADRS) as screening instruments for anxiety and depression disorders 4 months after stroke. METHODS: Stroke patients, consecutively admitted to a stroke unit, were assessed with HADS and MADRS 4 months after stroke (n=104). Depression and anxiety disorders were diagnosed using the Structured Clinical Interview for DSM-IV (SCID). Measures were compared in terms of correlations, sensitivity, specificity, positive and negative predictive value, overall agreement, kappa, and ROC curves, using DSM-IV diagnoses of "at least one current significant anxiety disorder" (Anxiety) and "any current depression" (Depression), as the clinical criteria. RESULTS: Anxiety occurred in 23% of patients and Depression in 19% (13% major depression, 3% minor depression, 4% dysthymia). For Anxiety, the optimal screening cut-off was 4 for HADS-A and 6 for HADS-total; for Depression, optimal cut-offs were 4 for HADS-D, 11 for HADS-total, and 8 for MADRS. At cut-offs commonly used in clinical practice for depression screening (HADS-D: 8, MADRS: 12), the MADRS performed marginally better than the HADS. CONCLUSION: Anxiety is as prevalent as depression 4 months after stroke. MADRS and HADS-D perform acceptably as screening instruments for depression, and HADS-A for anxiety after stroke. However, lower HADS cut-offs than recommended for the general population should be considered for stroke patients.

The association between history of diabetic foot ulcer, perceived health and psychological distress: the Nord-Trøndelag Health Study.

BACKGROUND: While the adverse impact of a history of a foot ulcer on physical health among persons with diabetes is well known, little is known about the association between foot ulcer, perceived health and psychological distress. Results from various studies are difficult to compare as different study designs, samples and/or different questionnaires have been used. The aim of this study was to compare levels of anxiety and depression, psychological well-being and perceived health between persons with diabetes, with or without a history of foot ulcer, and persons without diabetes in a large study of community-dwelling individuals. METHODS: This study included 65,126 persons, of whom 63,632 did not have diabetes, 1,339 had diabetes without a history of foot ulcer and 155 had diabetes and a history of foot ulcer. Levels of anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). Psychological well-being was measured on a four-item scale, and perceived health was measured with a one-item question. We investigated whether levels of anxiety, depression, psychological well-being and perceived health were different in the three study groups using multiple regression models controlling for demographic factors, body mass index, smoking and cardiovascular conditions. Separate multivariate analyses comparing the two diabetes samples were additionally adjusted for diabetes-specific variables. RESULTS: A history of foot ulcer was significantly associated with more depressive symptoms, poorer psychological well-being and poorer perceived health compared to participants without diabetes. In multivariate analyses, perceived health and psychological well-being were significantly poorer among those with a history of foot ulcer compared to those without diabetes. Among persons with diabetes, perceived health was significantly worse among those with a history of foot ulcer. After multivariate adjustment, levels of anxiety and depression and psychological well-being did not differ between the two diabetes groups. CONCLUSION: Perceived health and psychological well-being were significantly poorer among participants with diabetes and a history of foot ulcer compared to those without diabetes. Among people with diabetes, a history of foot ulcer had significant negative impact on perceived health but did not independently contribute to psychological distress.

Cancer patients' barriers to pain management and psychometric properties of the Norwegian version of the Barriers Questionnaire II.

The Barriers Questionnaire II (BQ-II) was developed to assess barriers to effective pain management. The purpose of this study was to evaluate the psychometric properties of the BQ-II in a sample of Norwegian cancer patients. The BQ-II was translated into Norwegian and pilot tested with eight oncology outpatients. Then, a convenience sample of 321 cancer patients from two different sites was recruited to maximize the number of questionnaires available for the psychometric analyses. Patients were included if they: were >18 years of age; had a diagnosis of cancer; and self-reported pain and/or use of analgesics. Construct validity of the Norwegian version of the BQ II (NBQ-II) was evaluated using an exploratory factor analysis. A seven-factor solution was found that was more consistent with the original version of the BQ. Construct validity of the NBQ-II was demonstrated through positive correlations between most of the subscale and total scores on the NBQ-II and pain intensity and pain interference scores. Finally, Cronbach's α coefficients of ≥0.7 for six of the seven subscales and 0.89 for the total scale demonstrated acceptable levels of internal consistency. In conclusion, the NBQ-II demonstrated adequate psychometric properties. However, further revision and testing of the questionnaire should be performed to confirm the factor structure that was identified in this study.

Prevalence rates for and predictors of self-reported adherence of oncology outpatients with analgesic medications.

OBJECTIVES: Inadequate adherence with an analgesic regimen may be a reason why oncology patients experience unrelieved pain. However, only a limited number of studies have evaluated the prevalence rates for adherence and no studies have attempted to determine predictors of adherence in patients with cancer pain. On the basis of concepts from the Health Belief Model, the purposes of this study were to describe oncology outpatients' level of adherence with an analgesic regimen and to evaluate the direct and indirect effects of selected demographic variables, pain characteristics, barriers to pain management, and self-efficacy (SE) on adherence with an analgesic regimen. METHODS: A descriptive, cross-sectional study recruited outpatients from oncology clinics in a large, tertiary referral cancer hospital in Norway. A sample of 174 oncology outpatients completed a demographic questionnaire, the Brief Pain Inventory, 2 self-reported adherence measures, the Barriers Questionnaire, and a SE questionnaire. RESULTS: Only 41% of the patients were adherent with their analgesic regimen. In the regression analysis, 29.9% of the variance in adherence was explained. Higher adherence scores were associated with male sex, and also lower SE for physical function scores, higher average pain intensity scores, higher pain relief scores, and the use of strong opioid analgesics. CONCLUSIONS: Improvements in pain management may occur if clinicians routinely assessed patients' level of adherence with their analgesics regimen.

Exercise capacity and quality of life after intracoronary injection of autologous mononuclear bone marrow cells in acute myocardial infarction: results from the Autologous Stem cell Transplantation in Acute Myocardial Infarction (ASTAMI) randomized controlled trial.

BACKGROUND: The effects on left ventricular function of intracoronary injection of bone marrow cells in acute myocardial infarction (AMI) have been studied with conflicting results. The aim of this substudy of the ASTAMI trial was to examine the effects of this novel treatment on exercise capacity and quality of life. METHODS: We studied 100 patients with anterior wall ST-elevation AMI. All had percutaneous coronary intervention with stent in the proximal or mid left anterior descending coronary artery 2 to 12 hours after start of symptoms. Patients were randomized to intracoronary injection of mononuclear bone marrow cells (mBMCs) in left anterior descending coronary artery 6 +/- 1.3 days after AMI (n = 50) or control (n = 50). Assessment of physical capacity by maximal symptom-limited bicycle ergometer exercise tests and quality of life by the Short Form 36 health survey was performed 2 to 3 weeks and 6 months after the AMI. RESULTS: There was a significantly greater improvement in exercise time in the mBMC group than in the control group (treatment effect 0.9 minute, 95% CI 0.3-1.6, P < .01), and a similar improvement in peak oxygen consumption in the groups (2.8 +/- 3.9 mL/[kg min] in the mBMC group vs 2.4 +/- 3.5 mL/[kg min] in controls, P = .62). Peak heart rate and percentage of heart rate reserve increased significantly more in the treatment group than in the control group. Treatment with mBMCs did not influence quality of life. CONCLUSIONS: In this randomized open-labeled study, the mBMC group significantly improved exercise time and heart rate responses to exercise compared with the control group. There was no treatment effect on peak oxygen consumption.

A comparison of the health-related quality of life in patients with diabetic foot ulcers, with a diabetes group and a nondiabetes group from the general population.

OBJECTIVE: The aim of this study was to describe health-related quality-of-life (HRQL) in patients with diabetic foot ulcers by comparing their HRQL with that of a sample from the general population without diabetes (general population) and a subgroup with diabetes (diabetes population), and to examine the differences between groups by sociodemographic characteristics and lifestyle factors. DESIGN AND METHODS: A cross-sectional study was made of 127 adults with current diabetic foot ulcer, recruited from six hospital outpatient clinics, a control sample categorized as a diabetes population (n = 221) from the Norwegian Survey of Level of Living, and a sample from the general population (n = 5903). Data on sociodemographic characteristics (sex, age, cohabitation, education and employment) and lifestyle (body mass index [BMI] and smoking status) and HRQL (SF-36) were obtained. RESULTS: In all the SF-36 subscales and in the two SF-36 summary scales, the patients with diabetic foot ulcer reported significantly poorer HRQL than the diabetes population. The most striking differences were for role limitation-physical (32.1 vs. 62.2, p < 0.001), physical functioning (57.5 vs. 77.3, p < 0.001) and role limitation-emotional (57.4 vs. 72.0, p < 0.001). The patients with foot ulcer had significantly lower HRQL than the general population on all scales, and in particular on role limitation-physical (32.1 vs. 74.3, p < 0.001), physical functioning (57.5 vs. 85.2, p < 0.001) and general health (50.1 vs. 74.3, p < 0.001). The most important sociodemographic characteristic that differed between the diabetic foot ulcer patients and the diabetes population was that significantly more of the foot ulcer patients were men living alone. The largest differences between the foot ulcer patients and the general population were that more of the foot ulcer patients were men, older, living alone, less well educated, and not working. The diabetic foot ulcer patients, the diabetes population and the general population differed in BMI: 28 kg/m(2) in the foot ulcer patients, 27 kg/m(2) in the diabetes population and 25 kg/m(2) in the general population. CONCLUSION: Diabetic foot ulcer patients had much worse HRQL compared with the diabetes population and the general population, especially in physical health. Foot ulcer patients were more often men living alone, and obesity was a problem in both the foot ulcer patients and the diabetes population.