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.