Patient motivation and preferences in changing co-occurring health risk behaviors in general hospital patients.

OBJECTIVES: More than 60% of general hospital patients report ≥ 2 health risk behaviors (HRBs), i.e. tobacco smoking, at-risk alcohol use, unhealthy diet, and/or insufficient physical activity. This study investigates a) the association between numbers of HRBs and motivation to change, b) patient preferences for receiving feedback on HRBs, and c) patients' expected gain in quality of life if behavior change made. METHODS: In 2020/2021, 256 18-64-year-old general hospital patients (72.1% of eligibles) reported on their motivation to change each of their HRBs. Associations between HRB number and motivation were assessed using multivariate linear regressions. Participants ranked HRBs concerning their interest in receiving feedback and concerning their expected gain in quality of life if behavior change occurred. RESULTS: Higher HRB number was negatively related to motivation among at-risk alcohol users (p = 0.034); 24.6% expected gain in their quality of life from behavior change. Participants overall appeared more favorable to feedback about vegetable/fruit intake and physical activity. CONCLUSIONS: Unhealthier lifestyle may be accompanied by decreased motivation to change in at-risk alcohol users. In case of co-occurring HRBs, asking patients for expected gain in quality of life may help guiding intervention target. PRACTICE IMPLICATIONS: Relying on patient selection only, may often leave substance-use unaddressed.

Association between Alcohol Consumption and Health-Related Quality of Life among Hospital and Ambulatory Care Patients with Past Year Depressive Symptoms.

BACKGROUND: Little is known about how substance use affects health-related quality of life (HRQOL) in depressed individuals. Here, associations between alcohol consumption and HRQOL in hospital and ambulatory care patients with past-year depressive symptoms are analyzed. METHOD: The sample consisted of 590 participants (26.8% non-drinkers) recruited via consecutive screenings. Individuals with alcohol use disorders were excluded. HRQOL was assessed with the Veterans Rand 12-item health survey (VR-12). Multivariable fractional polynomials (MFP) regression analyses were conducted (1) to test for non-linear associations between average daily consumption and HRQOL and (2) to analyze associations between alcohol consumption and the physical and mental health component summaries of the VR-12 and their subdomains. RESULTS: Alcohol consumption was positively associated with the physical health component summary of the VR-12 (p = 0.001) and its subdomains general health (p = 0.006), physical functioning (p < 0.001), and bodily pain (p = 0.017), but not with the mental health component summary (p = 0.941) or any of its subdomains. Average daily alcohol consumption was not associated with HRQOL. CONCLUSION: Alcohol consumption was associated with better physical HRQOL. Findings do not justify ascribing alcohol positive effects on HRQOL. Data indicate that non-drinkers may suffer from serious health disorders. The results of this study can inform the development of future alcohol- and depression-related interventions.

Proactive automatised lifestyle intervention (PAL) in general hospital patients: study protocol of a single-group trial.

INTRODUCTION: The co-occurrence of health risk behaviours (HRBs, ie, tobacco smoking, at-risk alcohol use, insufficient physical activity and unhealthy diet) increases the risks of cancer, other chronic diseases and mortality more than additively; and applies to more than half of adult general populations. However, preventive measures that target all four HRBs and that reach the majority of the target populations, particularly those persons most in need and hard to reach are scarce. Electronic interventions may help to efficiently address multiple HRBs in healthcare patients. The aim is to investigate the acceptance of a proactive and brief electronic multiple behaviour change intervention among general hospital patients with regard to reach, retention, equity in reach and retention, satisfaction and changes in behaviour change motivation, HRBs and health. METHODS AND ANALYSIS: A pre-post intervention study with four time points is conducted at a general hospital in Germany. All patients, aged 18-64 years, admitted to participating wards of five medical departments (internal medicine A and B, general surgery, trauma surgery, ear, nose and throat medicine) are systematically approached and invited to participate. Based on behaviour change theory and individual HRB profile, 175 participants receive individualised and motivation-enhancing computer-generated feedback at months 0, 1 and 3. Intervention reach and retention are determined by the proportion of participants among eligible patients and of participants who continue participation, respectively. Equity in reach and retention are measured with regard to school education and other sociodemographics. To investigate satisfaction with the intervention and subsequent changes, a 6-month follow-up is conducted. Descriptive statistics, multivariate regressions and latent growth modelling are applied. ETHICS AND DISSEMINATION: The local ethics commission and data safety appointee approved the study procedures. Results will be disseminated via publication in international scientific journals and presentations on scientific conferences. TRIAL REGISTRATION NUMBER: NCT05365269.

The Role of Tobacco Smoking in the Efficacy of Brief Alcohol Intervention: Results from a Randomized Controlled Trial.

This study investigated whether tobacco smoking affected outcomes of brief alcohol interventions (BAIs) in at-risk alcohol-drinking general hospital patients. Between 2011 and 2012 among patients aged 18−64 years, 961 patients were allocated to in-person counseling (PE), computer-based BAI containing computer-generated individual feedback letters (CO), and assessment only. PE and CO included contacts at baseline, 1, and 3 months. After 6, 12, 18, and 24 months, self-reported reduction of alcohol use per day was assessed as an outcome. By using latent growth curve models, self-reported smoking status, and number of cigarettes per day were tested as moderators. In PE and CO, alcohol use was reduced independently of smoking status (IRRs ≤ 0.61, ps < 0.005). At month 24, neither smoking status nor number of cigarettes per day moderated the efficacy of PE (IRR = 0.69, ps > 0.05) and CO (IRR = 0.85, ps > 0.05). Up to month 12, among persons smoking ≤ 19 cigarettes per day, the efficacy of CO increased with an increasing number of cigarettes (ps < 0.05). After 24 months, the efficacy of PE and CO that have been shown to reduce drinking did not differ by smoking status or number of cigarettes per day. Findings indicate that efficacy may differ by the number of cigarettes in the short term.

Longitudinal measurement invariance of the patient health questionnaire in a German sample.

BACKGROUND: The Patient Health Questionnaire-8 (PHQ-8) is a screening questionnaire of depressive symptoms. However, it is unknown whether it is equivalent across time and between groups of individuals. The aim of our paper was to test whether the PHQ-8 has the same meaning in two groups of individuals over time. METHODS: Primary care patients were proactively recruited from three German cities. PHQ-8 data from a baseline assessment (n = 588), two assessments during the intervention (n = 246/225), and a six (n = 437) and 12 months (n = 447) follow-up assessment were first used to examine the factor structure of the PHQ-8 by confirmatory factor analysis (CFA). The best fitting factor solution was then used to test longitudinal invariance across time and between intervention and control group by Multiple Group CFA. RESULTS: A two-factor structure consistently showed the best model fit. Only configural longitudinal invariance was evidenced when the baseline assessment was included in the analysis. Without the baseline assessment, strict longitudinal invariance was shown across the intervention and the follow-up assessments. Scalar invariance was established between the intervention and control group for the baseline assessment and strict invariance between groups and across the 6- and 12-month follow-up assessments. CONCLUSIONS: The lack of longitudinal invariance might be attributed to various differences between the baseline assessments and all following assessments, e.g., assessment mode (iPad vs telephone), potential changes in symptom perception, and setting. TRIAL REGISTRATION: DRKS0001163 5, date of trial registration: 20.01.2017; DRKS00011637 , date of trial registration: 25.01.2017.

Latent alcohol use patterns and their link to depressive symptomatology in medical care patients.

AIMS: To investigate latent patterns of alcohol use and bingeing by gender and their association with depressive symptom severity and individual depressive symptoms. DESIGN: Cross-sectional data were collected from January 2017 to March 2018 as part of a joint screening recruiting for different intervention studies. SETTING: Ambulatory practices and general hospitals from three sites in Germany. PARTICIPANTS: A total of 5208 male and 5469 female proactively recruited alcohol users aged 18-64 years. MEASUREMENTS: Frequency and typical quantity of alcohol use, frequency of bingeing, alcohol-related problems (assessed by the Alcohol Use Disorder Identification Test); depressive symptom severity, individual depressive symptoms (assessed with the Patient Health Questionnaire-8); and socio-demographics and health-related variables. FINDINGS: Latent categorical analysis identified six patterns of alcohol use, with the majority of patients engaging in 'light use plus no or occasional bingeing' (males: 41.85%; females: 64.04%), followed by 'regular use plus occasional bingeing' (males: 34.03%; females: 16.17%). Multinomial logistic regression analyses (three-step approach with correction for classification uncertainty, as implemented in the Mplus R3STEP command) controlling for socio-demographics and health-related variables revealed that severity of depressive symptoms was positively associated with 'frequent use plus frequent bingeing' when compared with 'light use plus no or occasional bingeing' [relative risk ratio (RRR)male  = 1.07, 95% confidence interval (CI) = 1.03-1.11; RRRfemale  = 1.09, 95% CI = 1.04-1.14]. Severity of depressive symptoms was negatively associated with 'regular use plus occasional bingeing' for males (RRRmale  = 0.98, 95% CI = 0.95-1.00) and positively with 'occasional use plus occasional bingeing' for females (RRRfemale  = 1.03, 95% CI = 1.01-1.05) when compared with 'light use plus no or occasional bingeing'. Individual depressive symptoms were differentially associated with alcohol use patterns, with depressed mood, poor appetite or overeating, feelings of worthlessness or guilt and psychomotor agitation or retardation, being especially pronounced in the 'frequent use plus frequent bingeing' class (RRRsmale  = 1.72-2.36; RRRsfemale  = 1.99-2.17). CONCLUSIONS: Patterns of 'frequent alcohol use plus frequent bingeing' and 'occasional alcohol use plus occasional bingeing' appear to have positive associations with depression when compared with 'light alcohol use plus no or occasional bingeing'.

Copattern of depression and alcohol use in medical care patients: cross-sectional study in Germany.

OBJECTIVE: To predict depressive symptom severity and presence of major depression along the full alcohol use continuum. DESIGN: Cross-sectional study. SETTING: Ambulatory practices and general hospitals from three sites in Germany. PARTICIPANTS: Consecutive patients aged 18-64 years were proactively approached for an anonymous health screening (participation rate=87%, N=12 828). Four continuous alcohol use measures were derived from an expanded Alcohol Use Disorder Identification Test (AUDIT): alcohol consumption in grams per day and occasion, excessive consumption in days per months and the AUDIT sum score. Depressive symptoms were assessed for the worst 2-week period in the last 12 months using the Patient Health Questionnaire (PHQ-8). Negative binomial and logistic regression analyses were used to predict depressive symptom severity (PHQ-8 sum score) and presence of major depression (PHQ-8 sum score≥10) by the alcohol use measures. RESULTS: Analyses revealed that depressive symptom severity and presence of major depression were significantly predicted by all alcohol use measures after controlling for sociodemographics and health behaviours (p<0.05). The relationships were curvilinear: lowest depressive symptom severity and odds of major depression were found for alcohol consumptions of 1.1 g/day, 10.5 g/occasion, 1 excessive consumption day/month, and those with an AUDIT score of 2. Higher depressive symptom severity and odds of major depression were found for both abstinence from and higher levels of alcohol consumption. Interaction analyses revealed steeper risk increases in women and younger individuals for most alcohol use measures. CONCLUSION: Findings indicate that alcohol use and depression in medical care patients are associated in a curvilinear manner and that moderation by gender and age is present.

Feasibility and Acceptability of an Intervention Providing Computer-Generated Tailored Feedback to Target Alcohol Consumption and Depressive Symptoms in Proactively Recruited Health Care Patients and Reactively Recruited Media Volunteers: Results of a Pilot Study.

BACKGROUND: A pre-post pilot study was conducted to test the feasibility, acceptability, and potential effectiveness of a fully automatized computer-based intervention targeting hazardous drinking and depressiveness in proactively recruited health care patients (HCPs). To address the importance of the sample selection when testing interventions, HCPs were compared to media recruited volunteers (MVs). METHOD: In a multicenter screening program 2,773 HCPs were screened for hazardous drinking and depressive symptoms. MVs were recruited via media solicitation. Over a period of 6 months, study participants received 6 individualized counseling letters and weekly short messages. Pre-post data were analyzed for 30 participants (15 HCPs, 15 MVs). Intervention acceptability was assessed in post-intervention interviews conducted with 32 study participants. RESULTS: MVs showed higher problem severity and motivation to change than HCPs. Over the course of the intervention both subsamples reduced regular binge drinking (HCPs: p = 0.016; MVs: p = 0.031) and depressiveness (HCPs: p = 0.020; MVs: p < 0.001). MVs further reduced average daily alcohol consumption (p = 0.034). The intervention received positive ratings from both subsamples, the alcohol module was rated more favorably by MVs than by HCPs (p = 0.012). Subsamples further differed in terms of intervention usage (p = 0.013). CONCLUSION: The intervention was technically and logistically feasible, well accepted, and may have the potential to reduce hazardous drinking and depressive symptoms in different populations. Subsamples differed in terms of problem severity, motivation to change, intervention usage, pre-post changes, and attitudes toward the intervention, showing that intervention development should involve the intended target populations to avoid biased conclusions on intervention effectiveness and acceptability.

Proactive multipurpose health risk screening in health care settings: Methods, design, and reach.

OBJECTIVES: Real world implementation of proactive screening and brief intervention in health care is threatened by high cost. Using e-health interventions and screening for multiple health risk factors may provide more efficiency. We describe methodological details of a proactive multipurpose health risk screening in health care settings and report on participation rates, participants' characteristics, and participation factors. METHODS: Patients between 18 and 64 years from ambulatory practices and hospitals were proactively approached by study assistants at three sites for a computerized screening on harmful alcohol and tobacco consumption, depressive symptoms, insufficient fruit/vegetable consumption, physical inactivity and overweight. On the basis of their health risk pattern, a computerized algorithm allocated patients to one of five studies each of them addressing a psychiatric research question. RESULTS: Among all eligible patients, 13,763 (86.5%) were screened. Younger age and being female predicted screening participation. Of those with complete data (n = 12,828), 82.9% reported at least two health risks and 34.0% were eligible for a study. Study participation ranged between 35.2% and 50.8%, and was associated with socio-demographics and problem severity. CONCLUSIONS: This study supports the use of systematic proactive screening for multiple health risks in health care settings as it is more resource-saving than single focused screening.

Measurement invariance of the alcohol use disorders identification test: Establishing its factor structure in different settings and across gender.

INTRODUCTION: The Alcohol Use Disorders Identification Test (AUDIT) is an internationally well-established screening tool for the assessment of hazardous and harmful alcohol consumption. To be valid for group comparisons, the AUDIT should measure the same latent construct with the same structure across groups. This is determined by measurement invariance. So far, measurement invariance of the AUDIT has rarely been investigated. We analyzed measurement invariance across gender and samples from different settings (i.e., inpatients from general hospital, patients from general medical practices, general population). METHODS: A sample of n = 28,345 participants from general hospitals, general medical practices and the general population was provided from six studies. First, we used Confirmatory Factor Analysis (CFA) to establish the factorial structure of the AUDIT by comparing a single-factor model to a two-factor model for each group. Next, Multiple Group CFA was used to investigate measurement invariance. RESULTS: The two-factor structure was shown to be preferable for all groups. Furthermore, strict measurement invariance was established across all groups for the AUDIT. CONCLUSION: A two-factor structure for the AUDIT is preferred. Nevertheless, the one-factor structure also showed a good fit to the data. The findings support the AUDIT as a psychometrically valid and reliable screening instrument.

Explaining the relation between pathological gambling and depression: Rumination as an underlying common cause.

Background and aims Symptoms of pathological gambling (SPG) and depression often co-occur. The nature of this relationship remains unclear. Rumination, which is well known to be associated with depression, might act as a common underlying factor explaining the frequent co-occurrence of both conditions. The aim of this study is to analyze associations between the rumination subfactors brooding and reflection and SPG. Methods Participants aged 14-64 years were recruited within an epidemiological study on pathological gambling in Germany. Cross-sectional data of 506 (80.4% male) individuals with a history of gambling problems were analyzed. The assessment included a standardized clinical interview. To examine the effects of rumination across different levels of problem gambling severity, sequential quantile regression was used to analyze the association between the rumination subfactors and SPG. Results Brooding (p = .005) was positively associated with the severity of problem gambling after adjusting for reflection, depressive symptoms, and sociodemographic variables. Along the distribution of problem gambling severity, findings hold for all but the lowest severity level. Reflection (p = .347) was not associated with the severity of problem gambling at the median. Along the distribution of problem gambling severity, there was an inverse association at only one quantile. Discussion and conclusions Brooding might be important in the development and maintenance of problem gambling. With its relations to depression and problem gambling, it might be crucial when it comes to explaining the high comorbidity rates between SPG and depression. The role of reflection in SPG remains inconclusive.

XENOTRANSFUSION IN AN ISLAND FOX (UROCYON LITTORALIS CLEMENTAE) USING BLOOD FROM A DOMESTIC DOG (CANIS LUPUS FAMILIARIS).

Successful xenotransfusion in an island fox ( Urocyon littoralis clementae) has not been previously reported but may be necessary in an emergency. An 11-yr-old male, intact, captive island fox was exhibiting clinical signs of rattlesnake envenomation including hypoperfusion, tachypnea, facial edema, and multifocal facial and cervical ecchymosis. Blood work revealed severe thrombocytopenia (18 K/µl) and anemia (Hct 15.8%). A presumptive diagnosis of rattlesnake ( Crotalus sp.) envenomation was made. Initial treatment included oxygen therapy, fluid therapy, antibiotics, antacids, pain medications, and polyvalent crotalid anti-venom. Emergency xenotransfusion using whole blood (45 ml) from a domestic dog was used due to worsening clinical signs from anemia. No acute or delayed transfusion reactions were observed in the fox and the patient made a full recovery 5 days later. Successful xenotransfusion in an island fox using whole blood from a domestic dog ( Canis lupus familiaris) is possible and may be lifesaving.

MYCOBACTERIUM GENAVENSE IN AN AFRICAN PENGUIN (SPHENISCUS DEMERSUS).

A 19-yr-old female African penguin (Spheniscus demersus) presented with labored breathing and anorexia. Radiographs revealed soft-tissue density lesions in the left lung fields and fluid in the right. The penguin died during the night. Postmortem examination demonstrated multiple granulomas in the lungs and air sacs. The right coelom was filled with opaque fluid. Histopathology of the lung, liver, kidney, and spleen identified Mycobacterium as a primary disease etiology. Large numbers of acid fast-positive, rod-shaped bacteria were recognized on tissue staining. Mycobacterium genavense was detected by polymerase chain reaction (PCR) using primers specific for the species. Further confirmation of M. genavense was accomplished using PCR with universal Mycobacterium spp. primers followed by sequencing of the amplicon obtained. To our knowledge, this is the first reported case of mycobacteriosis-and specifically M. genavense -in an African penguin. This case also demonstrates the similarities of presentation between the more commonly suspected and encountered aspergillosis and mycobacteriosis.