Multisite formative assessment for the Pathways study to prevent obesity in American Indian schoolchildren

We describe the formative assessment process, using an approach based on social learning theory, for the development of a school-based obesity-prevention intervention into which cultural perspectives are integrated. The feasibility phase of the Pathways study was conducted in multiple settings in 6 American Indian nations. The Pathways formative assessment collected both qualitative and quantitative data. The qualitative data identified key social and environmental issues and enabled local people to express their own needs and views. The quantitative, structured data permitted comparison across sites. Both types of data were integrated by using a conceptual and procedural model. The formative assessment results were used to identify and rank the behavioral risk factors that were to become the focus of the Pathways intervention and to provide guidance on developing common intervention strategies that would be culturally appropriate and acceptable to all sites.

Pathways: a culturally appropriate obesity-prevention program for American Indian schoolchildren

Pathways, a culturally appropriate obesity prevention study for third-, fourth-, and fifth-grade American Indian schoolchildren includes an intervention that promotes increased physical activity and healthful eating behaviors. The Pathways intervention, developed through a collaboration of universities and American Indian nations, schools, and families, focuses on individual, behavioral, and environmental factors and merges constructs from social learning theory with American Indian customs and practices. We describe the Pathways program developed during 3 y of feasibility testing in American Indian schools, with special emphasis on the activities developed for the third grade; review the theoretical and cultural underpinnings of the program; outline the construction process of the intervention; detail the curriculum and physical education components of the intervention; and summarize the formative assessment and the school food service and family components of the intervention.

Preventive health care among rural American Indians in New Mexico

BACKGROUND

Incidence of and mortality from cardiovascular disease, cancer, diabetes, and other chronic diseases are rapidly increasing among American Indians; however, the utilization of preventive services for these conditions is not well characterized in these ethnic groups.

METHODS

We interviewed 1,273 American Indian adults in New Mexico, ages 18 years and older, by telephone regarding routine health checks, including blood pressure, blood cholesterol, mammograms, clinical breast exams, Pap smears, influenza and pneumonia vaccinations, and diabetes using items from the CDC Behavioral Risk Factor Surveillance System.

RESULTS

We found that utilization of preventive service was surprisingly high among rural American Indians. Routine health checks and blood pressure checks within the past year were reported by more than 70% of the population. Blood cholesterol checks (41.1%) and pneumonia vaccinations (30.7%) were less commonly reported. Utilization of cancer screening for the most common women's cancers was also high. Most women reported ever having a Pap smear test (88.3%), a clinical breast examination (79.5%), and a mammogram (75.6%). The prevalence of diagnosed diabetes (8.8% overall and 26.4% for ages 50 years and older) greatly exceeds the nationwide prevalence.

CONCLUSIONS

The utilization of preventive services delivered by a unique governmental partnership is high among American Indians in New Mexico and, except for cholesterol screening, is comparable with rates for the U.S. population. Because cardiovascular disease is on the rise, more attention to preventive services in this arena is warranted. The high and increasing prevalence of diagnosed diabetes suggests that aggressive diabetes screening and interventions are needed.

Limiting neurological damage after stroke: a review of pharmacological treatment options

Acute ischaemic stroke is a leading cause of death and a major cause of long term disability worldwide. Effective treatments for limiting the neurological damage after stroke have proven elusive. An improved understanding of the complicated cascade of cellular events following the onset of cerebral ischaemia has led to exploration of a number of avenues for early intervention. Reperfusion of the ischaemic territory using thrombolytic drugs has shown promise in clinical trials as a method for achieving tissue salvage. Antithrombotic and antiplatelet agents have not demonstrated efficacy as acute therapies, although the early use of aspirin (acetylsalicylic acid) appears to produce a reduction in early stroke recurrence. A wide variety of drugs which interfere at various points in the ischaemic cascade, so-called 'neuroprotective agents', have also been studied, but with mixed success. Of these, antagonists of voltage-gated calcium channels, antagonists at the N-methyl-D-aspartate (NMDA) receptor and scavengers of free radicals have been most extensively studied. Despite proving effective in animal models of cerebral ischaemia, these drugs have largely failed to fulfil their promise in clinical trials. While individual compounds have proven ineffective, combinations of drugs with different mechanisms of action may yet provide the best treatment for acute ischaemic stroke.

Spontaneous reperfusion after ischemic stroke is associated with improved outcome

BACKGROUND AND PURPOSE

The rationale behind thrombolytic therapy in acute ischemic stroke is penumbral salvage by rapid restoration of cerebral blood flow. The relationship, however, between early reperfusion (potentially composed of both nutritional and nonnutritional components) and outcome remains unclear.

METHODS

To establish the relationship between reperfusion parameters and outcome variables (Canadian Neurological Scale, Barthel Index, outcome CT scans), we used 99Tc-hexamethylpropyleneamine oxime (99Tc-HMPAO) single-photon emission CT (SPECT) to examine 41 acute ischemic stroke patients. All patients had at least 2 SPECT studies (24 with 3 studies), and none had been treated with thrombolytic or other acute investigational drugs.

RESULTS

A total of 106 studies were performed. Mean time to acute study was 9.2 hours; that for subacute study was 42 hours and for outcome study was 150 days. Hypoperfusion (HP) volumes at each of the 3 time points correlated with outcome clinical state and final infarct size. Both early reperfusion (61% of patients) and nutritional reperfusion alone (56%), which is early reperfusion maintained at outcome, were associated with improvement in clinical state and better functional outcome. Early HP volume change (acute minus subacute HP volume) and total HP volume change (acute minus outcome HP volume) also correlated with clinical improvement and better outcome.

CONCLUSIONS

This study establishes the benefit of spontaneous reperfusion after ischemic stroke and emphasizes the prognostic value of HP deficit volumes. 99Tc-HMPAO SPECT may be used to screen patients and group them according to perfusion deficit in acute stroke trials, thereby decreasing patient numbers required to show drug effect.

The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine

BACKGROUND

Chronic depression appears to be a common, frequently disabling illness that is often inadequately treated. Unlike episodic depressions with shorter illness duration, neither acute nor long-term treatment approaches for chronic depression have been well studied.

METHOD

635 outpatients at 12 sites who met DSM-III-R criteria for chronic major depression or double depression were randomly assigned to 12 weeks of double-blind treatment with either sertraline (in daily doses of 50-200 mg) or imipramine (in daily doses of 50-300 mg). Efficacy and safety were assessed either weekly or every 2 weeks during the 12 weeks of acute treatment.

RESULTS

Despite high rates of chronicity (mean duration of major depression = 8.9+/-9.1 years; mean duration of dysthymia = 23+/-13 years) and high rates of comorbidity, 52% of patients achieved a satisfactory therapeutic response to sertraline or imipramine (by a conservative, intent-to-treat analysis). Approximately 21% of the patients who had achieved a therapeutic response at week 12 had not done so at week 8, confirming the longer time to response in depressions with high chronicity. Patients treated with sertraline reported significantly fewer adverse events and were significantly less likely to discontinue treatment due to side effects than imipramine-treated patients (6.3% vs. 12.0%).

CONCLUSION

These results indicate that patients suffering from depression with high chronicity can achieve a good therapeutic response to acute treatment with either sertraline or imipramine, although sertraline is better tolerated.

The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine

BACKGROUND

Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported.

METHOD

We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples.

RESULTS

Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples.

CONCLUSION

These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression.

Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty

BACKGROUND AND PURPOSE

The use of percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease is now commonplace. The occurrence of microemboli during invasive procedures such as cardiac angiography and bypass surgery is well documented, although neurological complications are relatively uncommon. To date, no investigation has been undertaken of the frequency or nature of microemboli occurring during PTCA or of the correlation with aortic atheroma.

METHODS

Twenty patients having elective PTCA underwent examination by transcranial Doppler ultrasonography (TCD) to detect left middle cerebral artery microemboli occurring during the procedure. Blinded off-line analysis correlated microembolic signal counts on TCD with the components of each stage of the PTCA. Patients later underwent transesophageal (TEE) echocardiography, with measurements made of the thickness of the intima and atheroma in the ascending and descending thoracic aortic arch by cardiologists blinded to the TCD results.

RESULTS

A total of 973 microembolic signals were detected (mean+/-SD, 48.7+/-36.7 per patient); 196 (20%) occurred on movement of the PTCA catheter and wire around the aortic arch, 84 (9%) with other PTCA catheter-associated movements, and 679 (70%) in association with injection of solutions (eg, saline and contrast). Mean signal counts during contrast injection were significantly greater than during the other 3 phases (P<0.001). No neurological events occurred in the study. Although not statistically significant, there was a trend toward greater microembolic signal counts with the number of times the catheter was passed around the aortic arch and the amount of arch atheroma detected by transesophageal echocardiography.

CONCLUSIONS

Microemboli detected on TCD are a common occurrence during PTCA but are largely asymptomatic. The majority of microembolic signals are most probably gaseous in origin and do not appear to be related to the extent of aortic atheroma or to clinical events.

Methodological advances and plans for improving regulatory success for confirmatory studies

Regulatory success for new medical products requires convincing statistical results from planned analyses for relevant and reliable data from well-designed clinical studies. Statistical methodology has a critical role for such success through strengthening the robustness of study findings to sources of bias, variability and spurious events. Areas of particular importance for statistical methodology include the structure for study design, the schedule and procedures for data collection, and plans for primary data analyses. This paper discusses some challenging statistical issues for these areas and suggests potential strategies for addressing them. The objective of these strategies as well as other methodological advances is the minimization of ambiguity in the findings of confirmatory studies. In this way, their effective use can enhance regulatory success.

Prediction of stroke outcome with echoplanar perfusion- and diffusion-weighted MRI

OBJECTIVES

We examined the utility of echoplanar magnetic resonance perfusion imaging and diffusion-weighted imaging (DWI) in predicting stroke evolution and outcome in 18 patients with acute hemispheric infarction.

METHODS

Patients were studied within 24 hours (mean, 12.2 hours), subacutely (mean, 4.7 days), and at outcome (mean, 84 days). Comparisons were made between infarction volumes as measured on perfusion imaging (PI) and isotropic DWI maps, clinical assessment scales (Canadian Neurological Scale, Barthel Index, and Rankin Scale), and final infarct volume (T2-weighted MRI).

RESULTS

Acute PI lesion volumes correlated with acute neurologic state, clinical outcome, and final infarct volume. Acute DWI lesions correlated less robustly with acute neurologic state, but correlated well with clinical outcome and final infarct volume. Three of six possible patterns of abnormalities were seen: PI lesion larger than DWI lesion (65%), PI lesion smaller than DWI lesion (12%), and DWI lesion but no PI lesion (23%). A pattern of a PI lesion larger than the DWI lesion predicted DWI expansion into surrounding hypoperfused tissue (p < 0.05). In the other two patterns, DWI lesions did not enlarge, suggesting that no significant increase in ischemic lesion size occurs in the absence of a larger perfusion deficit.

CONCLUSIONS

Combined early PI and DWI can define different acute infarct patterns, which may allow the selection of rational therapeutic strategies based on the presence or absence of potentially salvageable ischemic tissue.

Health-related quality of life for rural American Indians in New Mexico

OBJECTIVES

To determine health-related quality of life for rural American Indians using an economical telephone surveillance system.

DESIGN

We interviewed 618 American Indians by telephone about health-related quality of life using an adaptation of the Behavioral Risk Factor Surveillance System questionnaire.

RESULTS

A smaller proportion of rural New Mexico American Indians (50.7%) reported their general health as 'excellent' or 'very good' compared to the overall New Mexico (58.2%) and US populations (57.9%). American Indians reported a mental health limitation more frequently than the New Mexico and the US populations. However, 13% fewer rural New Mexico American Indians reported a limitation in usual activities. Most limitations were due to musculoskeletal conditions or diabetes mellitus. Survey respondents were found to be representative of the rural American Indian population as reported by the 1990 US Census Bureau by tribal group affiliation and age, but were not representative by income, education, and gender.

CONCLUSIONS

Health-related quality of life for rural American Indians differs little from that of other New Mexicans and the general US population; however, when physical and mental health was rated as poor, fewer American Indians reported a limitation in usual activities. A telephone survey focusing on New Mexico American Indians is an efficient method by which to conduct surveillance of health-related quality of life.

MSQ: Migraine-Specific Quality-of-Life Questionnaire. Further investigation of the factor structure

MSQ, the 16-item Migraine-Specific Quality-of-Life Questionnaire (Version 1.0), was developed by Glaxo Wellcome Inc. to assess the effect of migraine and its treatment on patients' health-related quality of life (HR-QOL). The MSQ was hypothesised to measure 3 meaningful dimensions: (i) Role Function-Restrictive; (ii) Role Function-Preventive; and (iii) Emotional Function. The objective of this research was to further investigate the number of dimensions as well as the items contained in each dimension through principal components factor analysis of clinical trial data. Secondary objectives were to determine whether the factor structure changed in post-treatment visits compared with screening visits, to make recommendations for coding the MSQ when the patient did not have a migraine in the previous 4 weeks, and to modify the MSQ if so indicated by this research. Results supported the existence of 3 distinct factors which agreed strongly with the hypothesised dimensions. The analysis of post-treatment data suggested that the underlying factor structure of the MSQ varies as a result of treatment. Based on evaluations of the 'did not have a migraine' response, it was concluded that it be dropped from the MSQ. All these changes have been incorporated into MSQ (Version 2.0) which is being evaluated in studies to determine if its psychometric properties are different than the properties of the previous version.

Non-ceremonial tobacco use among southwestern rural American Indians: the New Mexico American Indian Behavioural Risk Factor Survey

OBJECTIVES

To ascertain non-ceremonial tobacco use among rural American Indians in New Mexico (United States).

DESIGN

A geographically targeted telephone survey.

SETTING

Rural New Mexico.

PARTICIPANTS

American Indian residents aged 18 years and older.

MAIN OUTCOME MEASURES

Prevalence of ever-smokers and current smokers of cigarettes and ever-users and current users of smokeless tobacco, number of cigarettes smoked, and prevalence of cigarette smoking quitting behaviour.

RESULTS

Of the 1266 respondents, 38.5% (95% confidence interval (CI) = 34.5% to 42.1%) reported ever smoking, and 16.3% (95% CI = 13.5% to 19.0%) reported being current smokers. Current smokers averaged 7.6 (95% CI = 6.0 to 9.3) cigarettes per day. Current smoking prevalence was highest among men and lowest among college graduates. Prevalence of smokeless tobacco use was 24.1% for ever-use and 7.2% for current use and showed a strong male predominance of use.

CONCLUSIONS

The prevalence of current smokers among rural American Indians in New Mexico was lower than among American Indians of other regions in the United States, all New Mexicans, and the national population as a whole. Although smoking prevalence was lower among American Indians in New Mexico, variation by sex and education followed the same patterns as reported among American Indians of other regions.

Adaptation of the Dartmouth COOP Charts for use among American Indian people with diabetes

OBJECTIVE

To adapt the Dartmouth COOP Charts for use among American Indians with diabetes and to evaluate the operating characteristics of the adapted charts because measures of health status have not been evaluated for use among American Indians with diabetes.

RESEARCH DESIGN AND METHODS

American Indian adults participated in focus group conferences to adapt and review the Dartmouth COOP Charts for use in American Indian communities. American Indian participants with diabetes were interviewed and administered the adapted charts. The operating characteristics of the charts were evaluated by measuring internal and external consistency, reliability, and acceptability.

RESULTS

Some of the wording and pictures were considered to be offensive and culturally inappropriate in American Indian communities. The adapted charts showed internal consistency in a comparison of interchart variables.

CONCLUSIONS

The adapted Dartmouth COOP Charts are more culturally acceptable than the original charts and appear to measure constructs adequately.

Streptokinase in acute stroke: effect on reperfusion and recanalization. Australian Streptokinase Trial Study Group

The Australian Streptokinase Trial was a randomized, double-blind, placebo-controlled trial, in which streptokinase (SK, 1.5 million IU I.V.) was given within 4 hours of stroke onset. In a subset of 37 patients, 99mTc-labeled D,L-hexamethylpropylene amine oxime single-photon emission computed tomography (SPECT) and/or transcranial Doppler (TCD) studies were performed before and after therapy to test the hypothesis that SK may improve the hemodynamic measures of reperfusion/recanalization rates (TCD parameter) within 24 hours. Eighteen patients received SK and 19 placebo. Baseline characteristics were similar in both groups, and there were no differences in clinical outcomes assessed at 3 months after stroke. Although there was no increase in the group mean perfusion defect or volume on SPECT after thrombolytic therapy, a larger number of patients demonstrating the combined end point of reperfusion or recanalization was seen in the SK group (13/14, 93%) than in the placebo group (7/14, 50%; p = 0.01). Although SK given within 4 hours of acute ischemic stroke appears to improve arterial patency/tissue reperfusion, this effect is neither early nor extensive enough to influence overall clinical outcome.

Risk factors for stroke due to cerebral infarction in young adults

BACKGROUND AND PURPOSE

Stroke in the young is particularly tragic because of the potential for a lifetime of disablement. More than 10% of patients with stroke due to cerebral infarction are aged 55 years or younger. While a number of studies have addressed the issue of stroke mechanism in the young, quantitation of risk factors has rarely been undertaken. Given the importance of risk factor assessment in primary prevention, we aimed to assess this using case-control methodology in a hospital-based series and community-based control subjects.

METHODS

A total of 201 consecutive patients with first-onset stroke due to cerebral infarction aged 15 to 55 years (mean, 45.5 years) were accrued from four teaching hospitals during 1985 to 1992 and compared with their age- and sex-matched neighborhood controls. Information concerning potential risk factor exposure status was collected by structured questionnaire at interview. Stroke risks were estimated by calculating the odds ratios with multivariate logistic regression.

RESULTS

Significantly increased risk of stroke was found among those with diabetes (odds ratio, 11.6 [95% confidence intervals, 1.2 to 115.2]), hypertension (6.8 [3.3 to 13.9]), heart disease (2.7 [1.1 to 6.4]), current cigarette smoking (2.5 [1.3, 5.0]), and long-term heavy alcohol consumption (> or = 60 g/d) (15.3 [1.0 to 232.0]). However, heavy alcohol ingestion (> or = 60 g) within 24 hours preceding stroke onset was not a risk factor (0.9 [0.3 to 3.4]).

CONCLUSIONS

Diabetes, hypertension, heart disease, current smoking, and long-term heavy alcohol consumption are major risk factors for stroke in young adults. Given that the majority of these factors are either correctable or modifiable, prevention strategies may have the potential to reduce the impact of stroke in this age group.

Volumetric analysis of cerebral hypoperfusion on SPECT: validation and reliability

A method of volumetric analysis of hypoperfusion on 99mTc-labeled hexamethylpropylene amine oxime SPECT has been developed. This analysis integrates both the size and severity of perfusion reduction, yielding an equivalent volume of cortical tissue having zero blood flow, or the effective hypoperfusion volume. This study aimed to validate the methodology in vitro using the Hoffman brain phantom and two different camera systems, to examine the relationship between spatial resolution and accuracy of volume measurement and to assess the interobserver variability in SPECT studies of stroke patients.

METHODS

Simulated cortical lesions of three different sizes were sequentially incorporated into the Hoffman brain phantom and imaged using both single- and triple-head camera systems. For each system and for each lesion size, successive acquisitions were performed using three progressively larger radii of camera rotation. The hypoperfusion volume for each study was measured three times by a blinded observer, and the percentage difference from the true lesion volume was then calculated. SPECT studies of 32 stroke patients were independently analyzed by two blinded observers.

RESULTS

At the smallest radii of rotation, mean (s.d.) percentage difference between observed and true volumes was 0.90% (4.80%) for the triple-head and 4.50% (11.58%) for the single-head system. The degree of overestimation was similar for both systems. Percentage overestimation was strongly associated with radius of rotation (B = 0.71 +/- 0.32, p = 0.04 for the triple-head system; B = 1.26 +/- 0.55, p = 0.03 for the single-head system) but not with lesion size. The mean difference between hypoperfusion volumes of stroke patients obtained by two observers was 0.045 (3.240) cm3, which was not significant.

CONCLUSION

This study has shown that this technique of volumetric analysis of regional hypoperfusion on SPECT is both highly accurate and reproducible between two different camera systems. The degree of overestimation chiefly relates to diminishing spatial resolution. Despite some element of subjectivity, the interobserver variability is negligible.

Lung volume reduction surgery at a community hospital: program development and outcomes

STUDY OBJECTIVES

Description of the development and results of a program in lung volume reduction surgery (LVRS) at a community hospital.

DESIGN

Prospective data collection.

SETTING

A 320-bed community hospital.

PATIENTS

Fifty-five patients consecutively discharged from the hospital following LVRS. The mean preoperative FEV1 averaged 28% (+/-8%) of predicted values, while the preoperative PaCO2 averaged 49 mm Hg (+/-11.5 mm Hg). Forty-eight patients completed a preoperative conditioning regimen and underwent the procedure on an elective basis. Seven patients underwent the procedure during a hospital admission for a COPD exacerbation. Eight patients required mechanical ventilation preoperatively, including three who had required long-term mechanical ventilatory support.

RESULTS

Three patients (5%) died in the hospital following surgery. One patient developed chronic ventilator dependence. All three of the patients who required long-term mechanical ventilation preoperatively were weaned from the ventilator and returned home. Follow-up pulmonary function testing is available for 42 patients 3 months after surgery, and for 20 patients 6 months after the operation. At 3 months, the mean FEV1 improved 0.19 L (p=0.0002), the mean improvement for FVC was 0.37 L (p=0.0001), and the mean drop in residual volume was 0.97 L (p=0.0001). Similar changes are seen at 6 months. Highly significant improvements were also seen in quality of life measurements and exercise performance. The benefits of surgical treatment of emphysema seemed similar in both elective and urgent groups.

CONCLUSIONS

LVRS can be done safely and effectively at a community hospital, with significant improvement in pulmonary function and quality of life.