Change in Objectively Measured Activity Levels Resulting from the EMPOWER Study Lifestyle Intervention

Purpose

To examine changes in physical activity (PA) during a behavioral weight-loss intervention and determine baseline factors associated with PA goal achievement.

Methods

Overweight/obese community-dwelling adults with valid PA accelerometer data (N=116; mean age 51.7 years; 89% female; 83% non-Hispanic White) were recruited into a single-arm prospective cohort study examining the effects of a 12-month intervention that included 24 in-person group sessions, weight-loss, calorie, fat gram, and PA goals, self-monitoring, and feedback. Minutes of moderate-to-vigorous (MV) PA and steps were measured using a waist-worn accelerometer (ActiGraph GT3x) at baseline, 6 months, and 12 months. Achievement of the 150 minute/week MVPA goal was examined using total minutes and bout minutes (i.e., counting only PA occurring in bouts ≥10 minutes in length). Change in PA was analyzed using non-parametric tests for multiple comparisons. Associations of factors with meeting the PA goal were modeled using binary logistic regression.

Results

At 6 months, there were increases from baseline in MVPA (median [p25, p75]: 5.3 [-0.9, 17.6] minutes/day) and steps (863 [-145, 2790] steps/day), both p<0.001. At 12 months, improvements were attenuated (MVPA: 2.4 [-2.0, 11.4] minutes/day, p=0.047; steps: 374[-570, 1804] p=0.14). At 6 months, 33.6% of individuals met the PA goal (using total or bout minutes). At 12 months, the percent meeting the goal using total MVPA [31%] differed from bout MVPA [22.4%]. Male gender (OR=4.14, p=0.027) and an autumn program start (versus winter; OR=3.39, p=0.011) were associated with greater odds of goal achievement at 6 months.

Conclusions

The intervention increased PA goal achievement at 6 and 12 months with many making clinically meaningful improvements. Our results suggest female participants may require extra support toward improving PA levels.

0686 Diabetes Sleep Treatment Trial: The Effect Of Treatment Of OSA With CPAP On Glycemic Control In Type 2 Diabetes

Introduction

Evidence remains unclear whether treatment of OSA with CPAP results in improved glycemic control. This study evaluated if CPAP improved glucose control compared to sham-CPAP and the effect of adherence to active CPAP on glucose control after 6 and 12 weeks of treatment.

Methods

This was a multi-center, double-blind clinical trial. Participants were adults with type 2 diabetes (T2D), A1C≥6.5%, apnea + hypopnea index (AHI)≥10, and naïve to CPAP. All participants received diabetes education. Glucose control was evaluated with frucostamine and A1C levels; CPAP adherence with a wireless modem system. Statistical analysis followed an “intent-to-treat” approach with linear mixed modeling. The dose of active CPAP was calculated as the percentage of days with active CPAP use≥4 hours and the average adherence of active CPAP with sham coded as “0”dose”.

Results

Randomized participants (N=98, CPAP=50; sham-CPAP=48) were primarily middle-aged (age=58.7±9.8 years), White (75%), males (57%) obese (BMI=36.2±6.6), suboptimal glucose control (A1C=7.9%±0.9) and OSA (AHI=23.9±14.4). There were no significant baseline differences except in A1C (Active CPAP=7.7%±0.8; sham-CPAP=8.1%±1.0). There was no significant difference in use of their devices at 6 or 12 weeks. Based on linear mixed modeling, participants on active CPAP had improved A1C (b (SE): -.76 (.24), P&lt;.01) and frucostamine (-21.8 (10.5), P=.04) at 6 weeks with A1C trending to significance at 12 weeks (p=0.10). Both the % of cumulative days of active CPAP usage (≥4 hours/day) (.002 (.003), P=.09) and cumulative hours of active CPAP use (.03 (.03), P=.08) showed a trend being associated with greater change in A1C but not in frucostamine (P=.61, P=.51). The rate of change in A1C varied by time, increasing the % of cumulative days of CPAP use (≥4 hours/day) at week 6 predicted greater change in A1C (.006 (.002), P=.01) than week 12 (.002 (.003), P=.38). Higher average hours of CPAP usage were associated with greater change in A1C (.08 (.03), P=.01) at week 6 compared to week 12 (.03 (.03), P=.47).

Conclusion

In our study, individuals with T2D and OSA, adherence to active CPAP use improved glycemic control over 6 weeks.

Support

NIDDK grant R01DK096028; CTRI grant UL1TR001857 and UL1TR000005.

Trajectories of self-care agency and associated factors in lung transplant recipients over the first 12 months following transplantation

Self-care agency (SCA), defined as one's ability and willingness to engage in self-care behaviors, can influence actual performance of self-care behaviors in lung transplant recipients (LTRs). Understanding patterns of SCA over time may inform the design of interventions to promote self-care in LTRs. Using group-based trajectory modeling, we sought to identify patterns and correlates of SCA among 94 LTRs over the first 12 months post-transplant. Baseline measures of sociodemographic, clinical, and psychosocial factors, and longitudinally assessed psychological distress were examined for their associations with predicted trajectory group membership. Three distinct stable (ie, zero slope) SCA trajectories were identified as follows: persistently low, persistently moderate, and persistently high. Based on the final multivariate model, requiring a re-intubation after transplant (P=.043), discharged to a facility rather than home (P=.048), and reporting a higher level of baseline anxiety (P=.001) were significantly associated with lower SCA. Linear mixed models revealed that higher levels of anxiety and depression were associated with lower SCA in the persistently moderate and low SCA groups over the 12-month time period (Ps<.05). LTRs who require a re-intubation after transplant and are discharged to a facility other than home, and report high psychological distress, may need additional assistance to engage in post-transplant self-care behaviors.

Patterns of self-weighing behavior and weight change in a weight loss trial

BACKGROUND/OBJECTIVES

Regular self-weighing has been associated with weight loss and maintenance in adults enrolled in a behavioral weight loss intervention; however, few studies have examined the patterns of adherence to a self-weighing protocol. The study aims were to (1) identify patterns of self-weighing behavior; and (2) examine adherence to energy intake and step goals and weight change by self-weighing patterns.

SUBJECTS/METHODS

This was a secondary analysis of self-monitoring and assessment weight data from a 12-month behavioral weight loss intervention study. Each participant was given a scale that was Wi-Fi-enabled and transmitted the date-stamped weight data to a central server. Group-based trajectory modeling was used to identify distinct classes of trajectories based on the number of days participants self-weighed over 51 weeks.

RESULTS

The sample (N=148) was 90.5% female, 81.1% non-Hispanic white, with a mean (s.d.) age of 51.3 (10.1) years, had completed an average of 16.4 (2.8) years of education and had mean body mass index of 34.1 (4.6) kg m(-2). Three patterns of self-weighing were identified: high/consistent (n=111, 75.0% self-weighed over 6 days per week regularly); moderate/declined (n=24, 16.2% declined from 4-5 to 2 days per week gradually); and minimal/declined (n=13, 8.8% declined from 5-6 to 0 days per week after week 33). The high/consistent group achieved greater weight loss than either the moderate/declined and minimal/declined groups at 6 months (-10.19%±5.78%, -5.45%±4.73% and -2.00%±4.58%) and 12 months (-9.90%±8.16%, -5.62%±6.28% and 0.65%±3.58%), respectively (P<0.001). The high/consistent group had a greater mean number days per week of adherence to calorie intake goal or step goal but not higher than the moderate/declined group.

CONCLUSIONS

This is the first study to reveal distinct temporal patterns of self-weighing behavior. The majority of participants were able to sustain a habit of daily self-weighing with regular self-weighing leading to weight loss and maintenance as well as adherence to energy intake and step goals.

Fish oil supplementation does not lower C-reactive protein or interleukin-6 levels in healthy adults

BACKGROUND

The n-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may prevent a range of chronic conditions through anti-inflammatory actions. However, as clinical trials using these fatty acids for primary prevention are yet unavailable, their putative role in disease prevention rests, in part, on evidence of anti-inflammatory actions in healthy individuals.

OBJECTIVE

To investigate in a double-blind, placebo-controlled clinical trial whether supplementation with a moderate dose of EPA+DHA reduces common biomarkers of chronic, systemic inflammation in healthy individuals.

METHODS

A total of 261 healthy individuals aged 30-54 years who were free of inflammatory conditions and consumed ≤ 300 mg per day EPA+DHA were included in the study. Participants were randomly assigned to 18 weeks of either fish oil supplementation providing 1400 mg per day EPA+DHA or matching placebo. Outcome measures were serum levels of C-reactive protein (CRP) and interleukin (IL)-6. In a substudy, ex vivo cytokine production was measured. Missing data for CRP and IL-6 were estimated using regression imputation. Data analyses conformed to intention-to-treat principles.

RESULTS

Participant blinding was verified. Red blood cell EPA+DHA increased by 64% in the active treatment group, but serum CRP and IL-6 were not affected by supplementation (P ≥ 0.20). Findings were consistent with and without imputed values and across subgroups. Similarly, EPA+DHA supplementation did not alter ex vivo production of four pro-inflammatory cytokines (P ≥ 0.20).

CONCLUSIONS

Supplementation with 1400 mg EPA+DHA did not reduce common markers of systemic inflammation in healthy adults. Whether this or a higher dose affects other measures of inflammation, oxidative stress or immune function warrants examination.

Experiences of Daily Weighing Among Successful Weight Loss Individuals During a 12-Month Weight Loss Study

The purpose of the study was to describe participants' experience of daily weighing and to explore factors influencing adherence to daily weighing among individuals who were successful in losing weight during a behavioral weight loss intervention. Participants completed a 12-month weight loss intervention study that included daily self-weighing using a Wi-Fi scale. Individuals were eligible to participate regardless of their frequency of self-weighing. The sample ( N = 30) was predominantly female (83.3%) and White (83.3%) with a mean age of 52.9 ± 8.0 years and mean body mass index of 33.8 ± 4.7 kg/m². Five main themes emerged: reasons for daily weighing (e.g., feel motivated, being in control), reasons for not weighing daily (e.g., interruption of routine), factors that facilitated weighing, recommendations for others about daily weighing, and suggestions for future weight loss programs. Our results identified several positive aspects to daily self-weighing, which can be used to promote adherence to this important weight loss strategy.

PD04-07: Cognitive Function and Reproductive Hormones in Women Receiving Anastrozole

Background: The effects of adjuvant hormonal therapy on hormone levels may contribute to deterioration in cognitive function experienced by women with breast cancer. Estrogen receptors are present throughout the central nervous system. Estrogen binding increases ChAT, synaptogenesis and dendritic spine density in the hippocampus and hypothalamus and decreases monoamine oxidase activity. Aromatase inhibitors, such as anastrozole, interrupt estrogen biosynthesis resulting in profound estrogen reductions. We studied whether changes in reproductive hormone levels mediate changes in cognitive function in 3 cohorts of postmenopausal women; women with breast cancer who receive chemotherapy+anastrozole (CA; n=41) or anastrozole only (AO; n=50)] and age and education matched healthy women (n=44).

Methods: We assessed cognitive function and reproductive hormones (E2, LH, FSH) before therapy and at 6, 12 and 18 months post-therapy initiation. A battery of neuropsychological measures was used to assess multiple cognitive domains. Using mixed effects modeling, we analyzed changes in hormone levels from pretreatment to 6, 12 and 18 months post-therapy initiation and then explored intercorrelations between changes in hormone levels and cognitive function at all timepoints.

Results: Women were an average 59.3 years of age with an average 14.9 years of education. No significant group-by-time effects were found for LH. However, we found significant group by time effects for E2 when comparing CA with controls (p=.0002) and AO with controls (p&lt;.0001) and for FSH when comparing AO with controls (p=.03). We found that E2 declined from pretreatment in the breast cancer groups as follows; CA [E2 declined from pretreatment to immediately post-chemotherapy (p = .09), and at 6 (p=.0002) and 12 (p=.014) months post anastrozole initiation, and AO [E2 declined from pretreatment to 6 (p&lt;.0001), 12 (p=.004) and 18 (p&lt;.0001) months post-anastrozole initiation]. We also found increases in FSH in the AO group from pretreatment to 6 (p=.002) and 12 (p=.05) months. No significant within-group changes for E2, FSH, or LH were observed for controls.

For the full sample, the intercorrelations revealed that reductions in E2 were related to poorer psychomotor efficiency from baseline to 18 months post-baseline (rs=.358, p=.02). For the AO group, reductions in E2 were related to poorer executive function (r=.600, p= 002) from 6 to 12 months post-anastrozole initiation and poorer psychomotor efficiency (r=.453, p=.07) from pretreatment to 18 months post-anastrozole initiation. For the CA group, reductions in E2 were marginally significantly related to poorer attention (r=.307, p=.08) from pretreatment to post-chemotherapy; and to poorer executive function from pretreatment to 6 months (r=.446, p=.06) and 12 months (r=.651, p=.03) post-anastrozole initiation. No significant relationships between changes in E2 levels and cognitive function were found in the controls.

Conclusions: Reductions in E2 may be related to cognitive deterioration in women with breast cancer. Further examination of these relationships is needed to confirm the results and determine whether these relationships persist through the remainder and after the conclusion of therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD04-07.

P4-12-12: Patient-, Illness-, and/or Treatment-Related Baseline Predictors of Nonadherence to Oral Hormonal Therapy

Background: Nonadherence to oral hormonal therapy is problematic for women with breast cancer. Patient-, illness-, and treatment-related factors have been associated with nonadherence, but with inconsistent findings. Therefore, our aim was to explore predictors of nonadherence to hormonal therapy for women with early stage breast cancer from the baseline assessment (pre-hormonal therapy) to 6 months post-treatment.

Methods: A secondary analysis was performed to explore potential patient-, illness-, and treatment-related predictors of nonadherence for 198 women enrolled in either: 1) The Anastrozole Use in Menopausal Women Study (AIM Study, n=162), or, 2) Predictors of Adherence to Hormonal Therapy in Breast Cancer (ONS Study, n=36). Nonadherence was defined as the percentage of prescribed administrations of hormonal therapy that were not taken during the first 6 months of therapy as measured using an electronic Drug Exposure Monitor (eDEM) (AARDEX, Ltd.). Chi-square tests of independence and Mann-Whitney U tests were performed to determine whether data from the two studies could be pooled. Descriptive statistics were performed to characterize the sample. Multiple linear regression analyses were performed to identify the best model in two stages: 1) univariate relationships between each candidate predictor variable and the outcome variable (6-month nonadherence) were assessed using a cut-off of p=.20; and, 2) candidate predictors meeting the criteria were retained for further exploration in model-building multiple linear regression analyses (stepwise and backward) to determine the predictors of 6-month nonadherence summary scores. Candidate predictors were retained in the model if they remained associated at p&lt;.10 in the multiple linear regression analysis.

Results: Women were 98.3% Caucasian with a mean age 59.1 years (SD 7.5) and mean number of years of education of 15.0 (SD 2.9). Overall mean nonadherence was 11.6% (13.2% AIM Study, 4.6% ONS Study). Chi-square and Mann-Whitney U tests demonstrated that the two samples could be pooled, given the data were similar on key variables (number of years of education, depression, anxiety, fatigue, symptoms, and nonadherence). Both stepwise and backward elimination modeling algorithms demonstrated evidence of 3 significantly significant variables associated with nonadherence; however, the backward elimination model best represented the sample (R2=.106, adjusted R2=.086, s=0.28490). Women who worked (p=.082), whose primary occupation was clerical or administrative (p=.029), had DCIS tumor type (p=.017), or who had higher gastrointestinal (GI) symptoms scores (p=.013) were associated with nonadherence. The potential for interactions between primary occupation, DCIS tumor type, and higher GI symptoms was explored and was not significant. In addition, while all tumor types were examined as candidate predictors, participants with DCIS also had another tumor to be eligible for the parent studies.

Conclusions: Our study offers insight into potential predictors of nonadherence for women participating in one of two cohort studies. The findings suggest additional examinations of nonadherence concerning work and symptom burden and their relationship to nonadherence are indicated.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-12.

P4-12-02: The Association of Anastrozole Adherence and Cognitive Function in Breast Cancer

Background: Women with breast cancer experience deterioration in cognitive function with adjuvant therapy. Little is known about whether declines in cognitive function are associated with nonadherence to oral hormonal therapy over time. We investigated anastrozole adherence over time and its association with cognitive function over the first 12 months of therapy in women with breast cancer.

Methods: Using a prospective cohort design, 169 women with early stage breast cancer were monitored for 12 months 1) continuously for their adherence to anastrozole using electronic event monitoring and 2) objectively for cognitive function via a neuropsychological battery every 6 months for the first 12 months of hormonal therapy. Adherence data were summarized monthly as to the number of doses taken as the percentage of prescribed doses taken and the timing of doses taken as the percentage of days with correct intake and the percentage of doses with correct timing. Six cognitive factors, derived via exploratory factor analysis applied to the neuropsychological battery, were used for analysis. Data were analyzed using descriptive and longitudinal methods.

Results: Participants were white (n=166, 98.2%), well-educated (Mean=15.1 years; SD=2.9, range=10-26) and on average 61.1 years of age (SD=5.9, range=46-75). Most had stage 1 breast cancer (n=123, 72.8%) and were prescribed anastrozole either alone (n=110, 65.1%) or immediately after chemotherapy (n=59, 34.9%). Initial levels of adherence were fairly high based on number of (Mean=89.1, SD=27.1, range=0-111.1) and timing of doses taken (Days with correct intake: Mean=86.4, SD=26.8, range=0-100; Doses with correct timing: Mean=83.6, SD=29.8, range=0-100); however, adherence decreased over the first 12 months of therapy (p&lt;.05) in terms of the number of and timing of doses taken and regardless of chemotherapy use. Specifically, we found a linear decrease for the percentage of prescribed doses taken (linear: t=-2.97, p=.0035); however, nonlinear declines were observed for both the percentage of days with correct intake (linear: t=-3.33, p=.0011; quadratic: t=2.10, p=.0371) and the percentage of doses taken at the correct time (linear: t=-3.38, p=.0009; quadratic: t=2.28, p=.0242), suggesting a slowing of the rate of decline in adherence related timing of doses for months 9 through 12. We found that a decrease in executive functioning was related to lower percentages of prescribed doses taken (p=.06) and doses taken at the correct time (p=.06) from pretreatment to 6 months post-anastrozole initiation and even greater evidence (p&lt;.05) from pretreatment to 12 months post-anastrozole initiation. From 7 to 12 months post-anastrozole initiation, we found that a decrease in visual learning and memory was related to lower percentages of prescribed doses taken (p=.04), days with correct intake (p=.04), and doses taken at the correct time (p=.03), while a decrease in attention was related to a lower percentage of days with correct intake (p=.04).

Conclusions: These results suggest that breast cancer survivors who experience deterioration in cognitive function tend to have lower adherence. Efforts should be made to develop interventions to compensate for declines in cognitive function and to improve anastrozole adherence.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-02.

Factors associated with mortality after breast cancer metastasis

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Background: It is generally accepted that patients with breast cancer metastases have poor survival. Metastatic breast cancer patients can be considered a heterogeneous population with a varied clinical course, which underscores the need for accurate prediction of survival based on prognostic factors. The purpose of the present study was to identify factors related to survival in breast cancer patients after diagnosis with metastatic disease.

Methods: A total of 557 patients with breast cancer metastasis diagnosis seen at one large urban practice have been followed up between January 1, 1999 and June 30, 2008. Demographic, tumor characteristics, clinical factors as predictors of survival were analyzed using Cox regression model.

Results: The median survival length was 40 months (range 1-114 months) with 269 (48.3%) alive and 288 (51.7%) dead. This study demonstrated that hypertension, estrogen receptor (ER) and/or progesterone receptor (PR) status, human epidermal growth factor receptor-2 (HER2) status, number of metastatic sites, and body mass index (BMI) at diagnosis with metastatic breast cancer were the most relevant prognostic factors for survival after metastasis.

Conclusions: Findings of this study may form a foundation for the corpus of knowledge explaining the outcome differences in treatment of patients with metastatic breast cancer, potentially helping to create tailored counseling and personalized treatment approaches for this vulnerable group.

[Table: see text]

Medication-taking behaviours in young adults with schizophrenia: a pilot study

The purpose of this prospective and observational study was to explore medication-taking behaviours in community-based young adults with schizophrenia using an electronic monitoring system and patient self-report questionnaires. The Medication Event Monitoring System (MEMS®), the Index for Medication Adherence (IMA) and the Brief Evaluation of Medication Influences and Beliefs (BEMIB) measured medication-taking behaviours. Data were collected at baseline, 4 and 8 weeks. Descriptive statistics were used in analysis. A total of 11 subjects were recruited; one dropped out. Five were male, and five were female. Average age was 32.64 (SD = 5.70) years. Four (40%) were White people; six (60%) were non-White people. The average number of medications treating schizophrenia was 1.9 (SD = 0.57). MEMS® identified 71.77% (SD = 30.47) dose adherence and 55.92% (SD = 31.27) day adherence. Most subjects took medications irregularly (early, late or missing). The BEMIB demonstrated that 50%, 20% and 30% of subjects considered themselves to be adherent to their medications at baseline, 4 weeks and 8 weeks, while the IMA reported 90%, 90% and 80% at baseline, 4 weeks and 8 weeks, respectively. Regarding the observed discrepancies between patients' reports and their actual medication-taking behaviours, clinical implications were discussed. Effective interventions improving medication adherence in schizophrenia are needed for practice and for future studies.

The effect of risedronate on hip structural geometry in chemotherapy-induced postmenopausal women with or without use of aromatase inhibitors: a 2-year trial

INTRODUCTION

Osteoporosis is a major health problem for postmenopausal women. Adjuvant hormonal therapy with aromatase inhibitors (AIs) in postmenopausal breast cancer patients further worsens bone loss. Bisphosphonates are able to prevent AI-induced bone loss, but limited data exists on their effect on bone structure. Our objectives were to (1) examine the impact of AIs and no-AIs on hip structural geometry (HSA) of chemotherapy-induced postmenopausal women, and (2) determine if oral bisphosphonates could affect these changes.

METHODS

This is a sub-analysis of a 2-year double-blind randomized trial of 67 women with nonmetastatic breast cancer, newly postmenopausal following chemotherapy (up to 8 years), who were randomized to risedronate, 35 mg once weekly (RIS) and placebo (PBO). Many women changed their cancer therapy from a no-AI to an AI during the trial. Outcomes were changes in Beck's HSA-derived BMD and structural parameters.

RESULTS

Eighteen women did not receive adjuvant hormone therapy, while 41 women received other therapy and 8 received AIs at baseline distributed similarly between RIS and PBO. Women on AIs and PBO were found to have the lowest BMD and indices. RIS improved BMD and several HSA indices at the intertrochanteric site in women regardless of their hormonal therapy, but most improvement was observed in women who were not on AIs (all p< or =0.05 except buckling ratio). Changes at the narrow neck and femoral shaft were similar.

CONCLUSION

The use of AIs appears to lead to lower HSA-derived BMD and hip structural indices as compared to women on no or non-AI therapy in chemotherapy-induced postmenopausal breast cancer patients. Preventive therapy with once weekly oral risedronate maintains structural, skeletal integrity independently of the use of or type of adjuvant therapy.

Acupuncture for systemic lupus erythematosus: a pilot RCT feasibility and safety study

The objective of this study was to determine the feasibility of studying acupuncture in patients with systemic lupus erythematosus (SLE), and to pilot test the safety and explore benefits of a standardized acupuncture protocol designed to reduce pain and fatigue. Twenty-four patients with SLE were randomly assigned to receive 10 sessions of either acupuncture, minimal needling or usual care. Pain, fatigue and SLE disease activity were assessed at baseline and following the last sessions. Safety was assessed at each session. Fifty-two patients were screened to enroll 24 eligible and interested persons. Although transient side effects, such as brief needling pain and lightheadedness, were reported, no serious adverse events were associated with either the acupuncture or minimal needling procedures. Twenty-two participants completed the study, and the majority (85%) of acupuncture and minimal needling participants were able to complete their sessions within the specified time period of 5-6 weeks. 40% of patients who received acupuncture or minimal needling had >/=30% improvement on standard measures of pain, but no usual care patients showed improvement in pain. A ten-session course of acupuncture appears feasible and safe for patients with SLE. Benefits were similar for acupuncture and minimal needling.

Effect of risedronate on hip structural geometry: a 1-year, double-blind trial in chemotherapy-induced postmenopausal women

INTRODUCTION

Chemotherapy-induced menopause is associated with bone loss. The effect on structural geometry is unknown. Our objective was to determine if oral bisphosphonate therapy could maintain or improve femoral geometry in breast cancer patients with chemotherapy-induced menopause.

METHODS

This preplanned 1 year interim, secondary analysis of the Risedronate's Effect on Bone loss in Breast CAncer Study (REBBeCA Study) examined hip structure analysis (HSA), i.e. changes in the bone cross-sectional area (bone CSA), section modulus (SM: measure of bending strength), cortical thickness (CT) and buckling ratio (BR: index of cortical bone stability), in a double-blind trial of 87 newly postmenopausal, nonmetastatic breast cancer patients, randomized to risedronate, 35 mg once weekly (RIS) versus placebo (PBO).

RESULTS

After 12 months, intertrochanteric parameters demonstrated percentage improvement (RIS vs. PBO) from baseline in bone CSA (mean+/-SD: 4.25+/-6.29 vs. 0.60+/-5.99%), SM (3.97+/-6.40 vs. 0.80+/-7.08%), and CT [5.20+/-6.98 vs. 1.13+/-6.87% (all p-values <0.05 except SM p=0,0643)]. Similar improvements were observed at the femoral shaft [bone CSA: 2.24+/-5.74 vs. -0.78+/-5.73%; SM: 1.62+/-6.23 vs. -1.39+/-7.06%; CT: 3.79+/-7.84 vs. -0.17+/-7.90% (all p-values <0.05, RIS vs. PBO, except SM p= p =0.0568)]. At both sites, the BR had significant decreases consistent with improved strength.

CONCLUSION

We conclude that RIS improves measures of hip structural geometry in women with breast cancer following chemotherapy.

A randomized clinical trial of a standard versus vegetarian diet for weight loss: the impact of treatment preference

BACKGROUND

With obesity rampant, methods to achieve sustained weight loss remain elusive.

OBJECTIVE

To compare the long-term weight-loss efficacy of 2 cal and fat-restricted diets, standard (omnivorous) versus lacto-ovo-vegetarian, and to determine the effect of a chosen diet versus an assigned diet.

DESIGN, SUBJECTS

A randomized clinical trial was conducted with 176 adults who were sedentary and overweight (mean body mass index, 34.0 kg/m(2)). Participants were first randomly assigned to either receive their preferred diet or be assigned to a diet group and second, were given their diet of preference or randomly assigned to a standard weight-loss diet or a lacto-ovo-vegetarian diet. Participants underwent a university-based weight-control program consisting of daily dietary and exercise goals plus 12 months of behavioral counseling followed by a 6-month maintenance phase.

MEASUREMENTS

Percentage change in body weight, body mass index, waist circumference, low- and high-density lipoprotein, glucose, insulin and macronutrient intake.

RESULTS

The program was completed by 132 (75%) of the participants. At 18 months, mean percentage weight loss was greater (P=0.01) in the two groups that were assigned a diet (standard, 8.0% (s.d., 7.8%); vegetarian, 7.9% (s.d., 8.1%)) than in those provided the diet of their choice (standard, 3.9% (s.d., 6.1%); vegetarian, 5.3% (s.d., 6.2%)). No difference was observed in weight loss between the two types of diet. Over the 18-month program, all groups showed significant weight loss.

CONCLUSIONS

Participants assigned to their dietary preference did not have enhanced treatment outcomes. However, all groups lost weight with losses ranging from 4 to 8% at 18 months.

The use of life review to enhance quality of life of people living with AIDS: a feasibility study

People living with AIDS (PLWA) are confronted with uncertainty and their own mortality at an earlier than expected age. Life review, an intervention that has the potential to increase life satisfaction in the elderly experiencing transition points in their lives, may have a similar effect when used with PLWA. Therefore, the purpose of this feasibility study was to explore the use of life review in a sample of 20 PLWA through a randomized controlled trial of its effectiveness in decreasing depressive symptoms and in increasing self esteem, quality of life, and purpose in life. Compared to the control group, the treatment group had an improved overall quality of life and self-esteem over 12 months, less depressive symptoms over 12 months, and a greater purpose in life at 3 months. The effects that were seen were mainly small to medium effects. The findings from this feasibility study suggest the potential value of life review to enhance quality of life, purpose in life, and self-esteem, and to decrease depressive symptoms in PLWA. Further research is needed with a larger sample and with other groups such as PLWA experiencing virologic failure.

Staffing and pattern of mechanical restraint use across a multiple hospital system

BACKGROUND

In an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals.

OBJECTIVES

To determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing.

METHODS

This was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1-12 months for a total of 566 cumulative months during 1999.

RESULTS

The system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3-4.4%). More restraints were applied on night shifts (48.8%; n = 5,296) than on day (33.5%; n = 3,634) or evening shifts (17.7%; n = 1,926) (p < .0001) and most applied at midnight (31.7%; n = 3,441) followed by 0600-0900 (33.3%; n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001).

CONCLUSIONS

Restraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Dose response to cerebrospinal fluid drainage on cerebral perfusion in traumatic brain-injured adults

OBJECT

Intracranial hypertension remains a common complication of traumatic brain injury (TBI). Ventriculostomy drainage is a recommended therapy to decrease intracranial pressure (ICP), but little empirical evidence exists to guide treatment. The authors conducted a study to examine systematically the effect of cerebral spinal fluid (CSF) drainage on ICP and indices of cerebral perfusion.

METHODS

Intracranial pressure, cerebral perfusion pressure (CPP), cerebral blood flow velocity (CBFV), and near-infrared spectroscopy-determined regional cerebral oxygenation (rSO2) were measured in 58 patients (with Glasgow Coma Scale scores < or = 8) before, during, and after ventriculostomy drainage. Three randomly ordered CSF drainage protocols varied in the volume of CSF removed (1 ml, 2 ml, and 3 ml). Physiological variables were time averaged in 1-minute blocks from baseline to 10 minutes after cessation of ventricular drainage. There was a significant dose-time interaction for ICP with the three-extraction volume protocol, with incremental decreases in ICP (F [20, 1055] = 6.10; p = 0.0001). There was a significant difference in the CPP depending on the amount of CSF removed (F [2, 1787] = 3.22; p = 0.040) and across time (F [10, 9.58] = 11.9; p = 0.0003) without a significant dose-time interaction. A 3-ml withdrawal of CSF resulted in a 10.1% decrease in ICP and a 2.2% increase in CPP, which were sustained for 10 minutes. There was no significant dose, time or dose-time interaction with CBFV or rSO2.

CONCLUSIONS

Cerebrospinal fluid drainage (3 ml) significantly reduced ICP and increased CPP for at least 10 minutes. Analysis of these findings supports the use of ventriculostomy drainage as a means of at least temporarily reducing elevated ICP in patients with TBI.

Practice patterns related to mechanical restraint use across a multi-institutional health care system

In recent years, regulatory and governmental initiatives have focused increased scrutiny on the use and practices associated with mechanical restraints. Consequently, hospitals are increasingly measuring and comparing both internally and externally their restraint practices as they strive to optimize their use and assure the safe care of patients being restrained. This study analyzes 12,860 restraint episodes from 10 acute care hospitals in a single health care system. Overall findings support many previously identified trends related to the types of restraints used and reasons for application. However, findings from this study also suggest that there are differences among rural, community, and tertiary hospitals. This study also provides the first widespread documentation of rates and types of alternative methods attempted and common patient care practices carried out during restraint application. These results can serve as external comparisons for other acute care settings as they strive to minimize and assure safety in restraint application.

Cognitive function and reproductive hormones in adjuvant therapy for breast cancer: a critical review

Deterioration in cognitive function-particularly learning, memory, and attention-has been reported by women with breast cancer who receive adjuvant chemotherapy. Deficits in cognitive function reported by women with breast cancer are similar to those experienced by women as a consequence of natural or surgical menopause. The basis of these deteriorations may include reductions in reproductive hormone levels, particularly estrogens and progesterones, that occur as a result of adjuvant chemotherapy. This paper critically examines the literature related to the impact of adjuvant chemotherapy and reproductive hormone changes on cognitive function in women with breast cancer and suggests direction for future research in this area. The paper proposes a framework for investigation of the problem and discusses the challenges associated with the conduct of this research.

Adherence in chronic disease

Nonadherence to treatment regimen is a prevalent problem of patients with chronic disorders. Approximately half of the patients with a chronic disease have problems following their prescribed regimen to the extent that they are unable to obtain optimum clinical benefit. This chapter reviews the state of knowledge regarding adherence to chronic disease regimens across the life span and demonstrates that the extent and nature of the adherence problems are similar across diseases, across regimens, and across age groups. Adherence to the commonly prescribed regimens is addressed, including pharmacological therapies, therapeutic diets, and therapeutic exercise. Randomized, controlled studies focusing on various educational, behavioral, cognitive, and affective interventions to improve adherence are included. Based on this review, further work is needed to better understand and improve adherence. New strategies for analysis and measurement will support these needed advances in the field of adherence.

Problem drinking and medication adherence among persons with HIV infection

OBJECTIVE

To examine the relation between problem drinking and medication adherence among persons with HIV infection.

DESIGN

Cross-sectional survey.

SETTING/PARTICIPANTS

Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998.

MEASUREMENTS AND MAIN RESULTS

Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P =.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P =.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P <.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P <.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P =.10), running out of medications (15% vs 8%, P =.16), and consuming alcohol or drugs (26 % vs 3 %, P <.001).

CONCLUSION

Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence.

Psychometric properties of the Index of Homophobia Scale in registered nurses

The psychometric properties of the Index of Homophobia Scale (IHS; Bouton et al., 1987) were examined in a sample of registered nurses (n = 95). Scores on the IHS may range from 0 (no homophobia) to 28 (highly homophobic). This sample had relatively low total scores on the IHS (M = 7.99, SD = 5.41), indicating that subjects were predominantly not homophobic. Internal consistency as estimated by Cronbach's alpha was .88. The average item mean was 1.14 (SD = 0.29) ranging from .77 to 1.48. Corrected item-to-total scale correlations were satisfactory, ranging from .58 to .75. Inter-item correlations ranged from .35 to .67 indicating some redundancy in content sampling. The 7-item IHS indicates promise for future use with registered nurses, and perhaps also with other health care professionals in adequately and accurately measuring homophobia.

Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients

OBJECTIVE

In patients with severe head injuries, brain damage occurs not only from the primary trauma but also secondarily from a reduction in cerebral oxygenation as a result of brain swelling, ischemia, and elevated intracranial pressure (ICP). However, routine interventions designed to maintain oxygenation, such as endotracheal suctioning (ETS), also may negatively affect the cerebrovascular status by increasing the ICP. The purpose of this study was to determine whether ETS influences cerebral oxygenation in patients with traumatic brain injury.

DESIGN

Descriptive, prospective, with repeated assessments within each patient.

SETTING

Ten-bed trauma intensive care unit in a university Level I trauma center.

SUBJECTS

Nineteen patients who were 16 yrs or older, had acute head injury, a Glasgow Coma Scale score < or =8; external ventricular drain and arterial pressure devices in place, and were intubated and mechanically ventilated.

INTERVENTIONS

ETS protocol consisting of administration of four ventilator-delivered breaths at 135% of the patients' actual tidal volume, 100% F(IO)2, before and after suctioning with a standardized catheter at a 16-L flow rate.

MEASUREMENTS AND MAIN RESULTS

This study examined cerebrovascular responses as measured by the traditional measures of ICP and cerebral perfusion pressure, as well as middle cerebral artery velocity and jugular venous oxygen tension that occurred during ETS in head-injured adults. The results of this study show that both ICP and cerebral perfusion pressure are increased during ETS. In the majority of patients (84%), the ICP returned to baseline values within 2 mins.

CONCLUSIONS

The increase in jugular venous oxygen tension associated with increases in middle cerebral artery velocity and mean arterial pressure suggests that cerebral oxygen delivery was maintained during ETS. Cerebral changes associated with ETS using the described protocol are consistent with the preservation of cerebral oxygenation.

Optimism and its relationship to depression, coping, anger, and life events in rural adolescents

Optimism is a stable personality trait that has important implications for behavior, yet little attention has been given to examining optimism in adolescents. This article describes levels of optimism in rural adolescents and the relationship of optimism with depression, coping, anger, and life events. The identification of optimism may be a vulnerability factor when screening adolescent mental health and, as such, has implications for the psychiatric nurse clinician.

Screening and predicting adolescent depressive symptoms in rural settings

Adolescent depression with related suicidal behavior is a serious health problem. This article describes depressive symptoms, reported life events, and demographic risk factors in 846 rural adolescents. The results indicate that self-reported depressive symptoms in rural adolescents is significantly (p < .05) related to gender, death in the family, and the perceived positive and negative impact of life events, as well as the specific events of losing a close friend, an increase in number of arguments with parents, trouble with classmates, and trouble with police. The type of school program and trouble with siblings was marginally significant (p < .10). These demographic factors and life events may assist health-care professionals in identifying adolescents at risk for depressive symptoms.

School-based intervention to promote coping in rural teens

PURPOSE

To evaluate a program designed to help high school students with depressive symptomology to effectively cope.

DESIGN

Two-phase experimental study.

METHODS

Rural high school students (N = 222), ages 14 through 19 years, were surveyed to identify teens with depressive symptomatology, identify stressful life events and coping styles of at-risk subjects, and evaluate a cognitive-behavioral group intervention to enhance students' coping and affect levels of depression. Students with depressive symptomatology were randomized into control (n = 18) or intervention (n = 23) groups. Intervention subjects were treated with a nurse-led, 8-week cognitive skills group, conducted at school.

RESULTS

On posttesting, the intervention groups demonstrated reduced depressive symptoms in females and a wider range of coping compared with controls.

CLINICAL IMPLICATIONS

School-based nurses are in an ideal position to provide assessment, referral, and intervention programs in the natural setting of the school. Results of this study indicate that such programs can be implemented successfully in schools and have the potential to promote mental health in teenagers.

Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries

BACKGROUND

Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels.

OBJECTIVES

To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries.

METHODS

Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups.

RESULTS

Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level.

CONCLUSIONS

Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.

Effect of neuromuscular blockers and opiates on the cerebrovascular response to endotracheal suctioning in adults with severe head injuries

BACKGROUND: Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels. OBJECTIVES: To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries. METHODS: Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups. RESULTS: Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level. CONCLUSIONS: Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.

Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome

STUDY OBJECTIVES

To determine the incidence of, outcome of, and risk factors for anesthesia-related pulmonary aspiration in the predominantly pediatric population receiving anesthesia care.

DESIGN

Using a clinical concurrent quality assessment system we developed, we used data stored in a custom-designed computerized database to initiate a retrospective review. Statistical relationships were analyzed by Fisher's exact test and binary logistic regression with commercially available software.

SETTING

University-affiliated pediatric hospital.

PATIENTS

All patients receiving anesthesia (n = 50,880) between April 1, 1988, and March 31, 1993.

MEASUREMENTS AND MAIN RESULTS

Aspiration occurred in 52 (0.10% or 10.2 per 10,000) of the 50,880 general anesthesia cases. Aspirate was food or gastric contents in 25 cases (0.049% or 4.9 per 10,000), blood in 13 (0.026% or 2.6 per 10,000), and unknown material in 14 (0.0275% or 2.76 per 10,000). There were no deaths attributable to aspiration. Morbidity was confined to unanticipated hospital admission (n = 12), cancellation of the surgical procedure (n = 4), and intubation, with or without ventilation (n = 15). Aspiration occurred significantly more often in patients with greater severity of underlying illness (ASA physical status III or IV) (p = 0.0015), intravenous induction (p = 0.0054), and age equal to or greater than 6.0 years and less than 11.0 years (p = 0.0029). Emergency procedures had a marginally significant increased aspiration risk (p = 0.0527).

CONCLUSIONS

The overall incidence of anesthesia-related aspiration in our series (0.10%) was twice that reported in studies of adults, and four times (0.25%) higher for those at highest risk (ASA physical status III or IV vs. physical status I or II). Anesthesia-related pulmonary aspiration was proven to be a rare event in this tertiary pediatric center and its consequences relatively mild. Because of the very low frequency and the lack of serious outcome after aspiration in ASA physical status I and II pediatric patients, it appears that routine prophylactic administration of histamine blockers or propulsive drugs in healthy pediatric patients is unwarranted.

Health-related quality of life in chronic disorders: a comparison across studies using the MOS SF-36

The purpose of this report is to examine health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form-36, across patient populations with chronic disorders and to compare quality of life (QoL) in these subjects with normative data on healthy persons. Six studies, within the Center for Research in Chronic Disorders at the University of Pittsburgh School of Nursing, in patients with urinary incontinence, prostate cancer, chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), fibromyalgia and hyperlipidaemia provided the data for analysis. The results demonstrated that not only did the prostate cancer and hyperlipidaemia patients have the highest QoL across the chronic disorders, but their QoL was comparable to normative data on healthy persons. Homebound, elderly, incontinent patients had the lowest QoL for physical functioning, whereas patients hospitalized with AIDS had the lowest QoL in general health and social functioning. Patients with COPD had the lowest QoL in role-physical, role-emotional and mental health. Patients with fibromyalgia had the lowest QoL in bodily pain and vitality. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia generally had lower QoL. Prostate cancer and hyperlipidaemia patients had QoL comparable to normative data. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia had more variability for role-emotional. AIDS patients had more variability on physical functioning, bodily pain and social functioning compared to the normative data. These data suggest that patients with various chronic disorders may have QoL that is lower in most domains compared to a healthy population. However, there may be differences in the domains affected as well as the extent of variation across specific chronic disorders.

Critical care nurses, ethical decision-making and stress

Considerable attention has focused on describing ethical issues that critical care nurses face in their practice: however, less attention has been directed at describing the process of ethical decision-making. Systematic research linking aspects of ethical-decision making and stress is lacking. This cross-sectional study examines the relationship between selected aspects of ethical decision-making, stress and selected nurse characteristics. Sixty-one critical care nurses completed the Nurse's Ethical Decision Making--ICU Questionnaire and the Health Professions Stress Inventory. Findings revealed that nurses who selected the patient advocacy model had significantly higher nurse autonomy scores, that perceived anxiety had a negative association with nurse autonomy, and that workplace restrictions and stress were related.

An evaluation of a self-management program for adults with asthma

The purpose of this study was to evaluate the impact of a self-management program for adults with moderate to severe asthma on compliance with inhaled, prescribed, nonemergency medications; asthma symptoms; and airway obstruction. In this controlled experimental study, 55 subjects from a rural community were randomized to one of two groups. Self-efficacy theory served as the framework for this study. Primary measures included the Metered Dose Inhaler (MDI) Chronolog, a journal of daily asthma concerns, and a peak-flow meter to appraise airway obstruction. Secondary measures included the Asthma Self-Management Assessment Tool (ASMAT) and the Self-Efficacy for Asthma Management Scale (SEAMS). These measures were completed pre- and post-intervention. Data analysis using descriptive and inferential statistics revealed that subjects receiving the self-management program increased compliance with inhaled medications (U = 271, p = .043).

Multiple authorship: issues and recommendations

The increase in multidisciplinary research has led to a subsequent expansion of multiple authored articles in nursing as well as other disciplines. Although there are benefits to multiple authorship, there also are areas of possible conflict. The lack of adequate guidelines to address issues that may arise from multiple authorship heightens the possibility of disputes. Developing a blueprint for the preparation and presentation of papers emanating from a research team's work early in the project can avoid conflicts and ensure that the efforts of the appropriate individuals are reflected in the publications. This article discusses several issues related to authorship, including the assignment of authorship credit, the increased pressures to publish, and the complexity of authorship issues associated with multisite studies. The authors offer recommendations to reduce problems that may arise among members of a research team because of authorship issues. In addition, they include the guidelines that their multidisciplinary research team developed early in their project.

Effect of short-duration hyperventilation during endotracheal suctioning on intracranial pressure in severe head-injured adults

A repeated measures randomized within-group design was used to determine the effectiveness of controlled short-duration hyperventilation (HV) in blunting the increase of intracranial pressure (ICP) during endotracheal suctioning (ETS). A multimodal continuous real-time computerized data acquisition procedure was used to compare the effects of two HV ETS protocols on ICP, arterial pressure, cerebral perfusion pressure (CPP), heart rate, and arterial oxygen saturation in severe head-injured adult patients. The results indicated that short-duration HV for 1 minute, which decreases the PaCO2, reduced ETS-induced elevations in ICP while maintaining CPP. However, it is not clear whether short-duration HV is neuroprotective, particularly in ischemic regions of the brain. Therefore, before a change in practice is implemented on the use of short-duration HV as a prophylactic treatment against ETS-induced elevations in ICP, additional questions on cerebral oxygen delivery and uptake need to be answered.

Fatigue in women with myocardial infarction

This study measured fatigue in women 6 weeks after myocardial infarction. Fatigue was experienced by the women as chronic, generalized, intermittent, and longstanding. More than one third of the women attributed their fatigue directly to the heart attack or hospitalization. Significant relations were found between fatigue and the physiological dimension of the Sickness Impact Sale (SIP), the Perceived Health Assessment and Risk Protection Survey (PHARPS), and the site of infarction, as well as with the psychological dimension of the SIP. There was an inverse significant relation between fatigue scores and the Psychological General Well-Being (PGWB) Index. Although not reaching statistical significance, fatigue scores for women 65 and older were higher than for younger women.

Sensitivity and specificity of plasma and urine complement split products as indicators of lupus disease activity

OBJECTIVE

To determine if measurement of serum complement split products (C4d, Bb, C5b-9) is better than conventional C3 and C4 measurements in distinguishing patients with varying degrees of lupus disease activity, and to determine if the presence of C3d in urine is helpful in distinguishing lupus patients with from those without early lupus nephritis.

METHODS

Lupus disease activity was prospectively determined at 3 consecutive visits an average of 4 months apart, using the Systemic Lupus Activity Measure (SLAM), the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and physician global assessment (PGA). Blood samples were evaluated for the presence of C4d, Bb, and C5b-9 by quantitative microassay plate enzyme immunoassay at each patient visit. We characterized urinary excretion of C3 fragments (with attention to C3d) by sodium dodecyl sulfate-polyacrylamide gel electrophoresis with Western blotting.

RESULTS

Thirty-one SLE patients were enrolled in the study. The mean SLAM score and the mean SLEDAI score each correlated well with the PGA at all 3 visits. A SLAM score of 6 and a SLEDAI score of 4 had the best overall sensitivity and specificity for predicting moderate-to-severe disease activity by PGA (100% and 73%, respectively, for the SLAM and 86% and 94%, respectively, for the SLEDAI). Serum C4d and Bb were more sensitive indicators of current moderate-to-severe lupus disease activity at all 3 visits than were serum C5b-9, C3, and C4. C3 and C4 were more specific indicators of moderate-to-severe disease activity. Serum C4d and Bb were more sensitive at predicting moderate-to-severe disease activity at subsequent visits than were C5b-9, C3, and C4. Urine C3d was better than C3, plasma C4d, Bb, C5b-9 and anti-double-stranded DNA antibody in distinguishing patients with from those without acute lupus nephritis (P = 0.02).

CONCLUSION

C4d and Bb are sensitive indicators of moderate-to-severe lupus disease activity and may be most helpful in situations where conventional measurements are not, such as in lupus patients whose C3 and C4 levels remain normal despite evidence of clinical disease activity. It appears from this study that detection of urine C3d may be a simple way of measuring complement activation in the setting of lupus renal disease. The availability of instruments for clinical disease activity measurement such as the SLAM and the SLEDAI may enable more consistent definition of lupus disease activity and may thus provide a means for better examining the role of complement activation products in predicting lupus disease activity in larger patient populations.

Survival experience of chronically critically ill patients

Intensive care unit (ICU) patients were randomly assigned to either a traditional ICU or a special care unit (SCU) for chronically critically ill patients. The SCU used a low-technology, family-oriented environment, nursing case management, no physician house staff, and a shared governance model. In comparison, the ICU used high technology, limited family visiting, primary care nursing, and a bureaucratic management model. The survival experience of chronically critically ill patients in the two environments during hospitalization, as well as after hospital discharge, was examined. Using survival analytic techniques, the 1-year cumulative mortality for all patients in the study was found to be 59.9%. Risk of death was significantly lower after discharge than during hospitalization. Similar mortality experiences were found for SCU and ICU patients. Thus, the high-technology ICU environment did not produce better outcomes than the SCU environment.

Left ventricular dysfunction and duration of mechanical ventilatory support in the chronically critically ill: a survival analysis

OBJECTIVE

The purpose of this study was to determine whether there was a greater risk for prolonged duration of mechanical ventilatory support (MVS) for those who demonstrated left ventricular dysfunction (LVD) compared to those without evidence of LVD when controlling for nutritional and general health status and spontaneous breathing pattern.

DESIGN

A secondary analysis was used on data obtained in a retrospective survey of patient records.

SETTING

Five adult critical care units at an academic medical center in the Midwest.

SUBJECTS

Twenty-seven chronically critically ill adults requiring MVS who later successfully weaned from MVS.

OUTCOME MEASURE

Duration of MVS.

INSTRUMENTATION

LVD was determined with use of a criterion-based checklist. Serum albumin level as determined by the hospital's clinical laboratory served as the indicator of nutritional and general health status. The rapid shallow breathing index was used to describe the spontaneous breathing pattern.

RESULTS

Adjusted survival function estimates were obtained on fitting a Cox proportional hazards model. When adjusting for the known covariates, serum albumin level and rapid shallow breathing index, the duration of MVS was significantly longer for those who demonstrated LVD when compared to those without evidence of LVD [X2Wald(1) = 4.72, p < 0.05].

CONCLUSIONS

The findings of this secondary analysis lend support to the fact that when controlling for serum albumin level and rapid shallow breathing index, LVD is related to the duration of MVS in patients who successfully wean.

Exercise, education, and quality of life in lung transplant candidates

In addition to improved functional ability, patients who complete rehabilitation programs typically have positive psychologic changes, including increased motivation and an enhanced quality of life. Potentially, patients with end-stage lung disease awaiting a lung transplant can have similar benefits. However, no studies were identified that examined the impact of an exercise program on quality of life in patients awaiting lung transplantation. This pilot study was an initial step toward evaluating outcomes of a health maintenance program on exercise tolerance and quality of life. Subjects were nine lung transplant candidates who met lung transplant listing criteria and who were randomized to participate in a 6-week health maintenance program consisting of education alone or education plus exercise. Subjects completed cardiopulmonary exercise testing, a 6-minute walk, and the Quality of Well-being scale, Quality of Life Index, and Symptom Frequency/Symptom Distress scale before and after completion of the program. No significant between-group changes were seen. Quality of Well-being scores (p < 0.005) and 6-minute walk distance (p < 0.03) improved over time in both groups. Findings suggest that patients awaiting lung transplantation perceived improved quality of well-being and increased walk distance after participation in a health maintenance program. Education plus exercise conferred no benefits beyond those achieved by education alone. However, the number of subjects studied was small and duration of follow-up was limited.

Factors associated with long-term depressive symptoms of sexual assault victims

Of 63 sexual assault victims who were a mean 7.9 years postevent, almost two thirds (60%, n = 38) demonstrated some degree of depression. Over half (56%, n = 35) the sample also reported a history of childhood sexual abuse. Three factors had a significant positive association with higher levels of depression: nondisclosure of the assault to significant others due to concerns about stigma; the presence of children living with the victim; and a civil lawsuit pending. One factor, currently being sexually active, had a significant negative association with depression. Results are discussed from the perspective of depression, a common pathway by which unresolved sexual trauma is expressed.

The hemodynamic effects of ventricular pacing with and without atrioventricular synchrony in patients with normal and diminished left ventricular function

The relative hemodynamic effects of heart rate, inotropic state, and atrioventricular (AV) synchrony during ventricular pacing were evaluated in 10 patients with normal left ventricular ejection fraction (LVEF) (0.66 +/- 0.07, mean S.D.) and in eight patients with a diminished LVEF (0.34 +/- 0.18). Hemodynamics were measured at AV intervals of 130, 0, and -130 msec during ventricular pacing at a baseline rate that was 10 pulses/min greater than the resting heart rate, at 130 pulses/min alone, and at 130 pulses/min during continuous intravenous infusion of dobutamine. During baseline ventricular pacing and during ventricular pacing at 130 pulses/min with and without dobutamine, both groups of patients had a significant decrease in cardiac index, stroke volume index, and stroke work index when the AV pacing interval was decreased from 130 to 0 msec. The observed decrease in these three hemodynamic variables was similar when patients with diminished LVEF were compared to patients with normal LVEF. No further significant decrease in cardiac index, stroke volume index, and stroke work index occurred in either group when the AV interval was changed from 0 to -130 msec during baseline ventricular pacing or during ventricular pacing at 130 with and without dobutamine. Beneficial hemodynamic effects occur during ventricular pacing when AV synchrony is maintained at resting heart rates and during increases in heart rate and inotropic state in patients with normal and diminished LVEF.