Knowledge about cardiovascular risk factors among obese individuals.

BACKGROUND: Obesity is an important biological risk factor for cardiovascular disease (CVD). AIMS: The main aim of this study was to answer the question whether obese individuals differ from individuals with normal weight with regard to knowledge about risk factors for CVD. A further aim was to replicate previous findings that obese individuals are at higher risk of developing other biological risk factors for CVD. METHOD: Normal weights, BMI<25 kg/m(2) (n=385), and obese, BMI> or =30 kg/m(2) (n=159), individuals were identified from a screening program conducted among 50-year-old inhabitants of the County of V?stmanland, Sweden. Participants answered questions regarding their gender, level of education, and items relating to knowledge about cardiovascular risk factors. Total cholesterol and blood glucose levels, height, weight and blood pressure were measured. RESULTS: Obese individuals did not differ significantly from individuals with a normal weight regarding knowledge of cardiovascular risk factors when education was controlled for. Obesity and low level of education are associated with other risk factors for CVD such as high blood pressure and high serum cholesterol. CONCLUSION: Obese individuals are at an increased risk of developing other risk factors for CVD but are just as knowledgeable about risk factors for CVD as normal weighting individuals.     

Meanings of at‐homeness at end‐of‐life among older people

Maintaining the well‐being of older people who are approaching the end‐of‐life has been recognised as a significant aspect of well‐being in general. However, there are few studies that have explicitly focused on at‐homeness among older people. This study aims to illuminate meanings of at‐homeness among older people with advancing illnesses. Twenty men and women, aged 85 or older, with advancing illnesses and who lived in their own homes, in nursing homes or in short‐term nursing homes in three urban areas of Sweden were strategically sampled in the study. Data were generated in narrative interviews, and the analysis was based on a phenomenological hermeneutical method. After obtaining a naïve understanding and conducting structural analyses, two aspects of the phenomenon were revealed: at‐homeness as being oneself and at‐homeness as being connected. At‐homeness as being oneself meant being able to manage ordinary everyday life as well as being beneficial to one's life. At‐homeness as being connected meant being close to significant others, being in affirming friendships and being in safe dependency. Here, at‐homeness is seen as a twofold phenomenon, where being oneself and being connected are interrelated aspects. Being oneself and being connected are further interpreted by means of the concepts of agency and communion, which have been theorised as two main forces of the human being.     

Rewriting stories of trauma through peer‐to‐peer mentoring for and by at‐risk young people

Adverse childhood experiences are strongly associated with the development of mental health disorders during the life span. When mental health issues are not effectively dealt with during the adolescent period, young people can become long‐term consumers in the mental health system. A widely accepted method of intervention is the provision of mentoring. More recently, young people have been fulfilling the role of mentor to their peers and mentoring has played a large role in supporting young people who are considered at‐risk of not achieving the expected psychosocial, educational, and/or developmental goals. What is not known is why young people, previously identified as being at‐risk, are motivated to mentor their at‐risk peers. The study aim was to examine what motivates previously recognized at‐risk young people to provide mentoring to their at‐risk peers. Participants were twelve previously recognized at‐risk young people recruited through a formal peer‐to‐peer mentoring programme. Semi‐structured interviews were conducted, and the data analysed through narrative inquiry and reported in accordance with the consolidated criteria for reporting qualitative research guidelines (COREQ). Results indicate that young people are motivated by their own lived experiences of trauma(s) to provide at‐risk peer mentoring. The experience of mentoring afforded opportunities to rewrite individual personal journeys of trauma through mentoring their at‐risk peers, thus constructing a more positive self‐identity. Outcomes of developing positive peer relationships and prosocial behaviours could significantly assist mental health clinicians in providing more acceptable care to clients in an age group known to be reluctant to accept traditional mental health intervention.     

Providing opportunistic immunisations for at‐risk inpatients in a tertiary paediatric hospital

Attaining high immunisation coverage rates for children with medical conditions is vital. The Royal Children's Hospital (RCH) Immunisation Service has the opportunity to check each inpatient's immunisation status and provide opportunistic vaccines and/or bring the Australian Childhood Immunisation Register (ACIR) up‐to‐date. This paper highlights that during admission, one quarter of children were not up‐to‐date with routine scheduled immunisations and 42% of those inpatients due or overdue for immunisation were vaccinated. The model of establishing routine checking of immunisation records and reminding hospital staff about immunisation can result in improvements in vaccination coverage. Healthcare providers have a responsibility to check immunisation status and offer vaccines when necessary; however, often there are missed opportunities to immunise. This paper demonstrates that having a dedicated Immunisation Service, a partnership with a relevant government agency, and effective collaboration with inpatient clinical teams, opportunistic immunisation can be achieved for inpatients.     

The importance of appropriate prophylaxis for the prevention of venous thromboembolism in at‐risk medical patients

Background: Venous thromboembolism (VTE), which encompasses both deep‐vein thrombosis and pulmonary embolism, is a significant healthcare problem, leading to considerable morbidity, mortality and resource utilisation. Aims: This review discusses the adherence to VTE guideline recommendations and the available clinical evidence on the appropriate type, dose and duration of VTE prophylaxis. Methods: A literature survey was conducted using Pub Med and EMBASE to identify publications related to appropriate thromboprophylaxis in medically ill patients at risk of VTE. Results: Despite evidence from clinical trials and national guidelines, VTE prophylaxis in medically ill patients remains underutilised. The use of unfractionated heparin three‐times‐daily, low‐molecular‐weight heparin once‐daily and fondaparinux once‐daily has demonstrated effectiveness in clinical trials of medically ill patients. However, controversy exists about the use of unfractionated heparin twice‐daily, and fondaparinux has not yet received US Food and Drug Administration approval for VTE prophylaxis in medically ill patients. Conclusion: It is important for clinicians to have an understanding of the evidence‐based literature when selecting an appropriate drug, at the appropriate dose, for the appropriate duration for VTE prophylaxis in medically ill patients. VTE prophylaxis in medically ill patients is cost‐effective, and drugs that are expensive may still be cost‐effective when considering improved efficacy and/or safety. Recently, the underutilisation of VTE prophylaxis has led to the involvement of government and other regulatory agencies in an attempt to increase appropriate VTE prophylaxis in US hospitals and improve the clinical and economic outcomes in medical patients at risk of VTE.     

Racial/ethnic- and education-related disparities in the control of risk factors for cardiovascular disease among individuals with diabetes

OBJECTIVE

There is limited information on whether recent improvements in the control of cardiovascular disease (CVD) risk factors among individuals with diabetes have been concentrated in particular sociodemographic groups. This article estimates racial/ethnic- and education-related disparities and examines trends in uncontrolled CVD risk factors among adults with diabetes. The main racial/ethnic comparisons made are with African Americans versus non-Latino whites and Mexican Americans versus non-Latino whites.

RESEARCH DESIGN AND METHODS

The analysis samples include adults aged ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 1988–1994 and the NHANES 1999–2008 who self-reported having diabetes (n = 1,065, NHANES 1988–1994; n = 1,872, NHANES 1999–2008). By use of logistic regression models, we examined the correlates of binary indicators measuring 1) high blood glucose, 2) high blood pressure, 3) high cholesterol, and 4) smoking.

RESULTS

Control of blood glucose, blood pressure, and cholesterol improved among individuals with diabetes between the NHANES 1988–1994 and the NHANES 1999–2008, but there was no change in smoking prevalence. In the NHANES 1999–2008, racial/ethnic minorities and individuals without some college education were more likely to have poorly controlled blood glucose compared with non-Latino whites and those with some college education. In addition, individuals with diabetes who had at least some college education were less likely to smoke and had better blood pressure control compared with individuals with diabetes without at least some college education.

CONCLUSIONS

Trends in CVD risk factors among individuals with diabetes improved over the past 2 decades, but racial/ethnic- and education-related disparities have emerged in some areas.Diabetes is a leading cause of morbidity and mortality in the U.S., and the prevalence of this disease is rising (1). The Centers for Disease Control and Prevention, based on data from the National Health Interview Survey, estimated that the age-adjusted prevalence of diagnosed diabetes increased from 3.7% in 1980 to 7.7% in 2008 (2). The total direct and indirect costs associated with diabetes in the U.S. were estimated to be $174 billion in 2007, with ~33% ($58 billion) of the total cost being attributed to treatment of medical complications (3). Cardiovascular disease (CVD) is a widely documented potential complication of diabetes and a leading cause of mortality among individuals with diabetes (4–6). Although rates of CVD events have declined in recent decades among both individuals with and without diabetes, people with diabetes still are twice as likely as those without diabetes to experience a CVD event (4), and individuals with diabetes have heart disease mortality rates that are two to four times greater than those without diabetes (6).To prevent CVD and other complications of diabetes, the American Diabetes Association (ADA) in 2009 published updated standards for diabetes screening, diagnosis, and therapeutic care (7). These guidelines, which reflect new evidence from epidemiological studies and randomized controlled trials, included targets for glycemic control, blood pressure control, lipid control, and smoking (7). The ADA recommends that most adults with diabetes maintain an HbA_1c (a measure of blood glucose) level below or around 7.0%, blood pressure under 130/80 mmHg, and LDL cholesterol under 100 mg/dL (2.6 mmol/L) (7). All patients with diabetes are advised not to smoke. In addition, the National Cholesterol Education Program Adult Treatment Panel III recommends that individuals with diabetes keep their LDL under 100 mg/dL and total cholesterol under 200 mg/dL (8).Given that successful management of diabetes requires a coordinated team of health care providers (7) and access to health insurance (9), continuity of care (10), and patient knowledge and self-management skills (11), there may be differences in control of CVD risk factors across sociodemographic groups within the population of people with diabetes. On the basis of data from the National Health and Nutrition Examination Survey (NHANES) 1999–2000, previous researchers reported that only 7.3% of those with diagnosed diabetes achieve all three of the ADA (2009) targets for control of blood glucose, blood pressure, and total cholesterol (12). Between the NHANES 1988–1994 and the NHANES 1999–2000, trends in the control of blood cholesterol among individuals with diagnosed diabetes improved, but there was no change in the control of blood glucose and blood pressure levels (12). Poor glycemic control generally is more prevalent among African Americans and Mexican Americans with diabetes compared with non-Latino whites with diabetes (13–15), but these differences have been small in some studies (13) and limited to certain sex/race-ethnicity subgroups in other studies (14). Recent research based on individuals with diabetes interviewed in the NHANES 1999–2008 shows an overall trend of improvement in CVD risk factors and, notably, reductions in the predicted 10-year risk of coronary heart disease (16), but some findings show that socioeconomic status and racial/ethnic disparities persist (14–18).Using data from the NHANES 1988–1994 and the NHANES 1999–2008, we built on these important new results by 1) examining trends in the prevalence of diagnosed diabetes and the sociodemographic characteristics of the diagnosed diabetic population and 2) testing for racial/ethnic- and education-related disparities in poorly controlled risk factors for CVD among individuals with diagnosed diabetes. Given the mounting body of evidence showing the importance of controlling CVD risk factors (7) and the increasing focus on prevention in the 2010 health care reform law (19), it is critical to document current trends in the control of CVD risk factors among individuals with diabetes and to examine whether any improvements have been concentrated in particular sociodemographic groups.