Association of bone mineral density with postural stability and the fear of falling in Spanish postmenopausal women

Objective

The purpose of our study was to investigate the relationship between bone mineral density (BMD) and postural stability and the fear of falling in a 50- to 65-year-old postmenopausal population.

Study design

A cross-sectional, observational study was conducted on 118 postmenopausal women. According to their BMD values, participants were divided into two groups: BMD > −2.0 SD (n = 95) and ≤−2.0 SD (n = 23).

Main outcome measures

Postural stability, assessed with a resistive multi-sensor platform, fear of falling (FoF) and the history of falls in the last 12 months were investigated.

Results

Women with BMD ≤ −2.0 SD reported a significantly increased FoF when compared to women with BMD > −2.0 SD (P = 0.024, η² = 0.045, 1 − β = 0.624). In the postural stability analysis, the group with BMD ≤ − 2.0 SD showed, under the eyes-open condition, statistically significantly higher values for the velocity (VEO) (P = 0.040, η² = 0.037, 1 − β = 0.539) and the anteroposterior mean displacement of the center of pressure (YEO; P = 0.017, η² = 0.049, 1 − β = 0.669). No significant differences between groups were observed in the history of falls or in the rest of the stabilometric analyses.

Conclusions

In Spanish postmenopausal women under 65 years, a BMD ≤ −2.0 SD is significantly associated with postural instability (elevated VEO and XEO) and an increased FoF, which are two highly influential factors in the risk of falling.     

Riluzole effect on occipital cortex: A structural and spectroscopy pilot study

Background

To investigate the mechanism underlying the anxiolytic properties of riluzole, a glutamate-modulating agent, we previously studied the effect of this drug on hippocampal N-acetylaspartate (NAA) and volume in patients with generalized anxiety disorder (GAD). In the same cohort, we now extend our investigation to the occipital cortex, a brain region that was recently implicated in the antidepressant effect of riluzole.

Methods

Fourteen medication-free adult patients with GAD received 8-week of open-label riluzole. Ten healthy subjects served as a comparison group. The healthy group did not receive riluzole treatment. Both groups underwent magnetic resonance imaging and spectroscopy at baseline and at the end of Week 8. Hamilton Anxiety Rating Scale (HAM-A) and Penn State Worry Questionnaire (PSWQ) were used as the primary and secondary outcome measures, respectively.

Results

At baseline, we found clusters of increased cortical thickness in the occipital region in GAD compared to healthy subjects. In the right hemisphere, 8 weeks of treatment reduced occipital cortical thickness in the GAD group (t = 3.67, p = 0.004). In addition, the improvement in HAM-A scores was negatively correlated with post-treatment right occipital NAA (r = −0.68, p = 0.008), and with changes in NAA levels (r = −0.53, p = 0.051). In the left hemisphere, we found positive associations between changes in occipital cortical thickness and improvement in HAM-A (r = 0.60, p = 0.04) and PSWQ (r = 0.62, p = 0.03).

Conclusion

These pilot findings implicate the occipital cortex as a brain region associated with pathology and clinical improvement in GAD. In addition, the region specific effect of riluzole implies a distinct pathophysiology in the occipital cortex – compared to other, previously studied, frontolimbic brain structures.     

Development and psychometric validation of a scale to assess information needs in cardiac rehabilitation: The INCR Tool

Objective

To develop and psychometrically validate a tool to assess information needs in cardiac rehabilitation (CR) patients.

Methods

After a literature search, 60 information items divided into 11 areas of needs were identified. To establish content validity, they were reviewed by an expert panel (N = 10). Refined items were pilot-tested in 34 patients on a 5-point Likert-scale from 1 “really not helpful” to 5 “very important”. A final version was generated and psychometrically tested in 203 CR patients. Test–retest reliability was assessed via the intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and criterion validity was assessed with regard to patient's education and duration in CR.

Results

Five items were excluded after ICC analysis as well as one area of needs. All 10 areas were considered internally consistent (Cronbach's alpha > 0.7). Criterion validity was supported by significant differences in mean scores by educational level (p < 0.05) and duration in CR (p < 0.001). The mean total score was 4.08 ± 0.53. Patients rated safety as their greatest information need.

Conclusion

The INCR Tool was demonstrated to have good reliability and validity.

Practice implications

This is an appropriate tool for application in clinical and research settings, assessing patients’ needs during CR and as part of education programming.     

Does health coaching change patients’ trust in their primary care provider?

Objective

To assess the impact of health coaching on patients’ in their primary care provider.

Methods

Randomized controlled trial comparing health coaching with usual care.

Participants

Low-income English or Spanish speaking patients age 18–75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia.

Main outcome measure

Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0–100 scale.

Analysis

Linear mixed modeling.

Results

A total of 441 patients were randomized to receive 12 months of health coaching (n = 224) vs. usual care (n = 217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p = 0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p = .03).

Conclusions

Health coaching appears to increase patients trust in their primary care providers.

Practice Implications

Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.     

Consumer health information technology in an adult public health primary care clinic: A heart health education feasibility study

Objective

To explore the feasibility and short term outcomes of using an interactive kiosk integrated into office flow to deliver health information in a primary care clinic.

Methods

Fifty-one adults with BMI ≥25 were randomly assigned to use a kiosk with attached devices to receive a six-week healthy eating/weight monitoring (intervention) or general health/BP monitoring (attention-control) program. Outcomes were measured at baseline, 8 weeks (post) and three month follow-up.

Results

Participants completed an average of 2.73 weekly sessions, with transportation and time given as limiting factors. They found the kiosk easy to use (97%), liked the touchscreen (94%), and would use the kiosk again (81%). Although there were no differences between groups, the 27 completing all assessments showed reduced weight (p = .02), and decreased systolic (p = .01) and diastolic BP (p < .001) at follow-up. Although healthy eating behaviors increased, the change was not statistically significant.

Conclusion

Using a kiosk within a clinic setting is a feasible method of providing health information and self-monitoring. Multi-session educational content can provide beneficial short-term outcomes in overweight adults.

Practice implications

A kiosk with attached peripherals in a clinic setting is a viable adjunct to provider education, particularly in medically underserved areas.     

The Health Literacy Management Scale (HeLMS): A measure of an individual's capacity to seek,understand and use health information within the healthcare setting

Objective

Health literacy refers to an individual's ability to seek, understand, and use health information. This paper describes the development and psychometric testing of the Health Literacy Management Scale (HeLMS).

Methods

Content areas were identified from a conceptual framework derived from interviews and concept mapping. Items were generated from statements from concept mapping participants. Construction (N = 333) and replication (N = 350) samples were participants in chronic disease self-management programs and emergency department attendees. Factor analysis was used to refine constructs and define psychometric properties.

Results

Consultations generated 8 scales each with 4–5 items: Understanding health information, Accessing GP healthcare services, Communication with health professionals, Being proactive and Using health information, Patient attitudes towards their health, Social support, and Socioeconomic considerations. Confirmatory factor analyses indicated good fit of the data with the model (RMSEA = 0.07, SRMR = 0.05, CFI = 0.97) and all domains had high internal consistency (Cronbach alpha > 0.82).

Conclusion

The HeLMS has acceptable psychometric properties and assesses a range of health literacy constructs important to patients when seeking, understanding and using health information within the healthcare system.

Practice implications

The HeLMS presents a new approach to assessing health literacy in healthcare settings.     

Mindfulness-based therapy: A comprehensive meta-analysis

Background

Mindfulness-based therapy (MBT) has become a popular form of intervention. However, the existing reviews report inconsistent findings.

Objective

To clarify these inconsistencies in the literature, we conducted a comprehensive effect-size analysis to evaluate the efficacy of MBT.

Data sources

A systematic review of studies published in journals or in dissertations in PubMED or PsycINFO from the first available date until May 10, 2013.

Review methods

A total of 209 studies (n = 12,145) were included.

Results

Effect-size estimates suggested that MBT is moderately effective in pre-post comparisons (n = 72; Hedge's g = .55), in comparisons with waitlist controls (n = 67; Hedge's g = .53), and when compared with other active treatments (n = 68; Hedge's g = .33), including other psychological treatments (n = 35; Hedge's g = .22). MBT did not differ from traditional CBT or behavioral therapies (n = 9; Hedge's g = − .07) or pharmacological treatments (n = 3; Hedge's g = .13).

Conclusion

MBT is an effective treatment for a variety of psychological problems, and is especially effective for reducing anxiety, depression, and stress.     

Effects of continuous combined hormone replacement therapy and clodronate on bone mineral density in osteoporotic postmenopausal women: A 5-year follow-up

Objective

To determine the effects of HRT with or without clodronate on bone mineral density (BMD) change and bone turnover markers.

Design

Prospective, partly randomized trial.

Setting

Kuopio University Hospital, Finland.

Population

167 osteoporotic women (61 ± 2.7 years; T-score ≤ −2.5 SD).

Methods

Estradiol 2 mg + NETA 1 mg, randomization to additional 800 mg clodronate (n = 55, HT + C-group) or placebo (n = 55, HT-group); if contraindications to HRT, clodronate (n = 57, C-group).

Main outcome measures

BMD by DXA after 1, 3 and 5 years, serum osteocalcin (OC) and bone-specific alkaline phosphatase (BAP) at the baseline and after 3 years.

Results

After 5 years, adjusted lumbar BMD increased by 4.2% in the HT-group and 3.7% in the HT + C-group. The C-group showed a decrease of −1.1%, the total difference being 5.3% and 4.8% between HT, HT + C vs. C-group, respectively (p < 0.001). In the femoral neck, the adjusted 5-year BMD benefit was 1.3% and 2.4% in the HT- and HT + C-groups, respectively, the net loss of BMD in the C-group was −3.3% (p < 0.05 between HT + C vs. C). By 3 years, OC decreased by 55.0%, 70.3% and 53.8% in the HT-, HT + C- and C-groups, respectively (p < 0.001 vs. baseline). The significant decreases of BAP were 39.4% in the HT-group, 42.1% in the HT + C-group and 30.2% in the C-group with no significant differences between the groups after adjustments.

Conclusions

In postmenopausal women with osteoporosis, HRT increased spinal and femoral BMD, but the combination of HRT and clodronate did not offer an extra gain of bone mass.     

Effect of cognitive dysfunction on the relationship between age and health literacy

Objective

Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood.

Methods

We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction.

Results

Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r = −0.16, p = 0.001 vs. r = −0.35, p < 0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups.

Conclusion

Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults.

Practice implications

Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.     

Peer educator vs. respiratory therapist support: Which form of support better maintains health and functional outcomes following pulmonary rehabilitation?

Objective

This study examined if ongoing support delivered by telephone following pulmonary rehabilitation (PR) assisted chronic obstructive pulmonary disease (COPD) patients to maintain health outcomes.

Methods

Phase one (n = 79) compared post-rehabilitation telephone-based support delivered by peers compared to usual care (UC). The second phase (n = 168) compared post-rehabilitation support from peer educators, respiratory therapists (RT), or UC. Primary outcome variables were St. George's Respiratory Questionnaire (SGRQ) total score and the six minute walk test (6MWT). Measures were obtained at baseline, immediately following PR, and six-months post PR.

Results

Six-month follow-up data for phase one was collected for 66 COPD patients (n = 35 peer support, n = 31 UC) and 142 for phase two (n = 42 peer support, n = 52 RT support, n = 48 UC). Per-protocol and intention to treat (ITT) analysis in both phases found no significant group by time differences for SGRQ or 6MWT.

Conclusion

Providing peer or RT support via telephone following PR was not more effective than UC for maintaining health outcomes.

Practice implications

There are concerns with using peers to provide ongoing support to COPD patients. Additionally, COPD patients require a higher level of care than telephone support can provide.     

Validation of a Preparation for Decision Making scale

Objective

The Preparation for Decision Making (PrepDM) scale was developed to evaluate decision processes relating to the preparation of patients for decision making and dialoguing with their practitioners. The objective of this study was to evaluate the scale's psychometric properties.

Methods

From July 2005 to March 2006, after viewing a decision aid prescribed during routine clinical care, patients completed a questionnaire including: demographic information, treatment intention, decisional conflict, decision aid acceptability, and the PrepDM scale.

Results

Four hundred orthopaedic patients completed the questionnaire. The PrepDM scale showed significant correlation with the informed (r = −0.21, p < 0.01) and support (r = −0.13, p = 0.01) subscales (DCS); and discriminated significantly between patients who did and did not find the decision aid helpful (p < 0.0001). Alpha coefficients for internal consistency ranged from 0.92 to 0.96. The scale is strongly unidimensional (principal components analysis) and Item Response Theory analyses demonstrated that all ten scale items function very well.

Conclusion

The psychometric properties of the PrepDM scale are very good.

Practice Implications

The scale could allow more comprehensive evaluation of interventions designed to prepare patients for shared-decision making encounters regarding complex health care decisions.     

Communication matters: The impact of communication and participation in decision making on breast cancer patients’ depression and quality of life

Objective

This study explored the impact of breast cancer patients’ experiences of physician–patient communication and participation in decision making on patient depression and quality of life three and six months after primary treatment.

Methods

Participants were 135 German breast cancer patients, recruited within a week after the beginning of treatment. Women were asked to complete a self-administered questionnaire at baseline and three and six months later.

Results

Patients who rated their level of information at baseline as high were less depressed after three (p = .010) and six months (p < .001) and experienced higher quality of life after three (p < .001) and six months (p = .049). Patients who participated as much as they had wanted were more satisfied with the decision making process (p < .001) and had lower depression scores three months later (p = .005). The level of participation itself (passive, collaborative, active) and the treatment type had no impact.

Conclusion

The findings reveal the significance of physician–patient communication and stress the meaning of baseline depression for later adjustment.

Practice implications

A high level of information and tailoring the involvement in decision making to patients’ desired level can help patients to better cope with their illness. Physicians should assess and treat depression early in cancer treatment.     

Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials

Objective

Motivational Interviewing (MI) is a method for encouraging people to make behavioral changes to improve health outcomes. We used systematic review and meta-analysis to investigate MI's efficacy in medical care settings.

Methods

Database searches located randomized clinical trials that compared MI to comparison conditions and isolated the unique effect of MI within medical care settings.

Results

Forty-eight studies (9618 participants) were included. The overall effect showed a statistically significant, modest advantage for MI: Odd ratio = 1.55 (CI: 1.40–1.71), z = 8.67, p < .001. MI showed particular promise in areas such as HIV viral load, dental outcomes, death rate, body weight, alcohol and tobacco use, sedentary behavior, self-monitoring, confidence in change, and approach to treatment. MI was not particularly effective with eating disorder or self-care behaviors or some medical outcomes such as heart rate.

Conclusion

MI was robust across moderators such as delivery location and patient characteristics, and appears efficacious when delivered in brief consultations.

Practice implications

The emerging evidence for MI in medical care settings suggests it provides a moderate advantage over comparison interventions and could be used for a wide range of behavioral issues in health care.     

The effects of a transtheoretical model-based exercise stage-matched intervention on exercise behavior in patients with coronary heart disease: A randomized controlled trial

Objective

To determine whether a transtheoretical model-based exercise stage-matched intervention (ESMI) has positive effects on the exercise behavior of sedentary patients with coronary heart disease (CHD).

Methods

The study was a randomized controlled trial with a repeated measures design. Participants (N = 196) were randomly allocated to either a conventional (C) group, a patient education (PE) group, or an ESMI group. Exercise behavior was measured by exercise stages of change, exercise self-efficacy, exercise decisional balance, and duration of moderate exercise at baseline, immediate post-intervention, and at 3- and 6-month follow-up.

Results

Our results showed that the ESMI group demonstrated a more positive shift in exercise stages of change (p < 0.01), higher exercise self-efficacy (p < 0.01), greater exercise benefits (p < 0.01), fewer exercise barriers (p < 0.01), and longer moderate exercise duration (minutes/week) (p < 0.01) after completion of the 8-week intervention compared with the C and PE groups. These significantly positive effects were maintained at 3- and 6-month follow-up.

Conclusion

The transtheoretical model-based ESMI had significantly positive effects on the exercise behavior of sedentary CHD patients.

Practice implications

It is important to provide a structured education program for CHD patients, preferably guided by the transtheoretical model.     

Association of myasthenia gravis with polymorphisms in the gene of histamine N-methyltransferase

Introduction

Histamine N-methyltransferase (HNMT) is the main metabolizing enzyme of histamine. Histamine modulates immune responses and plays a role in the pathogenesis of autoimmune disorders.

Methods

The non-synonymous HNMT C314T polymorphism and the A939G single-nucleotide polymorphism (SNP) influencing HNMT mRNA stability were genotyped in 213 patients with myasthenia gravis (MG) and 342 healthy controls.

Results

The carrier frequency of the A allele of the A939G SNP was over-represented among patients with anti-AchR and anti-Titin antibodies (P = 0.05 and P = 0.004, respectively); the presence of the minor G allele was protective against anti-AchR and anti-Titin positive MG (OR = 0.67 and OR = 0.54, respectively). The combination of the G allele carrier status with wild-type C314C homozygosity was also protective against MG (OR = 0.55, P = 0.008) and against the development of anti-AchR antibodies (OR = 0.37, P = 0.01).

Discussion

The A939G HNMT polymorphism is associated with autoimmune MG, while no association with C314T SNP was found.     

Greater professional empathy leads to higher agreement about decisions made in the consultation

Objective

To examine the relationship between professional expression of empathy and agreement about decisions made in the consultation.

Methods

Consultations between 86 individuals with diabetes and four dieticians were audio-recorded. Immediately following consultations patients and dieticians independently reported decisions made in a booklet. Audio-recordings were coded directly for empathy using an amended version of the empathic communication coding system (ECCS).

Results

Empathy correlated significantly with patient and professional agreement about decisions made in the consultation (τ = .283, p = .0005). Multiple regression analysis indicates that for each dietician the greater the empathy the higher the level of agreement about decisions (p < .0005). Professional empathic response to patients statements of challenge was a significant factor in increasing agreement about decisions (p = .008).

Conclusion

Results support the hypothesis that greater professional empathy will result in greater agreement about decisions made in consultations.

Practice implications

Findings have implications for empathy training and provide guidance on the communication skills needed to support expression of empathy. Patient and professional agreement about decisions made provides a simple marker of effectiveness and highlights the importance of empathy as a seminal component of professional communication skills during a patient consultation.     

Motivational interviewing by HIV care providers is associated with patient intentions to reduce unsafe sexual behavior

Objective

Motivational interviewing (MI) can promote behavior change, but HIV care providers rarely have training in MI. Little is known about the use of MI-consistent behavior among untrained providers. This study examines the prevalence of such behaviors and their association with patient intentions to reduce high-risk sexual behavior.

Methods

Audio-recorded visits between HIV-infected patients and their healthcare providers were searched for counseling dialog regarding sexual behavior. The association of providers’ MI-consistence with patients’ statements about behavior change was assessed.

Results

Of 417 total encounters, 27 met inclusion criteria. The odds of patient commitment to change were higher when providers used more reflections (p = 0.017), used more MI consistent utterances (p = 0.044), demonstrated more empathy (p = 0.049), and spent more time discussing sexual behavior (p = 0.023). Patients gave more statements in favor of change (change talk) when providers used more reflections (p < 0.001) and more empathy (p < 0.001), even after adjusting for length of relevant dialog.

Conclusion

Untrained HIV providers do not consistently use MI techniques when counseling patients about sexual risk reduction. However, when they do, their patients are more likely to express intentions to reduce sexual risk behavior.

Practice implications

MI holds promise as one strategy to reduce transmission of HIV and other sexually transmitted infections.     

Randomised controlled trial of a pedometer-based telephone intervention to increase physical activity among cardiac patients not attending cardiac rehabilitation

Objective

To determine the effectiveness of a pedometer-based telephone intervention on the physical activity levels of cardiac patients who did not attend a CRP.

Methods

A randomised controlled trial was conducted with 215 patients referred to a CRP but who could not or chose not to attend. The 6-week intervention included self-monitoring of physical activity using a pedometer and step calendar; and behavioural counselling and goal setting sessions. Data were collected at baseline, 6 weeks and 6 months.

Results

Study groups did not differ significantly at baseline. After 6 weeks, improvements in total physical activity time (p = 0.027), total physical activity sessions (p = 0.003), walking time (p = 0.013) and walking sessions (p = 0.002) in the intervention group were significantly greater than the control group after adjusting for baseline differences, and remained significant at 6 months.

Conclusion

The findings that the pedometer-based telephone intervention was successful in increasing physical activity levels in cardiac patients who did not attend a CRP could result in major health benefits for this group of people.

Practical implications

The pedometer-based telephone intervention could be offered as an effective and accessible option for patients not attending a CRP to increase and maintain their physical activity levels after hospitalisation.     

The effects of two health information texts on patient recognition memory: A randomized controlled trial

Objective

To compare the effects of two health information texts on patient recognition memory, a key aspect of comprehension.

Methods

Randomized controlled trial (N = 60), comparing the effects of experimental and control colorectal cancer (CRC) screening texts on recognition memory, measured using a statement recognition test, accounting for response bias (score range −0.91 to 5.34). The experimental text had a lower Flesch–Kincaid reading grade level (7.4 versus 9.6), was more focused on addressing screening barriers, and employed more comparative tables than the control text.

Results

Recognition memory was higher in the experimental group (2.54 versus 1.09, t = −3.63, P = 0.001), including after adjustment for age, education, and health literacy (β = 0.42, 95% CI: 0.17, 0.68, P = 0.001), and in analyses limited to persons with college degrees (β = 0.52, 95% CI: 0.18, 0.86, P = 0.004) or no self-reported health literacy problems (β = 0.39, 95% CI: 0.07, 0.71, P = 0.02).

Conclusion

An experimental CRC screening text improved recognition memory, including among patients with high education and self-assessed health literacy.

Practice implications

CRC screening texts comparable to our experimental text may be warranted for all screening-eligible patients, if such texts improve screening uptake.