A mixed method evaluation of a group‐based educational programme for CPAP use in patients with obstructive sleep apnea

Rationale, aims and objectives Continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA) has a low long‐term adherence. Educational interventions are few and sparsely described regarding content, pedagogical approach and participants' perceptions. The aim was to describe adherence to CPAP treatment, knowledge about OSA/CPAP, as well as OSA patients' perceptions of participating in a group‐based programme using problem‐based learning (PBL) for CPAP initiation. Educational programme The PBL programme incorporated elements from theories and models concerning motivation and habits. Tutorial groups consisting of four to eight patients met at six sessions during 6 months. Methods A sequential explanatory mixed method design was used on 25 strategically selected patients. Quantitative data regarding, clinical variables, OSA severity, CPAP use, and knowledge were collected at baseline, after 2 weeks and 6 months. Qualitative data regarding patients' perceptions of participation were collected after 6 months by semi‐structured interviews using a phenomenographic approach. Results 72% of the patients were adherent to CPAP treatment after 2 weeks and 6 months. All patients improved their baseline knowledge about OSA and CPAP after 2 weeks and sustained it after 6 months. Anxiety and fear, as well as difficulties and needs were motivational factors for participation. Patients described the difficulties of behavioural change, an awareness that improvements do not occur immediately, a realization of the importance of both technical and emotional support and the need for a healthier lifestyle. Conclusion and practice implications A group‐based programme using PBL seems to facilitate adaptive and developmental learning and result in acceptable CPAP adherence levels.     

Behavioral goal assessment in patients with persistent musculoskeletal pain

Identification and achievement of behavioral goals is an important issue in pain rehabilitation. For this dual purpose, we developed a patient-specific clinical tool—the Patient Goal Priority Questionnaire (PGPQ). Using the PGPQ, this study identifies patients' behavioral goals for physical therapy (PT) in a primary health care sample of patients with persistent musculoskeletal pain. In addition, this study examines the concurrent validity of the PGPQ in relation to a generic measure of disability, the Pain Disability Index (PDI). In all, 197 subjects participated in the study. The behavioral goals differed among the patients, comprehending several everyday activities and behaviors, and thus an individualized and behavioral focus was relevant for these patients. The PGPQ was negatively and moderately correlated with the PDI, indicating patient-specific properties of the new instrument. An elaborated version of the PGPQ can serve (a) as a clinical tool for identification of the patient's priorities of behavioral goals for PT, (b) as a clinical tool for collaborative formative evaluation during treatment, and (c) as a complementary measure in research for assessment of clinically significant changes related to behavioral performance.     

Prevalence of diastolic dysfunction as a possible cause of dyspnea in the elderly

PURPOSE: Symptoms in patients with heart failure and preserved left ventricular ejection fraction may be caused by isolated diastolic dysfunction. The purpose of this study was to assess the prevalence of diastolic dysfunction as a potential cause of dyspnea in a sample of elderly subjects, as well as of isolated diastolic dysfunction as a potential cause of dyspnea in a subgroup with a preserved left ventricular ejection fraction and normal lung function. METHODS: A total of 152 subjects with dyspnea underwent echocardiography, electrocardiography, and lung function testing. Subjects with normal lung function test results (n = 60) underwent cardiac magnetic resonance imaging, chest radiography, bicycle exercise tests, and blood tests. Left ventricular diastolic function was assessed by a variety of echocardiographic/Doppler techniques. RESULTS: Of 129 subjects with dyspnea, 81 (63%) had signs of lung disease or 'obvious' cardiac disease. In the remaining 48 subjects, 32 (67%) had a potential cardiac/noncardiac cause of dyspnea. In all subjects with dyspnea, 1% to 11% had diastolic dysfunction, and in the 48 remaining subjects, 0% to 10% had isolated diastolic dysfunction, depending on the definition used. CONCLUSION: The frequency of diastolic dysfunction was low in the sample of elderly subjects with dyspnea as well as in the subgroup of persons with no signs of lung disease, left ventricular systolic dysfunction, atrial fibrillation, or valvular heart disease. Diastolic dysfunction was infrequent as a possible cause of dyspnea, and coexisting potential causes of dyspnea were often present.     

Circulating adhesion molecules in allergic and non-allergic asthma

Circulating forms of adhesion molecules (intercellular-adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin ) are related to the turnover of these molecules on the cell surface. In contrast to the other molecules, the levels of E-selectin probably exclusively reflect the activity of endothelial cells. The aim of this study was to compare levels of circulating adhesion molecules in patients with allergic (AA) and non-allergic asthma (NA) and to relate the levels of soluble adhesion molecules to methacholine responsiveness and lung function. The study comprised 19 patients with AA, 15 patients with NA and 17 healthy subjects. Soluble adhesion molecules, spirometry, methacholine responsiveness and peak flow variability was measured. The group of patients with AA had higher levels of sE-selectin than the reference group (P=0.046). Serum levels of sE-selectin correlated significantly with bronchial responsiveness (r=0.76) and peak flow variability (r=0.75) (P<0.01) in the NA but not in the AA group. All adhesion molecules in AA (P<0.05-<0.001), but only sE-selectin in NA (P<0.05), were correlated to airway conductance. sVCAM-1 was reduced by inhaled steroids (P<0.01). Our results indicate that endothelial cells are activated in asthma and that this activity has a bearing on airflow variability and bronchial responsiveness in NA.     

Natriuretic peptides in unstable coronary artery disease.

Patients with unstable coronary artery disease (CAD), i.e., unstable angina or non-ST-elevation myocardial infarction, vary widely in clinical presentation, prognosis and response to treatment. To select appropriate therapy, early risk stratification has become increasingly important. This review focuses on the emerging role of natriuretic peptides in the early assessment of patients with unstable CAD. We conclude that levels of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are strongly associated to mortality and the risk of future congestive heart failure, and carry important prognostic information independent from previously known risk factors in unstable CAD. There are some data indicating that these markers can also be helpful in the selection of appropriate therapy in these patients but further studies are needed. Before a routine use of BNP or NT-proBNP in unstable CAD can be recommended, the cost-effectiveness of adding these new markers to the currently routine markers and their impact on selection of treatment needs further evaluation.     

Experiences of a low-intensity anticoagulation regimen for extended secondary prevention of venous thromboembolism

Extended treatment with vitamin K antagonists for more than 6 months is often used for secondary prevention of venous thromboembolism (VTE) in patients at high or moderate risk for recurrent events. The intensity of anticoagulant therapy is usually maintained at an International Normalized Ratio (INR) of 2-3. An INR of 1.5-2 might also prevent thromboembolic events with less complications of bleeding, but results from randomized trials are not yet available. In a non-prospective, uncontrolled study 40 patients with a history of VTE and an estimated high risk for recurrent events due to several previous events and/or thrombophilic defects were, after a median of 11.5 months on regular intensity anticoagulation (INR 2-3), switched to a low intensity regimen (INR 1.5-2). In six of the patients an estimated high risk for complications of bleeding contributed to this decision. After a median follow-up of 36 months (140 patient-years) recurrent events, complications of bleeding and some basic quality of life measurements regarding the new treatment were registered. No recurrent events, four minor bleedings and no major bleedings were registered. Twenty-six patients preferred an INR of 1.5-2 compared to 2-3. The main reasons for that preference were a lower risk for bleeding (13 patients) and less frequent monitoring of the INR (18 patients). No patient preferred full-dose anticoagulation at INR 2-3. In patients at a high risk for recurrence of VTE an initial period of regular intensity anticoagulation, followed by a low-intensity regimen, may provide effective and safe secondary prophylaxis.     

Autoantibodies against 21-hydroxylase and side-chain cleavage enzyme in autoimmune Addison's disease are mainly immunoglobulin G1

OBJECTIVE: Immunoglobulin G (IgG) antibodies to the steroidogenic enzymes 21-hydroxylase (21OH) and side-chain cleavage enzyme (SCC) are important diagnostic markers for autoimmune Addison's disease and autoimmune polyendocrine syndromes (APS) types I and II. The characterization of autoantibody (IgG) subclasses may reveal information on how tIssue destruction takes place; therefore, IgG subtypes of anti-21OH and anti-SCC antibodies from sera of patients with Addison's disease, APS I and APS II were determined using recombinant 21OH and SCC. METHODS: SCC(51-521) and his-SCC(51-521) were expressed by pET-scc in the Escherichia coli strain BL21 Star (DE3) and inclusion bodies were purified. Full-length, human 21OH fused to an N-terminal 6x histidine affinity tag was expressed in insect cells by using the baculovirus expression system bac-to-bac. Western blots were used to investigate the IgG subtype(s) of the autoantibodies against 21OH and SCC in patients and healthy blood donors. RESULTS: All anti-SCC positive sera (n=10) contained autoantibodies of the IgG1 subclass, while four out of ten also contained IgG3. All anti-21OH positive sera (n=16) had autoantibodies exclusively against IgG1. Sera from 20 healthy subjects did not show any reactivity against 21OH or SCC. CONCLUSIONS: The finding of a predominating IgG1 response against 21OH and SCC may suggest that T helper (Th) cells of the Th1 subclass are involved in destruction of the adrenal cortex in patients with autoimmune Addison's disease.