Association of postural balance and falls in adult patients receiving haemodialysis: A prospective cohort study.

BACKGROUND: Static postural balance performance is often impaired in people receiving haemodialysis (HD) for the treatment of stage-5 chronic kidney disease (CKD-5). However, the question as to whether lower postural balance is associated with adverse clinical outcomes such as falls has not been addressed yet. RESEARCH QUESTION: We conducted a prospective cohort study to explore the association between static postural balance and falls in people receiving HD. We hypothesised that higher postural sway would be associated with increased odds of falling. METHODS: Seventy-five prevalent CKD-5 patients receiving HD (age: 61.8 ± 13.4 years) from three Renal Units were enrolled in this prospective cohort study. At baseline, postural balance was assessed with a force platform in eyes open (EO) and eyes closed (EC) conditions. Centre of pressure (CoP) measures of range, velocity and area were taken for the analysis. Falls experienced by study participants were prospectively recorded during 12 months of follow-up. Secondary outcomes included timed-up and go, five-repetition sit-to-stand test and the Tinetti falls efficacy scale (FES). RESULTS: In multivariable logistic regression analysis, higher CoP range in medial-lateral direction during EC was associated with increased odds of falling (OR: 1.04, 95 %CI: 1.00-1.07, p = 0.036). In ROC curve analysis, CoP velocity in EO exhibited the greatest prognostic accuracy (AUC: 0.69, 95 %CI: 0.55-0.82), however this was not statistically different from CoP measures of area and range. None of the postural balance measures exceeded the prognostic accuracy of the FES (AUC: 0.70, 95 %CI: 0.58-0.83, p = 0.005). SIGNIFICANCE: This prospective cohort study showed that higher postural sway in medial-lateral direction was associated with increased odds of falling in people receiving HD. CoP measures of range, velocity and area displayed similar prognostic value in discriminating fallers from non-fallers. The overall utility of static posturography to detect future fall-risk may be limited in a clinical setting.

The relative importance of frailty, physical and cardiovascular function as exercise-modifiable predictors of falls in haemodialysis patients: a prospective cohort study.

BACKGROUND: Stage 5 chronic kidney disease (CKD-5) patients on haemodialysis (HD) are at high risk of accidental falls. Previous research has shown that frailty is one of the primary contributors to the increased risk of falling in this clinical population. However, HD patients often present with abnormalities of cardiovascular function such as baroreflex impairment and orthostatic dysregulation of blood pressure (BP) which may also be implicated in the aetiology of falling. Therefore, we aimed to explore the relative importance of frailty and cardiovascular function as potential exercise-modifiable predictors of falls in these patients. METHODS: Ninety-three prevalent CKD-5 patients on HD from three Renal Units were recruited for this prospective cohort study, which was conducted between October 2015 and August 2018. At baseline, frailty status was assessed using the Fried's frailty phenotype, while physical function was evaluated through timed up and go (TUG), five repetitions chair sit-to-stand (CSTS-5), objectively measured physical activity, and maximal voluntary isometric strength. Baroreflex and haemodynamic function at rest and in response to a 60° head-up tilt test (HUT-60°) were also assessed by means of the Task Force Monitor. The number of falls experienced was recorded once a month during 12 months of follow-up. RESULTS: In univariate negative binomial regression analysis, frailty (RR: 4.10, 95%CI: 1.60-10.51, p = 0.003) and other physical function determinants were associated with a higher number of falls. In multivariate analysis however, only worse baroreflex function (RR: 0.96, 95%CI: 0.94-0.99, p = 0.004), and orthostatic decrements of BP to HUT-60° (RR: 0.93, 95%CI: 0.87-0.99, p = 0.033) remained significantly associated with a greater number of falls. Eighty falls were recorded during the study period and the majority of them (41.3%) were precipitated by dizziness symptoms, as reported by participants. CONCLUSIONS: This prospective study indicates that cardiovascular mechanisms implicated in the short-term regulation of BP showed a greater relative importance than frailty in predicting falls in CKD-5 patients on HD. A high number of falls appeared to be mediated by a degree of cardiovascular dysregulation, as evidenced by the predominance of self-reported dizziness symptoms. TRIAL REGISTRATION: ClinicalTrials.gov (trial registration ID: NCT02392299; date of registration: March 18, 2015).

Baroreflex function, haemodynamic responses to an orthostatic challenge, and falls in haemodialysis patients.

BACKGROUND: Stage 5 chronic kidney disease patients on haemodialysis (HD) often present with dizziness and pre-syncopal events as a result of the combined effect of HD therapy and cardiovascular disease. The dysregulation of blood pressure (BP) during orthostasis may be implicated in the aetiology of falls in these patients. Therefore, we explored the relationship between baroreflex function, the haemodynamic responses to a passive orthostatic challenge, and falls in HD patients. METHODS: Seventy-six HD patients were enrolled in this cross-sectional study. Participants were classified as "fallers" and "non-fallers" and completed a passive head up tilting to 60o (HUT-60°) test on an automated tilt table. ECG signals, continuous and oscillometric BP measurements and impedance cardiography were recorded. The following variables were derived from these measurements: heart rate (HR) stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR), number of baroreceptor events, and baroreceptor effectiveness index (BEI). RESULTS: The forty-four participants who were classified as fallers (57.9%) had a lower number of baroreceptor events (6.5±8.5 vs 14±16.7, p = .027) and BEI (20.8±24.2% vs 33.4±23.3%, p = .025). In addition, fallers experienced a significantly larger drop in systolic (-6.4±10.9 vs -0.4±7.7 mmHg, p = .011) and diastolic (-2.7±7.3 vs 1.8±6 mmHg, p = .027) oscillometric BP from supine to HUT-60° compared with non-fallers. None of the variables taken for the analysis were significantly associated with falls in multivariate logistic regression analysis. CONCLUSIONS: This cross-sectional comparison indicates that, at rest, HD patients with a positive history of falls present with a lower count of baroreceptor sequences and BEI. Short-term BP regulation warrants further investigation as BP drops during a passive orthostatic challenge may be implicated in the aetiology of falls in HD.

The utility of whole body vibration exercise in haemodialysis patients: a pilot study.

BACKGROUND: Exercise improves physical capacity in patients with end-stage renal disease on haemodialysis (HD), but few patients engage in it. Whole-body vibration exercise (WBVE) is a novel protocol that has been shown to benefit frail elderly patients' rehabilitation. We assessed the utility of WBVE before HD sessions and tested methods to inform the design of a randomized controlled trial (RCT). METHODS: Physical condition and quality of life were assessed at enrolment and repeated 2 weeks later in a pilot study of 49 patients undergoing regular HD. All patients then undertook 8 weeks of WBVE, thrice weekly for 3 min, after which the assessments were repeated and results compared (paired t-tests). Further assessments were made after a 4-week layoff. Patients completed a post-study questionnaire about their experiences of using WBVE. The reproducibility of WBVE and effects on measures of functionality, muscle strength, indirect exercise capacity, nutritional status, bone health and quality of life were recorded to undertake a power calculation for an RCT. RESULTS: Of 49 patients enrolled, 25 completed all assessments. The dropout rate was high at 49%, but overall, WBVE was an acceptable form of exercise. Functionality as assessed by the 60-s sit-to-stand test (STS-60) improved significantly by 11% (P = 0.002). Some quality of life domains also improved significantly. All improvements were maintained 4 weeks after discontinuing WBVE. CONCLUSIONS: WBVE was acceptable, safe, easily incorporated into the routine of HD and was associated with useful improvements in physical function sufficient to justify a RCT.

Patient experiences of nurse-led telephone follow-up following treatment for colorectal cancer.

PURPOSE: Colorectal cancer is the third most prevalent cancer worldwide, although mortality rates across most of Europe have decreased in recent years. Historically, patients are asked to return to hospital outpatient clinics following treatment to monitor for disease progression. However, new approaches are being called for that focus on meeting the information and support needs of patients. Telephone follow-up (TFU) by specialist nurses is an alternative approach; this study aimed to explore patient views of TFU. METHODS: Qualitative interviews were conducted with 26 colorectal cancer patients who had received TFU. One interview was also conducted with the specialist nurse who had used a structured intervention to provide TFU. Data were analysed using content analysis. RESULTS: All patients found TFU to be a positive experience and all stated a preference for continuing with TFU. Three main themes emerged from the patient interviews; 1) accessible and convenient care, 2) personalised care, and 3) relationship with the specialist nurse. The themes from the specialist nurse interview were 1) knowing the patient, 2) the benefits of TFU and 3) the challenges of TFU. CONCLUSIONS: TFU was well received by patients; it was perceived as highly convenient and had distinct advantages over hospital follow-up. Continuity of care was an important factor in building a trusting relationship between patient and nurse. Training in the use of the intervention is recommended and it may be useful for specialist nurses to initially meet eligible patients face to face to establish rapport before implementing TFU.

A Virtual World Versus Face-to-Face Intervention Format to Promote Diabetes Self-Management Among African American Women: A Pilot Randomized Clinical Trial.

BACKGROUND: Virtual world environments have the potential to increase access to diabetes self-management interventions and may lower cost. OBJECTIVE: We tested the feasibility and comparative effectiveness of a virtual world versus a face-to-face diabetes self-management group intervention. METHODS: We recruited African American women with type 2 diabetes to participate in an 8-week diabetes self-management program adapted from Power to Prevent, a behavior-change in-person group program for African Americans with diabetes or pre-diabetes. The program is social cognitive theory-guided, evidence-based, and culturally tailored. Participants were randomized to participate in the program via virtual world (Second Life) or face-to-face, both delivered by a single intervention team. Blinded assessors conducted in-person clinical (HbA1c), behavioral, and psychosocial measurements at baseline and 4-month follow-up. Pre-post differences within and between intervention groups were assessed using t tests and chi-square tests (two-sided and intention-to-treat analyses for all comparisons). RESULTS: Participants (N=89) were an average of 52 years old (SD 10), 60% had ≤high school, 82% had household incomes

Telephone follow-up after treatment for breast cancer: views and experiences of patients and specialist breast care nurses.

AIMS AND OBJECTIVES: To explore the views of patients and specialist breast care nurses on telephone follow-up after treatment for breast cancer. BACKGROUND: A recent randomised controlled trial demonstrated that nurse-led telephone follow-up led to high levels of patient satisfaction with no physical or psychological detriment. This study aimed to explore in more detail the views of patients randomised to telephone follow-up and the nurses who conducted telephone appointments. DESIGN: Qualitative. METHOD: Individual interviews with 28 patients and four specialist breast care nurses. Content analysis was used to analyse the interview data. RESULTS: Telephone follow-up was convenient for patients and provided continuity of care. Speaking on the telephone was perceived as a more 'normal' activity than attending hospital outpatient clinics. A structured approach was appreciated, instilling feelings of confidence that all questions had been asked and no errors had been made. Specialist nurses emphasised the high level of skill required to deliver the intervention and perceived that the telephone approach was well able to meet the individual needs of patients. CONCLUSIONS: Positive views on telephone follow-up were reported. An experienced and skilled practitioner, with effective communication skills, is required to deliver the intervention and a period of training is recommended. Nurse-led telephone interventions have a broader applicability to other disease conditions, although more work is needed to develop appropriate interventions and evaluate their effectiveness. RELEVANCE TO CLINICAL PRACTICE: Nurses at advanced levels of practice are uniquely placed to deliver such complex interventions. However, a period of initial training with effective peer support and channels for ongoing feedback are essential for administering an intervention that relies on audio rather than visual cues.

Promoting the health of people with chronic obstructive pulmonary disease: patients' and carers' views.

AIMS AND OBJECTIVES: The aim of this study was to generate in-depth insights into patients' and family members' understanding of the causation, progression and prevention of chronic obstructive pulmonary disease and the role of health promotion with this population. In particular, we were interested in identifying the ways patients and family members considered that they could maximise their (patients') health, in the presence of this disease. BACKGROUND: Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is, therefore, an important consideration. There are few examples in the literature of health promotion programmes for this population, including those directed at smoking cessation, which also focus on the family or significant others. DESIGN: An exploratory, descriptive design was employed. METHOD: Semi-structured, audio-recorded interviews were conducted with 14 patients and 12 family caregivers. Interviews were transcribed verbatim and thematically analysed using content analysis procedures which captured the meaning of the data. RESULTS: The three main themes were 'health promotion: what's that?', 'community resources for health promotion' and 'it wasn't just the smoking'. Many participants seemed unaware that their health might benefit from a healthier life style and provided little spontaneous information on any activities they carried out to maintain or improve their health. CONCLUSIONS: This study highlighted a dearth of health promoting activity amongst people affected by chronic obstructive pulmonary disease. The reality for most patients was to manage the day-to-day demands that the symptoms of the disease imposed on them. Our data suggest that a more wide-ranging approach, encompassing aspects of health promotion, might be welcomed by many patients and their family carers. RELEVANCE TO CLINICAL PRACTICE: The findings from this study highlight gaps in patients' and carers' understanding of the potential role of health promotion in chronic obstructive pulmonary disease and areas for intervention by health professionals. With the increase in smoking rates of women and predicted future increases in chronic obstructive pulmonary disease, it is imperative that health professionals find effective ways to provide support and health promotive care for patients and families.

A narrative review of interventions to support family carers who provide physical care to family members with cancer.

OBJECTIVES: Most reports of cancer caregivers' needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer. DESIGN: Narrative review. DATA SOURCES: Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews. REVIEW METHODS: All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied. RESULTS: In total, 19 studies were included in the review. Interventions focused on skills development (n=1), managing symptoms (n=9), problem solving (n=5) and learning (n=4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer. CONCLUSIONS: Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.

A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease.

AIMS AND OBJECTIVES: The objectives of this narrative review were to identify: (1) The information and support needs of carers of family members with chronic obstructive pulmonary disease; (2) appropriate interventions to support carers in their caregiving role; (3) information on carers' needs as reported in studies of patients living with COPD in the community. BACKGROUND: Chronic obstructive pulmonary disease is a major health problem in the UK resulting in significant burden for patients, families and the health service. Current National Health Service policies emphasise, where medically appropriate, early discharge for acute exacerbations, hospital-at-home care and other models of community care to prevent or reduce re-hospitalisations of people with chronic conditions. Understanding carers' needs is important if health care professionals are to support carers in their caregiving role. DESIGN: A narrative literature review. METHODS: Thirty five papers were reviewed after searching electronic databases. RESULTS: Few studies were identified which addressed, even peripherally, carers' needs for information and support, and no studies were found which described and evaluated interventions designed to enhance caregiving capacity. Several studies of hospital-at-home/early discharge, self care and home management programmes were identified which included some information on patients' living arrangements or marital status. However, there was little or no detail reported on the needs of, and in many cases, even the presence of a family carer. CONCLUSIONS: This review highlights the dearth of information on the needs of carers of chronic obstructive pulmonary disease patients and the need for future research. RELEVANCE TO CLINICAL PRACTICE: There is little research based knowledge of the needs of carers of chronic obstructive pulmonary disease patients and interventions to assist them in providing care. This knowledge is critical to ensure that carers receive the information they need to carry out this role while maintaining their own physical and emotional health.

Specialist community nurses: a critical analysis of their role in the management of long-term conditions.

The aim of this narrative review is to identify strategies in use by specialist community and public health nurses in the prevention, care and management of individuals with long-term conditions, specifically chronic obstructive pulmonary disease (COPD) and musculoskeletal disorders. These conditions have been selected as they are highly prevalent; a burden on health services globally and a major public health issue. From a UK policy perspective, specialist community nurses have been placed at the forefront of taking a lead role in the coordination and delivery of more responsive services for individuals with long-term conditions; whether this has been an effective use of skills and resource is questionable. We systematically searched relevant databases between 1999-2009 to identify interventions used by specialist community nurses and critically appraised the studies. This review reports on impact and value of interventions used by specialist community nurses in the prevention and management of COPD and musculoskeletal conditions, and makes recommendations for improving services.

Smoking behavior and patient education practices of oncology nurses in six countries.

Worldwide, tobacco is the leading cause of preventable death, resulting in approximately 5 million deaths annually. Nurses are keenly positioned to work toward reducing tobacco-related illness and deaths. Therefore, guided by the health belief model, the purpose of this study was to explore the smoking behavior, beliefs, smoking cessation education practices, and existing smoking policies at the institutions of a sample of practicing oncology nurses in Canada, Japan, Korea, Taiwan, United Kingdom, and the United States. A 27-item structured survey, designed for this study in English and translated and reverse translated by the Asian countries, was distributed to a convenience sample of nurses attending oncology meetings in each country. Totally 759 surveys were completed and analyzed using descriptive statistics. Principle findings indicate that 4.5% of these nurses currently smoke, although 23.3% reported smoking previously. While many nurses (74%) reported frequently assessing the smoking status of patients, only 50% reported discussing cessation with their patients that smoke. Although the majority (80%) reported feeling comfortable with asking their patients about smoking, only 23% felt it was the nurse's role. The findings indicate that while internationally oncology nurses recognize the importance of smoking cessation, significant room for improvement exists in translating this into practice.

Smoking cessation interventions in chronic obstructive pulmonary disease and the role of the family: a systematic literature review.

AIM: This paper is a report of a systematic review to assess the effectiveness of family-focused smoking cessation interventions for people with chronic obstructive pulmonary disease and to determine what data on families are documented in studies of smoking cessation interventions. BACKGROUND: Chronic obstructive pulmonary disease is a major public health problem and cigarette smoking is the most important factor contributing to its development and progression. However, smoking cessation rates are low and relapse is common. The role of families in smoking cessation efforts has received little attention. METHODS: All studies were included in the review that (i) addressed an evaluation of a psycho-social/educational smoking cessation intervention for people with chronic obstructive pulmonary disease, (ii) addressed some information on the family (i.e. living arrangements, marital status, smoking history of family members, support for quitting) and/or included the family as part of the intervention and (iii) were published between 1990 and 2006. Electronic data sources, existing systematic reviews of smoking cessation interventions and the grey literature were reviewed. RESULTS: Seven studies were included. Six studies (11 papers) included data on marital status, smoking status of household members, support for quitting smoking and related variables. In two of the studies, the variable on the family was used to analyse smoking cessation outcomes. One additional study met the inclusion criterion of an evaluation of a smoking cessation intervention, which also included a family focus in the intervention. CONCLUSION: No conclusions about the effectiveness of a family-focused smoking cessation intervention could be drawn from this review. Further research is needed to determine if a more family-focused intervention, in conjunction with pharmacological and counselling approaches, would lead to improved smoking cessation outcomes.

Relationship work in an early childhood home visiting program.

A significant component of the work of public health nurses and paraprofessional home visitors who provide home visits to families with young children involves establishing relationships to effectively deliver the visiting program. The purpose of this qualitative and descriptive study was to describe the relationships among participants in a home visiting program in one regional health authority in the Canadian province of Manitoba. Interviews were carried out with 24 public health nurses, 14 home visitors, and 20 parents. The findings related to establishing, maintaining, and terminating relationships as well as factors influencing relationship work are described. Public health nurses and home visitors put significant effort into the work of establishing relationships with each other and their clients and require adequate training, sufficient human resources, and support from the program's administration to sustain these relationships.

Caring for patients with COPD and their families in the community.

Community matrons have a key role to play in the management of patients with long-term conditions. With the expected increase in prevalence of Chronic Obstructive Pulmonary Disease (COPD), largely due to cigarette smoking, the management and care of patients with COPD is a priority for the NHS. This paper examines the current and future role of community matrons in the management of patients with COPD. Community matrons have a potential role in providing evidence based care and could fill a gap in the implementation of effective interventions to help patients and family members stop smoking. A family focused approach to assessment and case management are important to achieving quality care and management of these patients. Recommendations are made with respect to the improvement of service provision for individuals and families with COPD.

Issues related to delivering an early childhood home-visiting program.

PURPOSE: To describe the issues related to delivering an early childhood home visiting program, BabyFirst, from the perspective of public health nurses and lay home visitors (paraprofessionals). STUDY DESIGN AND METHODS: This descriptive, qualitative interpretive study had a sample of 24 public health nurses and 14 lay home visitors. One in-depth, semi-structured, audio-taped interview was conducted with each participant. Transcribed data were analyzed using content analysis techniques. RESULTS: Public health nurses and lay home visitors identified several issues associated specifically with the use of lay home visitors and more broadly with the delivery of the BabyFirst program. These are discussed in the following categories: issues related to (a) the lay home visitors, (b) the BabyFirst families, and (c) the general administration of the program. CLINICAL IMPLICATIONS: Findings from this study provide information about the issues related to providing home-visiting services delivered by lay home visitors that can be applied to policy and practice development. The findings suggest that in addition to careful selection of prospective applicants, considerable resources should be provided in preparing public health nurses and home visitors for their respective roles. The concerns identified by nurses and home visitors suggest the need to target the following three areas: (a) training and retention of nurses and home visitors, (b) program delivery, and (c) enrollment of families. Attention to the issues discussed in this article has implications for improving the BabyFirst home-visiting program and other similar early childhood programs.

"Living with risk": mothering a child with food-induced anaphylaxis.

Food-induced anaphylaxis (FIA) affects an increasing number of children and families encountered in a variety of nursing environments. Sensitive nursing care requires consideration of the psychosocial impact of the condition. The purpose of this phenomenological study was to arrive at an understanding of the mother's lived experience of parenting a child with FIA. Semistructured interviews were conducted with six mothers of children 6 to 12 years old considered at risk for FIA. Data analysis was carried out concurrently with data collection, revealing "Living with Risk" as the essence of the experience, supported by five themes: "Living with Fear," "Worrying About Well-Being," "Looking for Control," "Relying on Resources," and "It Is Hard But It Is Not." These findings should assist nurses in meeting families' education and support needs related to FIA.

Early childhood home visiting programme: factors contributing to success.

AIM: This paper reports a study of the factors that public health nurses, home visitors and parents consider important for the success of an early childhood home visiting programme. BACKGROUND: The primary aim of early child home visiting programmes is to promote healthy and safe growth and development of infants and children in at-risk families. Few studies have focused on actual programme components which foster this outcome. METHODS: The research was a descriptive, qualitative evaluation. Success of the programme was defined as positive changes in families which were seen as directly related to participation. The 58 participants were 24 public health nurses, 14 home visitors and 20 parents. One in-depth semistructured audio-taped interview was conducted with each participant between October 2003 and February 2004. All interviews were transcribed and analysed using open coding; themes and categories were developed and reviewed for congruence of coding. FINDINGS: Participants discussed several factors that they considered important for the success of the programme: its particular characteristics, the programme activities and the healthcare providers. CONCLUSION: Components contributing to the success of early childhood home visiting programmes include a strength-based philosophy, voluntary enrollment of parents, regularly scheduled home visits, a curriculum to structure the home visitor's interventions, and careful attention to the selection, training, and supervision of home visitors.

Use of a blood glucose monitoring manual to enhance monitoring adherence in adults with diabetes: a randomized controlled trial.

BACKGROUND: Frequent blood glucose (BG) monitoring is a critical component of diabetes management, yet many barriers exist to consistent monitoring. METHODS: In this randomized controlled trial, we sought to determine if an educational manual, the Blood Sugar Monitoring Owner's Manual (BGMOM), could increase adherence to BG monitoring by helping patients form realistic expectations and responses to BG monitoring results. The 199 participants were recruited from a multidisciplinary diabetes clinic and had high-risk diabetes (hemoglobin A(1C) >or=8.0%); 35% had type 1 diabetes mellitus. Participants were randomized to 1 of 3 groups: BGMOM intervention (BGM+), attention control (BG meter only [MT]), or standard care (SC). The BGM+ and MT groups received BG meters and meter education; the BGM+ group also received BGMOM booklets. The SC group received usual care. Data gathered during 6 months of follow-up included BG monitoring frequency and hemoglobin A(1C) measurement. RESULTS: Monitoring frequency increased significantly in the BGM+ group (1.9 +/- 1.3 to 2.8 +/- 1.5 times daily, P<.001) but only slightly in the MT group (1.7 +/- 1.3 to 2.0 +/- 1.3 times daily). The BGM+ group experienced the greatest improvement in hemoglobin A(1C) level (BGM+: -0.13 +/- 1.28; MT: -0.04 +/- 1.31; SC: 0.04 +/- 1.10). Further, a higher percentage of those in the BGM+ group (61%) improved their glycemic control compared with the other groups (44%; P = .05). Finally, the BGM+ group displayed the most knowledge about the definition of hemoglobin A(1C) (P = .04) and reported the least amount of negative affect about out-of-range BG monitoring results (P = .03). CONCLUSION: As an adjunct to standard diabetes education and support, a manual such as the BGMOM can help optimize BG monitoring and glycemic control.