Patient Experience during the Support, Educate, Empower Glaucoma Coaching Program to Improve Medication Adherence: A Pilot Study.

PURPOSE: To understand patients' qualitative experiences with the Support, Educate, Empower (SEE) personalized glaucoma coaching program, provide a richer understanding of the components of the intervention that were useful in eliciting behavior change, and understand how to improve the SEE Program. DESIGN: A concurrent mixed-methods process analysis. PARTICIPANTS: Thirty-nine patients with a diagnosis of any kind of glaucoma or ocular hypertension who were aged ≥40 years, were taking ≥1 glaucoma medication, spoke English, self-administered their eye drops, and had poor glaucoma medication adherence (defined as taking ≤80% of prescribed medication doses assessed via electronic medication adherence monitors) who completed the 7-month SEE Program. METHODS: All participants who completed the study were interviewed in-person using a semistructured interview guide after the intervention. Coders conducted qualitative analysis of transcribed interviews using Grounded Theory. Participants were then stratified into groups based on change in adherence, and thematic differences between groups were examined. MAIN OUTCOME MEASURES: Themes that emerged from interviews categorized by the number of participants who expressed a theme and the number of representative citations. RESULTS: Participants expressed positive views toward the program overall (95%, n = 37/39). They perceived program components as working together to improve their medication adherence. Interactions with the glaucoma coach (38 participants, 184 citations), motivation to aid personal change (38 participants, 157 citations), personalized glaucoma education (38 participants, 149 citations), electronic reminders, and hearing their adherence score (37 participants, 90 citations) were most commonly cited by participants as helpful program elements contributing to improved adherence. Patients expressed a desire for personalized education to be a standard part of glaucoma care. Participants who demonstrated more improvement in adherence had a more trusting attitude toward the adherence score and a greater magnitude of perceived personal need to improve adherence. CONCLUSIONS: Participants reported a highly positive response to the in-person glaucoma education and motivational interviewing intervention used in conjunction with automated adherence reminders.

Preoperative predictors of renal function decline after radical nephroureterectomy for upper tract urothelial carcinoma.

OBJECTIVES: To model renal function after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). To identify predictors of renal function decline after surgery, thereby allowing the identification of patients likely to be ineligible for cisplatin-based chemotherapy in the adjuvant setting. PATIENTS AND METHODS: We retrospectively identified 374 patients treated with RNU for UTUC at three centres between 1995 and 2010. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation before RNU and at early (1-5 months after RNU) and late (>5 months) time points after RNU. Only patients deemed eligible for cisplatin-based chemotherapy before RNU (preoperative glomerular filtration rate [GFR] ≥60 mL/min/1.73 m(2) ) were included. Multivariable analysis identified the preoperative predictors of eGFR after RNU at early postoperative and late postoperative time points. RESULTS: A total of 163 patients had an eligible early post-RNU eGFR measurement and 172 had an eligible late eGFR measurement. The median eGFR declined by 32% and did not show a significant trend toward recovery over time (P = 0.4). On multivariable analysis preoperative eGFR and patient age were significantly associated with early and late postoperative eGFR, while Charlson comorbidity index score was significantly associated with late postoperative eGFR alone. CONCLUSIONS: In patients with normal preoperative eGFR (≥60 mL/min/1.73 m(2) ), renal function decreases by one-third after RNU and does not show evidence of recovery over time. Elderly patients and those with pre-RNU eGFR closer to 60 mL/min/1.73 m(2) (lower eGFR in the present cohort) are more likely to be ineligible for adjuvant cisplatin-based chemotherapy regimens because of renal function loss after RNU.

Contemporary management of small renal masses: does practice environment matter?

INTRODUCTION: Population based studies imply underutilization of renal preservation for managing small renal mass (SRMs). Limited information is available regarding the impact of practice environment on SRM treatment. We evaluated practice patterns for SRMs in the context of a urologist's practice environment. MATERIALS AND METHODS: Survey instrument querying practice type (private versus academic/academic affiliation) was distributed to urologists of the Mid-Atlantic section of the American Urological Association. Physicians were presented three case scenarios (exophytic 2.5 cm SRM in a healthy 55-year-old, healthy 75-year-old, and comorbid 75-year-old patient) and were queried on management. RESULTS: Of the 281 respondents who manage kidney cancer, 92 practiced in an academic environment, and 189 were private practitioners. Thirty-four percent had completed residency training within 10 years, 25% between 11-20 years, and 41% over 20 years. For SRMs in a healthy 55-year-old, over 95% of practicing nephrologists advocated nephron-sparing treatments. Nonetheless, private practitioners were more likely to perform a radical nephrectomy (6% versus 0%, p = 0.03) and less likely perform a partial nephrectomy (79% versus 91%, p = 0.01) than academic counterparts. We observed an increase in the percentage of urologists offering thermal ablation (38% versus 12%, p < 0.0001) and observation (29% versus 1%, p < 0.0001) with a corresponding decline in the use of partial nephrectomy (32% versus 83%, p < 0.0001) in the 75-year-old versus 55-year-old patient. When considering management of a SRM in 75-year-old patients (healthy or comorbid), private practitioners were more likely to offer a thermal ablative procedure when compared to academic urologists (41% versus 32%, p = 0.05). CONCLUSIONS: Over 95% of urologists espouse renal preservation strategies for a SRM in a healthy, young patient. Private practitioners are more likely to perform a radical (and less likely a partial) nephrectomy in this cohort. While surveillance is increasingly utilized for SRMs in the elderly patient, private practitioners are more likely to recommend active treatment via thermal ablation when compared to academic counterparts.

Calculated metabolic equivalents: a tool for exercise prescription among African American women.

BACKGROUND: Average daily steps (ADS) are a low-technology measurement of activity that is useful for exercise prescription. However, research demonstrates poor validity for ADS as a measure of exercise capability. We present a superior low-technology measure of exercise capability, which is easily applied by practitioners in clinical or nonclinical settings. METHODS: Based on analysis of baseline data from an intervention study to test a sustainable approach to long-term physical activity improvement for employed African American women, between 2005 and 2008, we examined exercise tolerance metabolic equivalents (METs) and ADS of 158 participants and generated an alternative measure of exercise capacity. We conducted regression analysis to determine the impact of key health indicators on exercise capacity and examined associations between our predictive model and true (MET) exercise performance. RESULTS: Using our predictive equation, 79.33% of participants were correctly categorized (very high, high, medium) based on our tool, with 10 women (6.67%) mischaracterized by one level higher than actual MET achievement and 21(14.00%) mischaracterized as one category lower than actual MET achievement. In contrast, using ADS alone resulted in 22.15% correctly categorized participants. CONCLUSIONS: The proposed tool is superior to existing low-technology measures of exercise capacity while retaining strong utility in nonclinical and low-resource settings.

Are urology residents adequately exposed to conservative therapies for managing small renal masses?

PURPOSE: Increasing diagnosis of small renal masses (SRMs) necessitates trainees to be familiar with available therapies. We hypothesized that involvement in conservative treatments (ablation and/or active surveillance) occurs infrequently. Therefore, we evaluated resident exposure and participation in treatments as well as proposed management for SRMs. METHODS: A survey was distributed to residents of the American Urologic Association and queried exposure to ablation and surveillance for SRMs. Three case scenarios (SRM in a healthy 55-year-old, healthy 75-year-old, and comorbid 75-year-old patient) were presented for management. RESULTS: Two hundred fifty-seven residents responded to the survey. Two hundred thirty-four (91%) reported ablation was offered at their institution, although only 140 (54%) ever participated in this procedure. Of these, 80 (57%) were involved in fewer than five procedures. Experience with ablation did not increase at higher levels of training (U3-61%, U4-66%, and U5-63%). Two hundred twenty-four (87%) residents noted exposure to surveillance for managing SRMs, increasing from 70% in U1 to 94% in U5. When considering case scenarios, management strategy shifted significantly from extirpation to ablation or surveillance as patient age and comorbidity profile increased. In particular, almost 50% of respondents advocated ablation for SRMs in a comorbid 75-year-old patient. CONCLUSIONS: Although most residents are adequately exposed to surveillance strategies for SRMs, only 54% participated in an ablative procedure. Nonetheless, almost 50% of residents recommended ablation to manage SRMs in the aging, comorbid patient. This suggests a disconnect between training and future practice pattern.

Systematic review of quality of life and other patient-centred outcomes after cardiac arrest survival.

OBJECTIVES: In cardiac arrest patients (in hospital and pre hospital) does resuscitation produce a good Quality of Life (QoL) for survivors after discharge from the hospital? METHODS: Embase, Medline, The Cochrane Database of Systematic Reviews, Academic Search Premier, the Central Database of Controlled Trials and the American Heart Association (AHA) Resuscitation Endnote Library were searched using the terms ('Cardiac Arrest' (Mesh) OR 'Cardiopulmonary Resuscitation' (Mesh) OR 'Heart Arrest' (Mesh)) AND ('Outcomes' OR 'Quality of Life' OR 'Depression' OR 'Post-traumatic Stress Disorder' OR 'Anxiety OR 'Cognitive Function' OR 'Participation' OR 'Social Function' OR 'Health Utilities Index' OR 'SF-36' OR 'EQ-5D' as text term. RESULTS: There were 9 inception (prospective) cohort studies (LOE P1), 3 follow up of untreated control groups in randomised control trials (LOE P2), 11 retrospective cohort studies (LOE P3) and 47 case series (LOE P4). 46 of the studies were supportive with respect to the search question, 17 neutral and 7 negative. DISCUSSION: The majority of studies concluded that QoL after cardiac arrest is good. This review demonstrated a remarkable heterogeneity of methodology amongst studies assessing QoL in cardiac arrest survivors. There is a requirement for consensus development with regard to quality of life and patient centred outcome assessment in this population.

One size fits all? Race, gender and body mass index among U.S. adults.

This study examined the extent to which factors presumed to be correlated with body mass index (BMI) vary across four race- and gender-specific groups. Data were drawn from the American Changing Lives Survey to estimate separate multivariate regression models for the total study sample that included African-American males, Caucasian males, African-American females and Caucasian females. The dependant variable of interest was BMI. Independent variables included age, human capital variables, relationship and support measures, health status and behavior measures, and stress and outlook measures. Results from the pooled model indicated that BMI was associated with a number of factors such as employment status, chronic illness, financial strain and religiosity. However, race- and gender-specific regression models revealed that predictors of BMI varied considerably for African-American men, Caucasian men, African-American women and Caucasian women. In other words, these models disentangled important correlations not observed in the pooled model. These findings suggest that addressing racial disparities in body weight-related outcomes requires health practitioners to modify obesity prevention and treatment efforts to incorporate a broader array of factors inherent to specific racial and gender populations.

Failure of chronic pallidal stimulation in dystonic patients is a medical emergency.

Deep brain stimulation (DBS) therapy is a continually expanding field of functional neurosurgery for the treatment of movement disorders and neuropathic pain. However, occurrence of adverse events related to implanted hardware cannot be ignored, particularly in patients with dystonic conditions. We report on two such patients who required emergency hospital admission and pulse generator re-implantation following sudden and unexpected cessation of DBS effectiveness resulting from battery failure.

Kindergarten readiness skills in children with sickle cell disease: evidence of early neurocognitive damage?

Young children with sickle cell disease are at risk of brain damage, including stroke. We tested the hypothesis that such patients are also at risk of cognitive impairment. We characterized the cognitive ability of kindergarten children to minimize the effect of disease-related school absence. The Memphis City Schools use the Developing Skills Checklist, a teacher-administered test given in the classroom, to assess kindergarten-appropriate skills. Data were obtained for 34 patients, who were matched to controls by gender, race, date of birth, school, and approximate income. Two controls were selected for each patient, and paired t-tests were used to compare patient's scores to composite control scores. Patients scored lower than controls in auditory discrimination (P < .01), and there was a trend (P < .10) toward lower patient scores in language. Deficits cannot be attributed to school absence and may predict academic problems for patients with sickle cell disease.