Change in Objectively Measured Activity Levels Resulting from the EMPOWER Study Lifestyle Intervention.

Purpose: To examine changes in physical activity (PA) during a behavioral weight-loss intervention and determine baseline factors associated with PA goal achievement. Methods: Overweight/obese community-dwelling adults with valid PA accelerometer data (N=116; mean age 51.7 years; 89% female; 83% non-Hispanic White) were recruited into a single-arm prospective cohort study examining the effects of a 12-month intervention that included 24 in-person group sessions, weight-loss, calorie, fat gram, and PA goals, self-monitoring, and feedback. Minutes of moderate-to-vigorous (MV) PA and steps were measured using a waist-worn accelerometer (ActiGraph GT3x) at baseline, 6 months, and 12 months. Achievement of the 150 minute/week MVPA goal was examined using total minutes and bout minutes (i.e., counting only PA occurring in bouts ≥10 minutes in length). Change in PA was analyzed using non-parametric tests for multiple comparisons. Associations of factors with meeting the PA goal were modeled using binary logistic regression. Results: At 6 months, there were increases from baseline in MVPA (median [p25, p75]: 5.3 [-0.9, 17.6] minutes/day) and steps (863 [-145, 2790] steps/day), both p<0.001. At 12 months, improvements were attenuated (MVPA: 2.4 [-2.0, 11.4] minutes/day, p=0.047; steps: 374[-570, 1804] p=0.14). At 6 months, 33.6% of individuals met the PA goal (using total or bout minutes). At 12 months, the percent meeting the goal using total MVPA [31%] differed from bout MVPA [22.4%]. Male gender (OR=4.14, p=0.027) and an autumn program start (versus winter; OR=3.39, p=0.011) were associated with greater odds of goal achievement at 6 months. Conclusions: The intervention increased PA goal achievement at 6 and 12 months with many making clinically meaningful improvements. Our results suggest female participants may require extra support toward improving PA levels.

Experiences of Daily Weighing Among Successful Weight Loss Individuals During a 12-Month Weight Loss Study.

The purpose of the study was to describe participants' experience of daily weighing and to explore factors influencing adherence to daily weighing among individuals who were successful in losing weight during a behavioral weight loss intervention. Participants completed a 12-month weight loss intervention study that included daily self-weighing using a Wi-Fi scale. Individuals were eligible to participate regardless of their frequency of self-weighing. The sample ( N = 30) was predominantly female (83.3%) and White (83.3%) with a mean age of 52.9 ± 8.0 years and mean body mass index of 33.8 ± 4.7 kg/m2. Five main themes emerged: reasons for daily weighing (e.g., feel motivated, being in control), reasons for not weighing daily (e.g., interruption of routine), factors that facilitated weighing, recommendations for others about daily weighing, and suggestions for future weight loss programs. Our results identified several positive aspects to daily self-weighing, which can be used to promote adherence to this important weight loss strategy.

Trajectories of self-care agency and associated factors in lung transplant recipients over the first 12 months following transplantation.

Self-care agency (SCA), defined as one's ability and willingness to engage in self-care behaviors, can influence actual performance of self-care behaviors in lung transplant recipients (LTRs). Understanding patterns of SCA over time may inform the design of interventions to promote self-care in LTRs. Using group-based trajectory modeling, we sought to identify patterns and correlates of SCA among 94 LTRs over the first 12 months post-transplant. Baseline measures of sociodemographic, clinical, and psychosocial factors, and longitudinally assessed psychological distress were examined for their associations with predicted trajectory group membership. Three distinct stable (ie, zero slope) SCA trajectories were identified as follows: persistently low, persistently moderate, and persistently high. Based on the final multivariate model, requiring a re-intubation after transplant (P=.043), discharged to a facility rather than home (P=.048), and reporting a higher level of baseline anxiety (P=.001) were significantly associated with lower SCA. Linear mixed models revealed that higher levels of anxiety and depression were associated with lower SCA in the persistently moderate and low SCA groups over the 12-month time period (Ps<.05). LTRs who require a re-intubation after transplant and are discharged to a facility other than home, and report high psychological distress, may need additional assistance to engage in post-transplant self-care behaviors.

Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation.

Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.

Patterns of self-weighing behavior and weight change in a weight loss trial.

BACKGROUND/OBJECTIVES: Regular self-weighing has been associated with weight loss and maintenance in adults enrolled in a behavioral weight loss intervention; however, few studies have examined the patterns of adherence to a self-weighing protocol. The study aims were to (1) identify patterns of self-weighing behavior; and (2) examine adherence to energy intake and step goals and weight change by self-weighing patterns. SUBJECTS/METHODS: This was a secondary analysis of self-monitoring and assessment weight data from a 12-month behavioral weight loss intervention study. Each participant was given a scale that was Wi-Fi-enabled and transmitted the date-stamped weight data to a central server. Group-based trajectory modeling was used to identify distinct classes of trajectories based on the number of days participants self-weighed over 51 weeks. RESULTS: The sample (N=148) was 90.5% female, 81.1% non-Hispanic white, with a mean (s.d.) age of 51.3 (10.1) years, had completed an average of 16.4 (2.8) years of education and had mean body mass index of 34.1 (4.6) kg m(-2). Three patterns of self-weighing were identified: high/consistent (n=111, 75.0% self-weighed over 6 days per week regularly); moderate/declined (n=24, 16.2% declined from 4-5 to 2 days per week gradually); and minimal/declined (n=13, 8.8% declined from 5-6 to 0 days per week after week 33). The high/consistent group achieved greater weight loss than either the moderate/declined and minimal/declined groups at 6 months (-10.19%±5.78%, -5.45%±4.73% and -2.00%±4.58%) and 12 months (-9.90%±8.16%, -5.62%±6.28% and 0.65%±3.58%), respectively (P<0.001). The high/consistent group had a greater mean number days per week of adherence to calorie intake goal or step goal but not higher than the moderate/declined group. CONCLUSIONS: This is the first study to reveal distinct temporal patterns of self-weighing behavior. The majority of participants were able to sustain a habit of daily self-weighing with regular self-weighing leading to weight loss and maintenance as well as adherence to energy intake and step goals.

Fish oil supplementation does not lower C-reactive protein or interleukin-6 levels in healthy adults.

BACKGROUND: The n-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may prevent a range of chronic conditions through anti-inflammatory actions. However, as clinical trials using these fatty acids for primary prevention are yet unavailable, their putative role in disease prevention rests, in part, on evidence of anti-inflammatory actions in healthy individuals. OBJECTIVE: To investigate in a double-blind, placebo-controlled clinical trial whether supplementation with a moderate dose of EPA+DHA reduces common biomarkers of chronic, systemic inflammation in healthy individuals. METHODS: A total of 261 healthy individuals aged 30-54 years who were free of inflammatory conditions and consumed ≤ 300 mg per day EPA+DHA were included in the study. Participants were randomly assigned to 18 weeks of either fish oil supplementation providing 1400 mg per day EPA+DHA or matching placebo. Outcome measures were serum levels of C-reactive protein (CRP) and interleukin (IL)-6. In a substudy, ex vivo cytokine production was measured. Missing data for CRP and IL-6 were estimated using regression imputation. Data analyses conformed to intention-to-treat principles. RESULTS: Participant blinding was verified. Red blood cell EPA+DHA increased by 64% in the active treatment group, but serum CRP and IL-6 were not affected by supplementation (P ≥ 0.20). Findings were consistent with and without imputed values and across subgroups. Similarly, EPA+DHA supplementation did not alter ex vivo production of four pro-inflammatory cytokines (P ≥ 0.20). CONCLUSIONS: Supplementation with 1400 mg EPA+DHA did not reduce common markers of systemic inflammation in healthy adults. Whether this or a higher dose affects other measures of inflammation, oxidative stress or immune function warrants examination.

Feasibility of pedometers for adults with schizophrenia: pilot study.

The purpose of this prospective and observational design study was to assess the feasibility of using a pedometer and step log to explore level of physical activity (PA) and to assess motivation to be physically active in adults with schizophrenia. Descriptive statistics were used to analyse data of 7 male and 5 female subjects. Pedometer data indicated that subjects walked an average of 4731.03 (±3318.19) steps and 5002.58 (±3041.03) during the first week and second week of the study, respectively. A minimum 30-min walk was recorded on an average of 3.67 (±1.82) days (week one) and 4.5 (±1.88) days (week two). Step logs, inconsistently maintained by subjects, were not able to be analysed. Examination of the Motives for Physical Activity Measure-Revised (MPAM-R) at baseline indicates that exercise fitness and body appearance were subjects' primary motives for PA participation. Study findings indicate that it is feasible to use a pedometer to monitor the level of PA. However, maintenance of a concurrent step log requires further consideration to determine realistic outcomes. Extrinsically focused motivations for PA in this study sample may predict low PA adherence.

Medication-taking behaviours in young adults with schizophrenia: a pilot study.

The purpose of this prospective and observational study was to explore medication-taking behaviours in community-based young adults with schizophrenia using an electronic monitoring system and patient self-report questionnaires. The Medication Event Monitoring System (MEMS®), the Index for Medication Adherence (IMA) and the Brief Evaluation of Medication Influences and Beliefs (BEMIB) measured medication-taking behaviours. Data were collected at baseline, 4 and 8 weeks. Descriptive statistics were used in analysis. A total of 11 subjects were recruited; one dropped out. Five were male, and five were female. Average age was 32.64 (SD = 5.70) years. Four (40%) were White people; six (60%) were non-White people. The average number of medications treating schizophrenia was 1.9 (SD = 0.57). MEMS® identified 71.77% (SD = 30.47) dose adherence and 55.92% (SD = 31.27) day adherence. Most subjects took medications irregularly (early, late or missing). The BEMIB demonstrated that 50%, 20% and 30% of subjects considered themselves to be adherent to their medications at baseline, 4 weeks and 8 weeks, while the IMA reported 90%, 90% and 80% at baseline, 4 weeks and 8 weeks, respectively. Regarding the observed discrepancies between patients' reports and their actual medication-taking behaviours, clinical implications were discussed. Effective interventions improving medication adherence in schizophrenia are needed for practice and for future studies.

The effect of risedronate on hip structural geometry in chemotherapy-induced postmenopausal women with or without use of aromatase inhibitors: a 2-year trial.

INTRODUCTION: Osteoporosis is a major health problem for postmenopausal women. Adjuvant hormonal therapy with aromatase inhibitors (AIs) in postmenopausal breast cancer patients further worsens bone loss. Bisphosphonates are able to prevent AI-induced bone loss, but limited data exists on their effect on bone structure. Our objectives were to (1) examine the impact of AIs and no-AIs on hip structural geometry (HSA) of chemotherapy-induced postmenopausal women, and (2) determine if oral bisphosphonates could affect these changes. METHODS: This is a sub-analysis of a 2-year double-blind randomized trial of 67 women with nonmetastatic breast cancer, newly postmenopausal following chemotherapy (up to 8 years), who were randomized to risedronate, 35 mg once weekly (RIS) and placebo (PBO). Many women changed their cancer therapy from a no-AI to an AI during the trial. Outcomes were changes in Beck's HSA-derived BMD and structural parameters. RESULTS: Eighteen women did not receive adjuvant hormone therapy, while 41 women received other therapy and 8 received AIs at baseline distributed similarly between RIS and PBO. Women on AIs and PBO were found to have the lowest BMD and indices. RIS improved BMD and several HSA indices at the intertrochanteric site in women regardless of their hormonal therapy, but most improvement was observed in women who were not on AIs (all p< or =0.05 except buckling ratio). Changes at the narrow neck and femoral shaft were similar. CONCLUSION: The use of AIs appears to lead to lower HSA-derived BMD and hip structural indices as compared to women on no or non-AI therapy in chemotherapy-induced postmenopausal breast cancer patients. Preventive therapy with once weekly oral risedronate maintains structural, skeletal integrity independently of the use of or type of adjuvant therapy.

Acupuncture for systemic lupus erythematosus: a pilot RCT feasibility and safety study.

The objective of this study was to determine the feasibility of studying acupuncture in patients with systemic lupus erythematosus (SLE), and to pilot test the safety and explore benefits of a standardized acupuncture protocol designed to reduce pain and fatigue. Twenty-four patients with SLE were randomly assigned to receive 10 sessions of either acupuncture, minimal needling or usual care. Pain, fatigue and SLE disease activity were assessed at baseline and following the last sessions. Safety was assessed at each session. Fifty-two patients were screened to enroll 24 eligible and interested persons. Although transient side effects, such as brief needling pain and lightheadedness, were reported, no serious adverse events were associated with either the acupuncture or minimal needling procedures. Twenty-two participants completed the study, and the majority (85%) of acupuncture and minimal needling participants were able to complete their sessions within the specified time period of 5-6 weeks. 40% of patients who received acupuncture or minimal needling had >/=30% improvement on standard measures of pain, but no usual care patients showed improvement in pain. A ten-session course of acupuncture appears feasible and safe for patients with SLE. Benefits were similar for acupuncture and minimal needling.

Effect of risedronate on hip structural geometry: a 1-year, double-blind trial in chemotherapy-induced postmenopausal women.

INTRODUCTION: Chemotherapy-induced menopause is associated with bone loss. The effect on structural geometry is unknown. Our objective was to determine if oral bisphosphonate therapy could maintain or improve femoral geometry in breast cancer patients with chemotherapy-induced menopause. METHODS: This preplanned 1 year interim, secondary analysis of the Risedronate's Effect on Bone loss in Breast CAncer Study (REBBeCA Study) examined hip structure analysis (HSA), i.e. changes in the bone cross-sectional area (bone CSA), section modulus (SM: measure of bending strength), cortical thickness (CT) and buckling ratio (BR: index of cortical bone stability), in a double-blind trial of 87 newly postmenopausal, nonmetastatic breast cancer patients, randomized to risedronate, 35 mg once weekly (RIS) versus placebo (PBO). RESULTS: After 12 months, intertrochanteric parameters demonstrated percentage improvement (RIS vs. PBO) from baseline in bone CSA (mean+/-SD: 4.25+/-6.29 vs. 0.60+/-5.99%), SM (3.97+/-6.40 vs. 0.80+/-7.08%), and CT [5.20+/-6.98 vs. 1.13+/-6.87% (all p-values <0.05 except SM p=0,0643)]. Similar improvements were observed at the femoral shaft [bone CSA: 2.24+/-5.74 vs. -0.78+/-5.73%; SM: 1.62+/-6.23 vs. -1.39+/-7.06%; CT: 3.79+/-7.84 vs. -0.17+/-7.90% (all p-values <0.05, RIS vs. PBO, except SM p= p =0.0568)]. At both sites, the BR had significant decreases consistent with improved strength. CONCLUSION: We conclude that RIS improves measures of hip structural geometry in women with breast cancer following chemotherapy.

A randomized clinical trial of a standard versus vegetarian diet for weight loss: the impact of treatment preference.

BACKGROUND: With obesity rampant, methods to achieve sustained weight loss remain elusive. OBJECTIVE: To compare the long-term weight-loss efficacy of 2 cal and fat-restricted diets, standard (omnivorous) versus lacto-ovo-vegetarian, and to determine the effect of a chosen diet versus an assigned diet. DESIGN, SUBJECTS: A randomized clinical trial was conducted with 176 adults who were sedentary and overweight (mean body mass index, 34.0 kg/m(2)). Participants were first randomly assigned to either receive their preferred diet or be assigned to a diet group and second, were given their diet of preference or randomly assigned to a standard weight-loss diet or a lacto-ovo-vegetarian diet. Participants underwent a university-based weight-control program consisting of daily dietary and exercise goals plus 12 months of behavioral counseling followed by a 6-month maintenance phase. MEASUREMENTS: Percentage change in body weight, body mass index, waist circumference, low- and high-density lipoprotein, glucose, insulin and macronutrient intake. RESULTS: The program was completed by 132 (75%) of the participants. At 18 months, mean percentage weight loss was greater (P=0.01) in the two groups that were assigned a diet (standard, 8.0% (s.d., 7.8%); vegetarian, 7.9% (s.d., 8.1%)) than in those provided the diet of their choice (standard, 3.9% (s.d., 6.1%); vegetarian, 5.3% (s.d., 6.2%)). No difference was observed in weight loss between the two types of diet. Over the 18-month program, all groups showed significant weight loss. CONCLUSIONS: Participants assigned to their dietary preference did not have enhanced treatment outcomes. However, all groups lost weight with losses ranging from 4 to 8% at 18 months.

Staffing and pattern of mechanical restraint use across a multiple hospital system.

BACKGROUND: In an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals. OBJECTIVES: To determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing. METHODS: This was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1-12 months for a total of 566 cumulative months during 1999. RESULTS: The system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3-4.4%). More restraints were applied on night shifts (48.8%; n = 5,296) than on day (33.5%; n = 3,634) or evening shifts (17.7%; n = 1,926) (p < .0001) and most applied at midnight (31.7%; n = 3,441) followed by 0600-0900 (33.3%; n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001). CONCLUSIONS: Restraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Prevalence and recognition of depressive symptoms among homebound older adults with urinary incontinence.

Within a group of homebound elders with urinary incontinence, the objectives of this study were to (1) examine the prevalence of depressive symptoms, (2) examine the extent to which depression had previously been recognized by health care providers, (3) describe the type and intensity of antidepressant treatment prescribed for subjects, and (4) identify the demographic and functional characteristics associated with depressive symptomatology. A descriptive correlational design was used. The 15-item Geriatric Depression Scale (GDS-15) was administered to 345 homebound adults age 60 years and over referred to a study examining the effectiveness of behavioral therapy for urinary incontinence. Individuals were referred to the study by home care nurses from two large Medicare-approved home health agencies in a large metropolitan county in Pennsylvania. Data were collected during in-home assessments and by chart review. Measures included the GDS-15, structured medical history, in-home review of medications, Older Americans Research and Service Center Physical and Instrumental Activities of Daily Living scales, Mini-Mental State Examination (MMSE), Clock Drawing Test, Performance-Based Toileting Assessment, and bladder diaries. One half of the participants (n = 173; 50.1%) had significant depressive symptomatology, with 35.7% having scores suggesting mild depression and 14.5% severe depression. Only 26.4% and 34.7% of those with mild and severe depressive symptoms, respectively, had a previous diagnosis of depression and only 21.7% and 34.0%, respectively, had been prescribed an antidepressant. The most commonly prescribed class of antidepressants was tricyclic antidepressants, being taken by 9.0% (n = 31) of the total sample, 14 (11.4%) of those with mild symptoms and 4 (8.0%) of those with severe depressive symptomatology. A little over half (60.0%) of subjects being treated with antidepressants continued to exhibit significant depressive symptomatology. Greater dependence in physical activities of daily living, the need for assistance during ambulation, higher MMSE scores, and higher levels of comorbidity were associated (P < .05) with a GDS-15 score of 5 or higher. Depression symptoms are common in homebound older adults with urinary incontinence, but clinical recognition and treatment are limited.

Comparison of fever treatments in the critically ill: a pilot study.

BACKGROUND: Fever in critically ill patients is often treated with antipyretics or physical cooling methods. Although fever is a host defense response that may benefit some critically ill patients, others may not tolerate the cardiovascular demands associated with fever. OBJECTIVES: To compare antipyretics and physical cooling for their effects on core body temperature and cardiovascular responses in critically ill patients. METHODS: The antipyretic administered was 650 mg of acetaminophen. Physical cooling was accomplished by anterior placement of a cooling blanket at 18 degrees C. Core temperature and cardiovascular responses were measured in 14 febrile (body temperature, 38.8 degrees C) critically ill patients at baseline before treatment and up to 3 hours after treatment. Patients able to receive acetaminophen were randomly assigned to receive either acetaminophen only (n = 5) or acetaminophen in combination with a cooling blanket (n = 3). Patients not able to receive acetaminophen were treated with physical cooling only (n = 6). RESULTS: Mean body temperature decreased minimally from baseline to 3 hours after treatment in the physical-cooling-only group (from 39.1 degrees C to 39.0 degrees C) and in the physical cooling and acetaminophen group (from 39.1 degrees C to 38.6 degrees C), but the mean body temperature increased in the acetaminophen-only group (from 39.2 degrees C to 39.4 degrees C). Other notable findings included a slight increase in systemic vascular resistance index in the physical-cooling-only group and in the physical-cooling-plus-acetaminophen group. CONCLUSIONS: Although the study included only 14 subjects, the findings will provide information for future studies in febrile critically ill patients.

Primary care patients' personal illness models for depression: a preliminary investigation.

BACKGROUND: Despite the fact that more than half of depressed persons are treated for this disorder by primary care physicians, depression is often under-recognized or treated inadequately. There is continued emphasis on effective treatment of depression in primary care patients, but little attention has been paid to the role of the depressed person's illness cognitions in coping with this disorder. Given the often recurring and chronic nature of depression, the individual's self-management strategies may be critical to effective treatment, recovery and remaining well. OBJECTIVES: The purpose of this pilot study was to determine whether primary care patients' personal illness cognitions for depression are associated with depression coping strategies and treatment-related behaviour. METHODS: Forty-one primary care patients with depressive symptoms or disorder completed interviews and questionnaires assessing illness cognitions for depression, depression coping strategies and other treatment-related behaviour. Descriptive statistics are used to present patients' illness cognitions for depression. t-tests and correlational analyses were completed to assess the relationship between illness cognitions, depression coping strategies and treatment-related behaviour. RESULTS: Preliminary data describing illness cognitions for depression are presented. Participants' illness cognitions for depression were significantly associated with current and past treatment-seeking behaviour, medication adherence and coping strategies. CONCLUSIONS: Although preliminary, these findings indicate that patients' understanding of depression and its consequences are associated with how they manage this illness. Future research is needed to examine the mediating and moderating effects of illness cognitions for depression on medication adherence and other self-management behaviours of depressed primary care patients. Knowledge about primary care patients' personal illness models will aid in the development of adherence interventions, self-management training and support services appropriate to patients' needs in the primary care setting.

Circulating plasma leptin and IGF-1 levels in girls with premature adrenarche: potential implications of a preliminary study.

Premature adrenarche is a condition characterized by precocious development of pubic and/or axillary hair, due to early onset of adrenal androgen secretion. Girls with premature adrenarche may later develop menstrual irregularities, hyperandrogenism, and the classic polycystic ovary syndrome. As leptin is thought to modulate the onset of pubertal development, we measured plasma leptin levels in 7 girls with premature adrenarche, and 8 age-matched comparison girls. Because leptin, the hypothalamic-pituitary-adrenal (HPA), the hypothalamic-pituitary-gonadal axes are functionally interrelated, we also determined salivary and plasma cortisol, dehydroepiandrosterone (DHEA), DHEA-sulfate, androstenedione, estradiol, and estrone. Finally, since IGF-I may play a role in adrenocortical function, we determined plasma levels of IGF-1, and IGF-BP1. Plasma was collected by an intravenous catheter at times 0, 20, and 40 min, starting at 1.30 p.m. Girls with premature adrenarche had a higher body mass index (BMI) and an over two-fold elevation of their plasma leptin than comparison girls. This group also had elevated levels of salivary and plasma cortisol, and increased levels of DHEA, DHEA-S, androstenedione, estradiol and estrone. Plasma IGF-1 and the ratio of IGF-1/IGF-BP1 were elevated. We propose that girls with premature adrenarche may represent an overlapping group characterized by both features of increased adiposity and HPA axis activity, which together, and depending on the genetic/constitutional background of the individual, may account for the development of adrenal hyperandrogenism, and, later, the polycystic ovary syndrome.

Cognitive function and reproductive hormones in adjuvant therapy for breast cancer: a critical review.

Deterioration in cognitive function-particularly learning, memory, and attention-has been reported by women with breast cancer who receive adjuvant chemotherapy. Deficits in cognitive function reported by women with breast cancer are similar to those experienced by women as a consequence of natural or surgical menopause. The basis of these deteriorations may include reductions in reproductive hormone levels, particularly estrogens and progesterones, that occur as a result of adjuvant chemotherapy. This paper critically examines the literature related to the impact of adjuvant chemotherapy and reproductive hormone changes on cognitive function in women with breast cancer and suggests direction for future research in this area. The paper proposes a framework for investigation of the problem and discusses the challenges associated with the conduct of this research.

Problem drinking and medication adherence among persons with HIV infection.

OBJECTIVE: To examine the relation between problem drinking and medication adherence among persons with HIV infection. DESIGN: Cross-sectional survey. SETTING/PARTICIPANTS: Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998. MEASUREMENTS AND MAIN RESULTS: Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P =.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P =.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P <.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P <.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P =.10), running out of medications (15% vs 8%, P =.16), and consuming alcohol or drugs (26 % vs 3 %, P <.001). CONCLUSION: Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence.

Practice patterns related to mechanical restraint use across a multi-institutional health care system.

In recent years, regulatory and governmental initiatives have focused increased scrutiny on the use and practices associated with mechanical restraints. Consequently, hospitals are increasingly measuring and comparing both internally and externally their restraint practices as they strive to optimize their use and assure the safe care of patients being restrained. This study analyzes 12,860 restraint episodes from 10 acute care hospitals in a single health care system. Overall findings support many previously identified trends related to the types of restraints used and reasons for application. However, findings from this study also suggest that there are differences among rural, community, and tertiary hospitals. This study also provides the first widespread documentation of rates and types of alternative methods attempted and common patient care practices carried out during restraint application. These results can serve as external comparisons for other acute care settings as they strive to minimize and assure safety in restraint application.