Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial.

AIMS: To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy. METHODS: We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment. RESULTS: Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes. CONCLUSIONS: Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02056431).

Symbioses: a key driver of insect physiological processes, ecological interactions, evolutionary diversification, and impacts on humans.

Symbiosis is receiving increased attention among all aspects of biology because of the unifying themes it helps construct across ecological, evolutionary, developmental, semiochemical, and pest management theory. Insects show a vast array of symbiotic relationships with a wide diversity of microorganisms. These relationships may confer a variety of benefits to the host (macrosymbiont), such as direct or indirect nutrition, ability to counter the defenses of plant or animal hosts, protection from natural enemies, improved development and reproduction, and communication. Benefits to the microsymbiont (including a broad range of fungi, bacteria, mites, nematodes, etc.) often include transport, protection from antagonists, and protection from environmental extremes. Symbiotic relationships may be mutualistic, commensal, competitive, or parasitic. In many cases, individual relationships may include both beneficial and detrimental effects to each partner during various phases of their life histories or as environmental conditions change. The outcomes of insect-microbial interactions are often strongly mediated by other symbionts and by features of the external and internal environment. These outcomes can also have important effects on human well being and environmental quality, by affecting agriculture, human health, natural resources, and the impacts of invasive species. We argue that, for many systems, our understanding of symbiotic relationships will advance most rapidly where context dependency and multipartite membership are integrated into existing conceptual frameworks. Furthermore, the contribution of entomological studies to overall symbiosis theory will be greatest where preoccupation with strict definitions and artificial boundaries is minimized, and integration of emerging molecular and quantitative techniques is maximized. We highlight symbiotic relations involving bark beetles to illustrate examples of the above trends.

Supplemental insurance and use of effective cardiovascular drugs among elderly medicare beneficiaries with coronary heart disease.

CONTEXT: Cost-sharing in US prescription drug coverage plans for elderly persons varies widely. Evaluation of prescription drug use among elderly persons by type of health insurance could provide useful information for designing a Medicare drug program. OBJECTIVE: To determine use of effective cardiovascular drugs among elderly persons with coronary heart disease (CHD) by type of health insurance. DESIGN, SETTING, AND PATIENTS: Cross-sectional evaluation of 1908 community-dwelling adults, aged 66 years or older, with a history of CHD or myocardial infarction from the 1997 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. MAIN OUTCOME MEASURES: Use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), beta-blockers, and nitrates, and out-of-pocket expenditures for prescription drugs, stratified by type of health insurance: Medicare without drug coverage (Medicare only or self-purchased supplemental insurance) or with drug coverage (Medicaid, other public program, Medigap, health maintenance organization, or employer-sponsored plan). RESULTS: Statin use ranged from 4.1% in Medicare patients with no drug coverage to 27.4% in patients with employer-sponsored drug coverage (P<.001). Less variation between these 2 types occurred for beta-blockers (20.7% vs 36.1%; P =.003) and nitrates (20.4% vs 38.0%; P =.005). In multivariate analyses, statin use remained significantly lower for patients with Medicare only (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05-0.49) and beta-blocker use was lower for Medicaid patients (OR, 0.55; 95% CI, 0.34-0.88) vs those with employer-sponsored coverage. Nitrate use occurred less frequently in persons lacking drug coverage (patients with Medicare only, P =.049; patients with supplemental insurance without drug coverage, P =.03). Patients with Medicare only spent a much larger fraction of income on prescription drugs compared with those with employer-sponsored drug coverage (7.9% vs 1.7%; adjusted P<.001). CONCLUSION: Elderly Medicare beneficiaries with CHD who lack drug coverage have disproportionately large drug expenditures and lower use rates of statins, a class of relatively expensive drugs that improve survival.

The case for a medicare drug coverage benefit: a critical review of the empirical evidence.

The lack of an outpatient prescription drug benefit under Medicare has become a conspicuous omission in the face of accelerated growth in prescription drug expenditures and increased availability of highly effective medications. This article provides a critical review of the empirical evidence on the effect of drug coverage on the use of prescription drugs, health care outcomes, and health care costs among Medicare beneficiaries. The existing literature provides considerable evidence that drug coverage is associated with greater use of all drugs and clinically essential medications and that not all forms of coverage provide the same protection. Longitudinal evidence from elderly and disabled persons in Medicaid indicates that restricting coverage has serious adverse health outcomes for sick and low-income beneficiaries that actually lead to increased health care costs.

Use of antihypertensive drugs by Medicare enrollees: does type of drug coverage matter?

Research has demonstrated that Medicare beneficiaries with drug coverage consume more clinically essential drugs. However, generosity of coverage varies considerably across beneficiaries. This study examines the association between types of drug coverage and the consumption and cost per tablet of essential antihypertensive medications among beneficiaries with hypertension. The findings indicate that while both state- and employer-sponsored drug coverage are associated with greater consumption of antihypertensive drugs and lower out-of-pocket costs per tablet, private supplemental coverage is not associated with greater use and is associated with only slightly lower out-of-pocket costs than among noncovered beneficiaries.

Application of the vestibular disorders activities of daily living scale.

OBJECTIVE: Existing scales of functional performance are either insufficiently sensitive or omit some important daily life tasks. This paper demonstrates that a new scale of self-perceived disablement in the vestibularly impaired population-the Vestibular Disorders Activities of Daily Living Scale (VADL)-differentiates between disabled and healthy persons and evaluates the associations of this assessment with other measures of vestibular disorders. STUDY DESIGN: Prospective. METHODS: Subjects were 1) asymptomatic, healthy adults, 2) patients with benign paroxysmal positional vertigo, 3) patients with chronic vestibulopathy excluding Meniere's disease, postsurgical vertigo, and postconcussion vertigo, and 4) family members. Patient were assessed on the VADL, the Dizziness Handicap Inventory, level of vertigo, and computerized dynamic posturography. Healthy subjects and family members completed the VADL. RESULTS: The VADL differentiates healthy persons from patients but does not differentiate between patient groups. Patients perceived themselves as more independent than their spouses perceived them to be. Scores are weakly correlated with vertigo frequency and posturography scores for conditions with unreliable kinesthesia and absent or unreliable vision. The VADL is more responsive to higher levels of impairment than the Dizziness Handicap Inventory. CONCLUSIONS: This well-normed, self-administered scale of self-perceived disablement is useful for evaluating the functional status of patients with peripheral vestibular disorders. Perceptions of patients and significant others vary, but scores are moderately correlated with some standard measures of vestibular function. As it assesses a different domain of function than do standard diagnostic tests, the VADL will augment these tests during initial evaluation and may be useful for assessing posttreatment change.

Evidence of self-report bias in assessing adherence to guidelines.

OBJECTIVE: To assess trends in the use of self-report measures in research on adherence to practice guidelines since 1980, and to determine the impact of response bias on the validity of self-reports as measures of quality of care. METHODS: We conducted a MEDLINE search using defined search terms for the period 1980 to 1996. Included studies evaluated the adherence of clinicians to practice guidelines, official policies, or other evidence-based recommendations. Among studies containing both self-report (e.g. interviews) and objective measures of adherence (e.g. medical records), we compared self-reported and objective adherence rates (measured as per cent adherence). Evidence of response bias was defined as self-reported adherence significantly exceeding the objective measure at the 5% level. RESULTS: We identified 326 studies of guideline adherence. The use of self-report measures of adherence increased from 18% of studies in 1980 to 41% of studies in 1985. Of the 10 studies that used both self-report and objective measures, eight supported the existence of response bias in all self-reported measures. In 87% of 37 comparisons, self-reported adherence rates exceeded the objective rates, resulting in a median over-estimation of adherence of 27% (absolute difference). CONCLUSIONS: Although self-reports may provide information regarding clinicians' knowledge of guideline recommendations, they are subject to bias and should not be used as the sole measure of guideline adherence.

An exploratory study of arm-reach reaction time and eye-hand coordination.

The study examined the time taken to reach and touch keys positioned both within and just outside the traditional reach envelope, as well as within and just outside the region of easy visibility, defined as being within a 30 degrees cone centered on the line of sight. Movements were required from a start key positioned in front of the subject to a response key positioned at one of 140 positions, defined by seven heights (from 360 to 1080 mm above the seat reference point (SRP), five angles (in vertical planes positioned from 30 degrees across the body to 90 degrees ipsilaterally) and four radii (from 200 mm closer to the body than the normal reach boundary to 100 mm further away than the normal reach boundary). The time taken was divided into detection time (the time from illumination of response signal to release of start key), and movement time (the time from release of start key to contact with response key). Results suggested that the visual cone should be extended downwards, as detection time increased rapidly to keys positioned outside the visual cone upwards, but not in the downwards direction. In general, responses to keys positioned anywhere that was both within the reach envelope and also within the visual cone took approximately the same time, from 371 to 420 ms. Movement time increased with distance moved, but disproportionately so, up to 595 ms, when movement was required to positions that were at one or more of the extremes of height, angle or radius.

Automatic teller machines and the older population.

Subjects aged 50 years or older who had never used an automatic teller machine (ATM) were trained to use an ATM manufactured by NCR. There were four groups of 20 subjects. In all groups the training ended with a brief demonstration. Group 1 received the demonstration alone. Group 2 received a flash-card based training task which taught the meaning of the ATM keys. Group 3 received a simulator-based task which taught the idea of pressing buttons sequentially in order to complete a task unrelated to ATMs. Group 4 received all conditions. Results indicated that the demonstration alone was unsuccessful but that there were significant gains from both of the active training tasks. Results from a questionnaire suggested that, for the better performers, the training task also increased motivation to use an ATM. The implications of the results for a practical training task are discussed.

Conspicuity in realistic scenes: an eye-movement measure.

An experiment is described to measure the distracting effects of advertisements on the conspicuity of routing signs in realistic scenes. Slides of railway station scenes were shown in which subjects had to search for a target word used in a routing sign present in the scene. Eye movements were recorded to determine search time and number of fixations during search time. Both search time and number of fixations increased systematically with the number of advertisements in two of the three experimental scenes. The distribution of fixations over the scenes is discussed.

Control of cardiac response under aversive stimulation. Superiority of a heart-rate feedback condition.

The relative heart rate effects of biofeedback training, deep muscle relaxation, and a no-feedback/music procedure were compared during two criterion situations. The first consisted of a 25-min training period during which subjects received the assigned treatments. The second consisted of the pre- to posttraining reductions in heart rate reactivity to a series of aversive tone-shock trials. On the first criterion, the heart rate decreases of the feedback and no-feedback/music groups were not clearly distinguishable; however, both groups fell significantly below the muscle-relaxation group. By contrast, on the second criterion, the three groups were clearly distinguishable, with feedback subjects evidencing the most heart rate "control", followed by the muscle-relaxation and no-feedback/music groups, respectively. On the segment of the posttraining aversive trials conducted in the absence of the feedback signal, transfer of heart rate control was incomplete for feedback subjects, but still remained below the level of the other two groups. Training effects were more pronounced on tonic than on phasic heart rate changes. The difference between the two criterion situations suggests the possible need for and feasibility of employing a situational arousal methodology in evaluating the extent and limitation of physiological training procedures.

Short-term memory for intonation.

Ss were presented with lists of 16 words, each word spoken in one of four intonations. The final word was a repetition of one of the first 15 words, 40 Ss having to judge whether it was spoken in the same intonation as its earlier occurrence. A control group of 40 Ss did a similar task, ignoring intonation. Retention of intonation was significantly poorer, indicating that intonation is an additional load not normally retained. This argues against acoustic or articulatory encoding in short-term memory and in favor of an abstract-verbal encoding mode. Results are also interpreted as supporting the position that verbal and motor short-term membory obey similar laws.

The role of visual feedback in short-term motor memory.

Previous experiments examining the role of feedback in short-term motor memory have permitted vision not only during the movement, but also of the starting and terminal positions. In the present experiment, presence or absence of vision (a) prior to the start of the movement, and (b) during the movement were independently manipulated in a 2 × 2 between-subjects design, using 15 subjects per group. During prior vision subjects were able to see the terminal position of the movement they were about to make. Results, showing that vision during the movement did not contribute to performance, were taken as providing evidence against the Adams (1971) closed-loop theory of motor learning.