Nurses' attitudes concerning the delivery of brief cessation advice to hospitalized smokers.

BACKGROUND: Nurses have a unique opportunity to assist hospitalized smokers with cessation. However, relatively little is known about nurses' attitudes and beliefs toward their role in assisting patients with cessation. METHODS: A cross-sectional survey of staff nurses at four hospitals was conducted. Four scales based on constructs from the Theory of Planned Behavior were developed for this survey: attitudes toward offering cessation advice, beliefs about the outcome of offering advice, perceived normative beliefs, and perceived ability to offer advice. Other survey items included sociodemographics, employment characteristics (shift, unit worked), and personal smoking status. RESULTS: Of the nurses surveyed, 397 (68%) returned completed questionnaires. Nurses had a relatively positive attitude toward helping patients to quit smoking, 63% believed that hospitalization was an ideal time for patients to try to quit smoking, and 59% believed a nurse had an obligation to advise patients to quit smoking. In the final multiple linear regression model, self-reported delivery of cessation advice was related to attitudes toward offering cessation advice, perceived ability to offer advice, and unit worked. CONCLUSIONS: Efforts should be made to educate staff nurses about the efficacy of brief cessation advice and current smoking cessation methods and practices.

Factors associated with the risk of liver enzyme elevation in patients with type 2 diabetes treated with a thiazolidinedione.

STUDY OBJECTIVE: To characterize frequency of liver enzyme elevation in patients with type 2 diabetes mellitus receiving troglitazone. DESIGN: Retrospective study. SETTING: Hospital-affiliated medical center. PATIENTS: Two hundred ninety-one patients with type 2 diabetes mellitus. INTERVENTION: Data from patients with an average troglitazone exposure of 412.7 +/- 255.6 days were studied. MEASUREMENTS AND MAIN RESULTS: Enzyme elevations more than 1.5 times the upper limit of normal (ULN) occurred in 17 patients (5.8%) and more than 3-fold elevations in 6 (2.1%). The relationship among enzyme elevation events, demographic factors, duration of troglitazone exposure, frequency of monitoring, and concurrent drugs (limited to glucose and lipid-lowering agents) was assessed by multiple logistic regression. Age was an independent predictor of risk (p=0.009), and concurrent insulin therapy approached statistical significance (p=0.051) for 1.5-fold ULN elevation in liver enzymes. Age and concurrent therapy with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors were the only significant predictors of 3-fold ULN elevations (p=0.03 and p=0.04, respectively). CONCLUSION: Several factors appear to increase the risk of enzyme elevation events in patients treated with troglitazone.

Diabetes disease stage predicts weight loss outcomes with long-term appetite suppressants.

OBJECTIVES: Characterize degree of weight loss with stage of diabetes and describe its effect on cardiovascular disease risk factors in obese patients with and without diabetes. RESEARCH METHODS AND PROCEDURES: Retrospective cohort analysis from patients participating in a long-term weight management protocol using diet, exercise, behavioral modification, and appetite-suppressant therapy. Patient groups, with (n = 19) and without diabetes (n = 19) were matched for age, gender, and weight before weight loss therapy. The effect of 12 months of therapy on weight, blood pressure, glycemic control, lipid profile, and medication requirements were tested. Additionally, patients were grouped or staged based upon therapy required for control of diabetes at the beginning of weight loss intervention. Analysis of covariance described relationships between diabetes disease stage and weight loss at 12 months. RESULTS: Nondiabetic patients had greater mean reduction in BMI than the diabetic group (7.98 kg/m2 vs. 4.77 kg/m2, p<0.01). A significant linear trend (p<0.001) for decreasing weight loss with stage of diabetes was observed. Blood pressure, lipid profile, and glycemia improved significantly. The average daily glyburide-equivalent dose decreased from 9.4 to 3.0 mg (p<0.01). DISCUSSION: Patients with diabetes lost less weight than similarly obese patients without diabetes. Regardless of differential weight loss between groups, cardiovascular disease risk factors improved. Hypoglycemic medication requirements decreased with weight loss therapy. A predictive relationship may exist between diabetes disease stage before weight loss therapy and future weight loss potential.

The prevalence of cardiac valvular insufficiency assessed by transthoracic echocardiography in obese patients treated with appetite-suppressant drugs.

BACKGROUND: After case reports of cardiac-valve abnormalities related to the use of appetite suppressants were published, we undertook a study to determine the prevalence of the problem using transthoracic echocardiography. METHODS: We examined patients who had taken dexfenfluramine alone, dexfenfluramine and phentermine, or fenfluramine and phentermine for various periods. We enrolled obese patients who had taken or were taking these agents during open-label trials from January 1994 through August 1997. We also recruited subjects who had not taken appetite suppressants and who were matched to the patients for sex, height, and pretreatment age and body-mass index. The presence of cardiac-valve abnormalities, defined by the Food and Drug Administration and Centers for Disease Control and Prevention as at least mild aortic-valve or moderate mitral-valve insufficiency, was determined independently by at least two cardiologists. Multivariate logistic-regression analysis was used to identify factors associated with cardiac-valve abnormalities. RESULTS: Echocardiograms were available for 257 patients and 239 control subjects. The association between the use of any appetite suppressant and cardiac-valve abnormalities was analyzed in a final matched group of 233 pairs of patients and controls. A total of 1.3 percent of the controls (3 of 233) and 22.7 percent of the patients (53 of 233) met the case definition for cardiac-valve abnormalities (odds ratio, 22.6; 95 percent confidence interval, 7.1 to 114.2; P<0.001). The odds ratio for such cardiac-valve abnormalities was 12.7 (95 percent confidence interval, 2.9 to 56.4) with the use of dexfenfluramine alone, 24.5 (5.9 to 102.2) with the use of dexfenfluramine and phentermine, and 26.3 (7.9 to 87.1) with the use of fenfluramine and phentermine. CONCLUSIONS: Obese patients who took fenfluramine and phentermine, dexfenfluramine alone, or dexfenfluramine and phentermine had a significantly higher prevalence of cardiac valvular insufficiency than a matched group of control subjects.

Predicting psychiatric emergency admissions and hospital outcome.

OBJECTIVES: A decision support tool for psychiatric hospital admissions was developed and validated to provide reliable, clinically relevant information to providers and case managers. METHODS: Using the Severity of Psychiatric Illness rating system, an empirical model of psychiatric emergency decision-making was constructed and validated on a spilt sample of 254 crisis cases. RESULTS: Three dimensions of the Severity of Psychiatric Illness system-Suicide Potential, Danger to Others, and Severity of Symptoms-were used to construct a model that successfully predicted 73% of decisions about level of care (inpatient or outpatient). Clear misses, patients with a 0.20 probability of being hospitalized who were admitted, and patients with an 0.80 probability or greater of being hospitalized who were not admitted were reviewed to allow for utilization review. This decision support tool then was validated by predicting hospital outcomes in two additional samples. First, a random sample of consecutive admissions to a not-for-profit psychiatric hospital were studied. Second, a panel of admissions from a large managed care firm were evaluated. CONCLUSIONS: Results demonstrate that the decision to hospitalize patients in psychiatric hospitals is rational and that models predicting admission also can predict in-hospital outcomes.

Patterns of mental health service utilization.

How many and which individuals, with which psychiatric disorders, receive (and do not receive) mental health services from which professionals in what settings? This question falls within the purview of mental health services research, which is a multidisciplinary field that brings together the methodologies of epidemiology, econometrics, and clinical research. First, in this article, we present an explication of what is known about those individuals in need of psychotherapy and how they access services. Next, we describe the numbers, professional affiliations, and service sites of professionals who are engaged in the practice of psychotherapy. We summarize our current knowledge about the actual utilization of psychotherapy services relative to the needs of patients and the professional background of therapists. Finally, we identify aspects of psychotherapy service utilization that are, as yet, unaddressed.

The clinician's illusion and the psychotherapy practice: an application of stochastic modeling.

The caseload of practicing clinicians tends to be unrepresentative of the population of psychotherapy patients. This results from the fact that, although the majority of patients use relatively few treatment sessions, the majority of a clinician's time is spent with longer term cases--a minority of patients consume the majority of services. Here, a stochastic model is used to describe the development of caseloads under 4 different treatment regimens. It is shown that a psychotherapy practice will reach a steady state (a stable case mix) in relatively short time and at that this will limit the open appointment slots available each week to serve new patients. Implications for training and clinic staffing are discussed.

Using significance tests to evaluate equivalence between two experimental groups.

Equivalency testing, a statistical method often used in biostatistics to determine the equivalence of 2 experimental drugs, is introduced to social scientists. Examples of equivalency testing are offered, and the usefulness of the method to the social scientist is discussed.

PIP: Equivalency testing. currently used by biostatisticians to determine whether 2 drugs have an equally effective outcome, offers social scientists a method for analysis of various interventions. This is the method of choice when researchers are able to specify a small, non-zero difference between 2 treatments that can serve to define an equivalence interval around a difference of zero. The goal is to reject the null hypothesis and provide evidence for an alternative hypothesis that the difference between 2 groups is smaller than that specified in the null hypothesis. The process involves the definition of equivalency and the performance of 2 simultaneous 1-sided tests of the hypothesis. The Westlake confidence interval approach to equivalency is applied, for illustrative purposes, to data generated by 3 social scientific studies. In the 1st example, the procedure was used to determine whether the mean Minnesota Multiphasic Personality Inventory scores of drug addicted subjects were within 10% of the means of scores of alcoholic subjects. The 2nd study represented an attempt to assess the relative effectiveness of several therapeutic approaches (psychotherapy alone, psychotherapy in combination with antidepressant medication, behavioral approaches, cognitive therapy) to the treatment of depression. Finally, the 3rd study compared baseline characteristic equivalence among nonpregnant black adolescents, pregnant adolescents who carried to term, and those who aborted. It is noted that this method offers a means of evaluating published negative findings to determine whether a reasonable definition of equivalence exists. Moreover, equivalency testing can be used in the social sciences to justify the pooling of study groups.