[Show abstract][Hide abstract] ABSTRACT: Background: Several studies have reported on the co-occurrence of chronic obstructive pulmonary disease (COPD) and psychiatric conditions, with the most robust evidence base demonstrating an impact of comorbid anxiety and depression on COPD-related outcomes. In recent years, research has sought to determine if there is a co-occurrence between COPD and posttraumatic stress disorder (PTSD) as well as for associations between PTSD and COPD-related outcomes. To date, there have been no published reviews summarizing this emerging literature. Objectives: The primary objective of this review was to determine if there is adequate evidence to support a co-occurrence between PTSD and COPD. Secondary objectives were to: 1) determine if there are important clinical considerations regarding the impact of PTSD on COPD management, and 2) identify targeted areas for further research. Methods: A structured review was performed using a systematic search strategy limited to studies in English, addressing adults, and to articles that examined: 1) the co-occurrence of COPD and PTSD and 2) the impact of PTSD on COPD-related outcomes. To be included, articles must have addressed some type of nonreversible obstructive lung pathology. Results: A total of 598 articles were identified for initial review. Upon applying the inclusion and exclusion criteria, n=19 articles or abstracts addressed our stated objectives. Overall, there is inconclusive evidence to support the co-occurrence between PTSD and COPD. Studies finding a significant co-occurrence generally had inferior methods of identifying COPD; in contrast, studies that utilized more robust COPD measures (such as a physician exam) generally failed to find a relationship. Among studies that examined the impact of PTSD on COPD-related outcomes, there was more consistent evidence that PTSD affects the perception of respiratory symptom burden and management. In addition, methods for measuring an important confounder (smoking) were generally lacking. Conclusion: There is inconclusive evidence to support the co-occurrence of COPD and PTSD. There was stronger evidence implicating PTSD as an important comorbidity impacting COPD management. Further research is needed to: 1) determine whether or not COPD and PTSD are likely to be comorbid, and 2) further elucidate the mechanisms connecting PTSD and COPD-related outcomes.
Preview · Article · Oct 2015 · International Journal of COPD
[Show abstract][Hide abstract] ABSTRACT: The Hawthorne Effect is a prevalent observer effect that causes behavioral changes among participants of epidemiological studies or infection control interventions. The purpose of the review is to describe the origins of the Hawthorne Effect, to understand the term in relation to current scientific literature, to describe characteristics of the Hawthorne effect, and to discuss methods to quantify and overcome limitations associated with the Hawthorne Effect.
Infect. Control Hosp. Epidemiol.
No preview · Article · Sep 2015 · Infection Control and Hospital Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Background:
Age-related cognitive decline is common and well-documented. Cognitive speed of processing training (SOPT) has been shown to improve trained abilities (Useful Field of View; UFOV), but transfer to individual non-trained cognitive outcomes or neuropsychological composites is sparse. We examine the effects of SOPT on a composite of six equally weighted tests - UFOV, Trail-making A and B, Symbol Digit Modality, Controlled Oral Word Association, Stroop Color and Word, and Digit Vigilance.
681 patients were randomized separately within two age-bands (50-64, ≥ 65) to three SOPT groups (10 initial hours on-site, 10 initial hours on-site plus 4 hours of boosters, or 10 initial hours at-home) or an attention-control group (10 initial hours on-site of crossword puzzles). At one-year, 587 patients (86.2%) had complete data. A repeated measures linear mixed model was used.
Factor analysis revealed a simple unidimensional structure with Cronbach's α of 0.82. The time effect was statistically significant ( p < 0.001; ηp 2 = 0.246), but the time by treatment group ( p = 0.331), time by age-band ( p = 0.463), and time by treatment group by age-band ( p = 0.564) effects were not.
Compared to the attention-control group who played a computerized crossword puzzle game, assignment to 10-14 hours of SOPT did not significantly improve a composite measure of cognitive abilities.
No preview · Article · Sep 2015 · International Psychogeriatrics
[Show abstract][Hide abstract] ABSTRACT: Tobacco use adversely affects the health and readiness of military personnel. Although rates of cigarette smoking have historically been elevated among men serving in the military, less is known about tobacco use in servicewomen.
To examine the prevalence and correlates of tobacco use among women serving in the Active Component (AC) and Reserve/National Guard (RNG) as well as factors associated with starting to smoke during military service.
Cross-sectional surveys of 1320 women serving in the AC or RNG were used to examine cigarette use in servicewomen. Associations between self-reported tobacco use history, sociodemographics, military service, and psychosocial factors were investigated using logistic regression analyses.
Thirty-six percent of servicewomen had a lifetime history of cigarette use, with 18% reporting current smoking. Thirty-one percent of lifetime smokers initiated smoking during military service. Factors associated with current smoking included pay grade, marital status, use of psychotropic medications, past-year alcohol use, and lifetime illicit drug or illegal prescription medication use. An enlisted pay grade, being white, and a history of deployment were all associated with starting to smoke during military service.
Although progress has been made in reducing the gap in tobacco use between military and civilian populations, nearly 1 in 5 servicewomen in our sample smoked cigarettes. Further efforts are needed to address tobacco use in this population. In addition to providing resources to assist smokers with quitting, additional attention should be given to preventing smoking initiation, particularly among deployed female personnel.
[Show abstract][Hide abstract] ABSTRACT: Background Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids. Objective We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012. Design Observational cohort study using Veterans Health Administration (VHA) administrative databases. Participants All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year. Main Measures Prevalent and incident opioid receipt during each year of the study period. Key Results The overall prevalence of opioid receipt increased from 18.9 % of all veteran outpatients in FY2004 to 33.4 % in FY2012, a 76.7 % relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4 % vs. 32.9 %), and the youngest veterans (18–34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥80 years) (47.6 % vs. 17.9 %). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5 %, and the highest of 50.8 %. Annual incident opioid receipt increased from 8.8 % in FY2004 to 10.2 % in FY2011, with a decline to 9.8 % in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame. Conclusions Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.
No preview · Article · Dec 2014 · Journal of General Internal Medicine
[Show abstract][Hide abstract] ABSTRACT: Introduction
Our objective was to use meta-analytic techniques to assess the strength of the overall relationship and role of potential moderators in the association between smoking and depression in adults.
Two popular health and social science databases (PubMed and PsycINFO) were systematically searched to identify studies which examined the association between adult smoking behavior and major depressive disorder (MDD) or depressive symptoms. A total of 85 relevant studies were selected for inclusion. Studies were analyzed using a linear mixed effects modeling package (“lme4” for R) and the Comprehensive Meta-Analysis program version 2.
Multiple nested linear mixed-effects models were compared. The best fitting models were those that included only random study effects and smoking status. In cross-sectional studies, current smokers were more likely to be depressed than never smokers (OR = 1.50, CI = 1.39–1.60), and current smokers were more likely to be depressed than former smokers (OR = 1.76, CI = 1.48–2.09). The few available prospective studies, that used the requisite statistical adjustments, also showed smokers at baseline had greater odds of incident depression at follow-up than never smokers (OR = 1.62, CI = 1.10–2.40).
In cross-sectional studies, smoking was associated with a nearly two-fold increased risk of depression relative to both never smokers and former smokers. In the smaller set of prospective studies, the odds of subsequent depression were also higher for current than never smokers. Attesting to its robustness, the relationship between smoking and depression was exhibited across several moderators. Findings could help health care providers to more effectively anticipate co-occurring health issues of their patients. Several methodological recommendations for future research are offered.
No preview · Article · Oct 2014 · Addictive Behaviors
[Show abstract][Hide abstract] ABSTRACT: Objective:
We evaluated the effects of cognitive speed of processing training (SOPT) on the development of additional Instrumental Activities of Daily Living (IADL) difficulties and the reduction of depressive symptoms in the Iowa Healthy and Active Minds Study (IHAMS).
Six hundred eighty-one patients were randomized to 4 groups: 10 hr of on-site SOPT, 10 hr of on-site SOPT plus 4 hr of boosters, 10 hr of at-home SOPT, or 10 hr of on-site attention-control (crossword puzzles). Developing additional difficulties with IADLs and reductions in depressive symptoms 1 year later were evaluated using multiple logistic regression.
The on-site SOPT with boosters group had reduced odds of developing additional difficulties with IADLs (adjusted odds ratio [AOR] = 0.45, p = .044) compared with attention-controls. The on-site SOPT with boosters group also had increased odds of reduced depressive symptom levels (AOR = 2.93, p = .003) compared with attention-controls.
These findings provide evidence that SOPT transfers beyond the cognitive skills trained to meaningful downstream improvements in the lives of middle-aged and older adults.
No preview · Article · Sep 2014 · Journal of Aging and Health
[Show abstract][Hide abstract] ABSTRACT: Objective. Hand hygiene surveillance programs that rely on direct observations of healthcare worker activity may be limited by the Hawthorne effect. In addition, comparing compliance rates from period to period requires adequately sized samples of observations. We aimed to statistically determine whether the Hawthorne effect is stable over an observation period and statistically derive sample sizes of observations necessary to compare compliance rates. Design. Prospective multicenter cohort study. Setting. Five intensive care units and 6 medical/surgical wards in 3 geographically distinct acute care hospitals. Methods. Trained observers monitored hand hygiene compliance during routine care in fixed 1-hour periods, using a standardized collection tool. We estimated the impact of the Hawthorne effect using empirical fluctuation processes and F tests for structural change. Standard sample-size calculation methods were used to estimate how many hand hygiene opportunities are required to accurately measure hand hygiene across various levels of baseline and target compliance. Results. Exit hand hygiene compliance increased after 14 minutes of observation (from 56.2% to 60.5%; P < .001) and increased further after 50 minutes (from 60.5% to 66.0%; P < .001). Entry compliance increased after 38 minutes (from 40.4% to 43.4%; P = .005). Between 79 and 723 opportunities are required during each period, depending on baseline compliance rates (range, 35%-90%) and targeted improvement (5% or 10%). Conclusions. Limiting direct observation periods to approximately 15 minutes to minimize the Hawthorne effect and determining required number of hand hygiene opportunities observed per period on the basis of statistical power calculations would be expected to improve the validity of hand hygiene surveillance programs.
No preview · Article · Sep 2014 · Infection Control and Hospital Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Background: Visual reminders, such as point-of-use signs, are used to improve hand-hygiene (HH) compliance. To date, little attention has been given to the characteristics of signs associated with the greatest impact. Signs designed using language and concepts theoretically grounded in health behavior and communication theories have the potential to improve HH compliance. Methods: Four distinct point-of-use signs were designed using constructs in health behavior and communication theories: personal vs. patient susceptibility, gain vs. loss framing and social norms/appeal to professional role. A clinical trial of the 4 signs was embedded in a cluster-randomized trial (CRT). Two study questions were tested: 1) Do point-of-use signs improve HH overall? 2) Do certain messages on signs work better than others at improving HH? The CRT began in Mar 2011 in 11 wards and ICUs in three geographically distinct acute-care hospitals. In Feb 2012 the 4 signs were placed next to HH dispensers on 5 randomly chosen wards/ICUs. The remaining 6 control wards/ICUs did not have signs. HH compliance was determined by secret shopper direct observations of entry/exit compliance. Quasi-poisson mixed-effect models to account for within room correlation were used. Results: 13,221 HH opportunities were observed pre-intervention and 915 opportunities were observed in the intervention period. Baseline entry compliance was 38.8% in control and 34% on sign wards. Exit compliance was 56.4% in control and 52.5% on sign wards. Rooms with point-of-use signs had a non-significant 4.11% decrease in entry (p=0.71) and a non-significant 11.68% increase in exit (p=0.44) compliance. However, a sign with patient-focused and gain-framed language had the highest entry compliance 53% vs 29% for the other signs (p=0.042) and the highest exit compliance 79% vs 52% for the other signs (p=0.36). Conclusion: Overall, placement of point-of-use signs led to minimal improvement in HH compliance. However, a sign designed using a theoretically grounded approach with patient-focused and gain-framed language was associated with increased entry and exit compliance. Theoretically-guided HH interventions have the potential to improve HH.
No preview · Article · May 2014 · Infection Control and Hospital Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Age-related cognitive decline is common and may affect memory, orientation, attention, abstract thinking and perception, which may lead to substantial difficulties and disabilities in everyday life. Much evidence suggests that computerized cognitive training interventions may mitigate decline by improving neuropsychological outcomes in older adults, but there is clearly a need for large-scale, methodologically rigorous comparative effectiveness trials in the area. This article underscores that need and reviews eight trials that met a set of predetermined criteria before highlighting two novel and complementary analytic methods - big data analytics and network meta-analysis - that may be used to facilitate decisions regarding which cognitive training programs should serve as candidate interventions for large comparative effectiveness trials.
No preview · Article · Mar 2014 · Journal of Comparative Effectiveness Research
[Show abstract][Hide abstract] ABSTRACT: This paper examines blood pressure (BP) control after 6 months of an intensive pharmacist-managed intervention in a mixed-methods randomized controlled trial conducted at the Iowa City Veteran Affairs Health Care System and two community-based outreach clinics. Patients received the pharmacist intervention for the first 6 months. The study coordinator conducted a summative evaluation with 37 patients 18 to 24 months following the initial 6-month intervention period. BP was significantly reduced in diabetic patients following an intensive pharmacist intervention (-8.0/-4.0±14.4/9.1 mm Hg systolic/diastolic, P<.001 and P=.001, respectively). BP was reduced even more in nondiabetic patients (-14.0/-5.0±1.9/10.0 mm Hg, P<.001). Medication adherence significantly improved from baseline to 6 months (P=.017). BPs were significantly lower at 6 months following an intensive pharmacist intervention. Patients also expressed a high level of satisfaction with and preference for co-management of their hypertension, as well as other chronic diseases.
Full-text · Article · Feb 2014 · Journal of Clinical Hypertension
[Show abstract][Hide abstract] ABSTRACT: The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians' (EPs) and nurses' (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A's framework (Ask-Advise-Assess-Assist-Arrange) in the ED.
We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.
The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients' receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A's in the ED.
There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.Trial registration: ClinicalTrials.gov registration number NCT00756704.
Full-text · Article · Jan 2014 · Addiction science & clinical practice
[Show abstract][Hide abstract] ABSTRACT: Blood pressure exhibits circadian variability, and nighttime blood pressure is one of the best predictors of cardiovascular (CV) events. Adults with hypertension who lack a nighttime dipping pattern are at particularly high risk. Several studies have found that bedtime dosing of antihypertensive agents reduces sleep blood pressure and improves the dipping pattern in nondippers. One small study and 2 substudies of diabetes and chronic kidney disease suggest that bedtime dosing of ≥1 antihypertensives significantly reduced CV events. A Cochrane review of 5 studies found no difference in adverse events between morning and evening dosing. However, several evaluations in ophthalmology have found that nocturnal arterial hypotension precipitated ocular vascular disorders such as ischemic optic neuropathy. Some authors have suggested that additional studies of nighttime dosing of antihypertensive agents that evaluate CV events need to be conducted. The authors describe a randomized controlled pragmatic trial that is being planned at the University of Iowa and Duke University. Patients with hypertension and other comorbid conditions will be randomized to either continue morning dosing of all antihypertensive agents or to switch their nondiuretic medications to bedtime dosing. Patients will be followed for 36 to 42 months. This study will determine whether nighttime dosing reduces CV risk when compared with traditional morning dosing of antihypertensive agents.
Full-text · Article · Dec 2013 · Journal of Clinical Hypertension
[Show abstract][Hide abstract] ABSTRACT: This paper examines baseline characteristics from a prospective, cluster-randomized trial in 32 primary care offices. Offices were first stratified by percentage of minorities and level of clinical pharmacy services and then randomized into 1 of 3 study groups. The only differences between randomized arms were for marital status (P=.03) and type of insurance coverage (P<.001). Blood pressures (BPs) were similar in Caucasians and minority patients, primarily blacks, who were hypertensive at baseline. On multivariate analyses, patients who were 65 years and older had higher systolic BP (152.4±14.3 mm Hg), but lower diastolic BP (77.3±11.8 mm Hg) compared with those younger than 65 years (147.4±15.0/88.6±10.6 mm Hg, P<.001 for both systolic and diastolic BP). Other factors significantly associated with higher systolic BP were a longer duration of hypertension (P=.04) and lower basal metabolic index (P=.011). Patients with diabetes or chronic kidney disease had a lower systolic BP than those without these conditions (P<.0001). BP was similar across racial and socioeconomic groups for patients with uncontrolled hypertension in primary care, suggesting that patients with uncontrolled hypertension and an established primary care relationship likely have different reasons for poor BP control than other patient populations.
Full-text · Article · Jun 2013 · Journal of Clinical Hypertension