Predicting ability to drive after stroke

Efforts to redesign education in ambulatory settings are hampered by a lack of rigorous and coherent research on the learning process in these settings and the desired outcomes of the educational experiences. The authors present 13 priority research topics and 51 important research questions concerning education in ambulatory settings that were defined by a distinguished group of medical educators, clinicians, and policymakers who attended an invitational conference on education in ambulatory settings in 1996. The need to establish valid and reliable measures of quality and outcomes of educational programs and instructional interventions stood out as the major prerequisite for conducting research on education in ambulatory settings. Issues of theory building, research priorities, and research design are discussed, and policy recommendations are made for the development of valid measures of educational outcomes. The creation of a "Medical Education Outcomes Commission" is proposed to act as a repository for measures and instruments, and to provide the field with mechanism to validate instruments and uniform recommendations to conduct studies of quality. The authors urge funding agencies with missions that support medical education to invest in basic research on the outcomes of education in ambulatory settings.     

Worksite characteristics and changes in worksite tobacco-control initiatives. Results from the COMMIT study

Few studies have prospectively examined the characteristics associated with worksite adoption of tobacco-control initiatives. Data were collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, which conducted interventions in 11 communities. This smoking cessation intervention was based on community organization principles and delivered through multiple community channels, including worksites, health care providers, the media, and cessation resources. This article reports results from telephone interviews of intervention community worksites having 50 or more employees, conducted at baseline and the end of the intervention period. Among worksites that responded to both baseline and final surveys, 83% had not adopted a smoke-free policy at baseline, and 61% did not offer any cessation aid or quitting resources at baseline. By the final survey, 34% of those with no smoking ban at baseline had become smoke-free, and 36% of those offering no cessation assistance at baseline were offering cessation resources at the follow-up. The prevalence of policy adoption was higher among worksites employing more female employees and offering other health-promotion activities; manufacturing businesses were significantly less likely than businesses other than service and wholesale/retail businesses to adopt policies. Adoption of cessation programs was significantly more likely among worksites employing 100 to 249 workers, compared with those employing 50 to 99 workers; those predominantly employing men; those offering other types of health-promotion activities; and those with a higher rate of turnover. These results provide important information about the characteristics of worksites likely to engage in tobacco-control efforts. Health educators and others may choose to target those worksites most ready for adoption of tobacco control policies and programs, as indicated by these findings.     

a Medical Food-Supplemented Detoxification Program in the Management of Chronic Health Problems

Objective * To evaluate the effectiveness of a medical food-supplemented detoxification program versus a hypoallergenic, calorie-controlled diet alone in the management of symptoms in chronically ill patients. Design * Outcome-focused study of patient response to dietary interventions. Setting * Clinical outpatient research facility. Patients * 106 chronically ill patients. Intervention * A medical food supplement designed to provide nutritional support for gastrointestinal healing and hepatic detoxification in addition to an oligoantigenic, calorie-controlled diet, versus an oligoantigenic, calorie-controlled diet alone. Results * The 84 patients in the experimental group, who consumed the medical food supplement, had a 52% reduction in symptoms over 10 weeks as measured by the Metabolic Screening Questionnaire. In comparison, the 22 patients on the control diet had only a 22% reduction of symptoms. Symptom reduction in the intervention group occurred concomitantly with the normalization of hepatic phase I cytochrome P450 activity in relation to phase II glycine conjugation detoxification function measured before and after intervention. The intervention group also had a statistically significant increase in urinary sulfate-to-creatinine ratio after treatment, suggesting improved reserves of sulfur-conjugating nutrients and glutathione status. Enhanced nutrient absorption after intervention was implied by the increased absorption and urinary excretion of mannitol after the 10 weeks of therapy, although the results were only marginally significant. Conclusions * These results suggest that this supplemental medical food program may provide an important adjunctive therapy for the management of many complex symptoms associated with the chroni     

Nutrient Intake Report: a coordination of patient dietary assessment between physicians and registered dietitians

The Nutrient Intake Report (NIR) is based on a 7-day dietary recall questionnaire used previously in research for dietary assessment and adapted for clinical use. Used to provide information and counseling as part of total patient care, the NIR acts as a cornerstone for dietary education and interaction between physician, registered dietitian, and patient. The NIR is ordered by physicians or registered dietitians, scanned and assessed by a registered dietitian, and incorporated into the laboratory section of the medical record. It documents the patient's dietary intake in the context of his or her diagnosis and general health status. The NIR also opens a dialogue between physicians and registered dietitians. Incorporation of the NIR into the medical record makes the work of the registered dietitian available to other health practitioners, which is welcome in an era when licensing and reimbursement are contingent on systematic documentation of dietary assessment and its role in patient care.     

Monitoring dietary change in a low-fat diet intervention study: advantages of using 24-hour dietary recalls vs food records

OBJECTIVE: The purpose of the study was to evaluate two methods of dietary assessment for monitoring change in fat intake in a low-fat diet intervention study. DESIGN: The two dietary assessment methods were a 4-day food record (4DFR) and an unannounced 24-hour dietary recall conducted by telephone interview (referred to as a telephone recall [TR]). Subjects were assigned randomly to either a low-fat diet intervention group or a control group that received no counseling about fat intake. Dietary data were collected at baseline, 6 months, and 12 months. SUBJECTS: Two hundred ninety postmenopausal women with localized breast cancer were recruited at seven clinical centers in the United States. STATISTICAL ANALYSIS: Analysis of variance was used to test for significant differences in mean fat and energy intakes. RESULTS: Three sources of error were identified: (a) an instrument effect, suggesting underreporting at baseline of approximately 8% in mean energy intake and 11% in mean fat intake in the TR group compared with the 4DFR group (P = .0001); (b) a repeated measures effect observed for the 4DFR, suggesting underreporting of approximately 7% for energy intake and 14% for fat intake in the control group at 6 and 12 months compared with baseline values (P < .001); and (c) an adherence effect (or compliance bias), suggesting greater compliance to the low-fat intervention diet when subjects were keeping food records than when estimates were based on the unannounced TR. Compared with the TR, the 4DFR overestimated the extent of fat reduction in the low-fat diet intervention group by 41% (P = .08) and 25% (P = .62) at 6 and 12 months, respectively. APPLICATION: Multiple days of unannounced 24-hour recalls may be preferable to multiple-day food records for monitoring dietary change in diet intervention studies.     

Health promotion for women with physical disabilities: A pilot study.

Objective: To pilot test a health promotion intervention for women with physical disabilities. Design: Pre- and postintervention questionnaires. Participants: Two groups of women with physical disabilities (n=15). Intervention: Seven-session weekly workshop intervention grounded primarily in social-cognitive theory. Setting: Disability and rehabilitation settings. Main Outcome Measures: Indicators of health status. Results: Statistically significant positive changes between pre- and postintervention scores on measures of self-efficacy for dietary behaviors, medical decision making, social interaction, physical functioning, impact of physical limitation on role activities, and vitality. Conclusion: Women with disabilities who participate in this health promotion intervention may exhibit improvements on indicators of health status. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of research conducted in psychology program training clinics.

Although the importance of promoting research in psychology program training clinics (PPTCs) has often been stated, there are no reviews that document the extent and nature of published research from these settings. We conducted a literature search, a systematic review of selected journals, and a survey of training clinic directors to identify a substantial body of published research that has been conducted in training clinics. Publications that provide useful information about PPTCs are reviewed within the following categories: the nature and organization of training clinics, client characteristics, assessment, intervention, clinical training, and research and research training. Finally, examples of PPTCs that have fostered programmatic research are cited, and recommendations are made for improving the contribution of research conducted in PPTCs to increase knowledge of these settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Joint attention and early social communication: implications for research on intervention with autism

Highly structured, intensive early intervention may lead to significant developmental gains for many children with autism. However, a clear understanding of early intervention effects may currently be hampered by a lack of precision in outcome measurement. To improve the precision and sensitivity of outcome assessment it may be useful to integrate research on the nature of the social disturbance of autism with research on early intervention. In this regard, it may be that measures of nonverbal social communication skills are especially important in the study of preschool intervention programs. This is because these measures appear to tap into a cardinal component of the early social disturbance of autism, and because these measures have been directly related to neurological, cognitive, and affective processes that may play a role in autism. The research and theory that support the potential utility of these types of measures for early intervention research are reviewed. Examples are provided to illustrate how these types of measures may assist in addressing current issues and hypotheses about early intervention with autism including the "recovery hypothesis," the "pivotal skill hypothesis," and the relative effectiveness of discrete trial versus incidental learning approaches to early intervention. A cybernetic model of autism is also briefly described in an effort to better understand one potential component of early psychoeducational treatment effects with children with autism.     

Worksite physical activity interventions

BACKGROUND: National objectives for public health have targeted worksite as important settings for interventions to increase physical activity. However, expert reviews reveal no scientific consensus about the effectiveness of worksite interventions for increasing physical activity or fitness. METHODS: We judged the quantity and quality of existing evidence against scientific standards for the internal and external validity of the research design and the validity of measurements. Meta-analytic methods were used to quantify the size of effects expressed as Pearson correlation coefficients (r). Variation in effect was examined in relation to several features of the studies deemed important for implementing successful worksite interventions. Pre-experimental cohort studies were excluded because they are sensitive to secular trends in physical activity. RESULTS: Twenty-six studies involving nearly 9,000 subjects yielded 45 effects. The mean effect was heterogeneous and small, r = 0.11 (95% CI, -0.20 to 0.40), approximating 1/4 S.D., or an increase in binomial success rate from 50% to 56%. Although effects varied slightly according to some of the study features we examined, effects were heterogeneous within levels of these features. Hence, the moderating variables examined did not explain variation in the effects (P > 0.05). The exception was that effects were smaller in randomized studies compared with studies using quasi-experimental designs (P < 0.05). CONCLUSIONS: Our results indicate that the typical worksite intervention has yet to demonstrate a statistically significant increase in physical activity or fitness. The few studies that have used an exemplary sample, research design, and outcome measure have also yielded small or no effects. The generally poor scientific quality of the literature on this topic precludes the judgment that interventions at worksites cannot increase physical activity or fitness, but such an increase remains to be demonstrated by studies using valid research designs and measures.     

Alcohol counseling: physicians will do it

OBJECTIVE: To assess the use of a brief provider-delivered alcohol counseling intervention of 5 to 10 minutes with high-risk drinking patients by primary care provider* trained in the counseling intervention and provided with an office support system. DESIGN: A group randomized study design was used. Office sites were randomized to either a usual care or special intervention condition, within which physicians and patients were nested. The unit of analysis was the patient. SETTING: Primary care internal medicine practices affiliated with an academic medical center. PARTICIPANTS: Twenty-nine providers were randomized by practice site to receive training and an office support system to provide an alcohol counseling special intervention or to continue to provide usual care. INTERVENTION: Special intervention providers received 2 1/2 hours of training in a brief alcohol-counseling intervention and were then supported by an office system that screened patients, cued providers to intervene, and made patient education materials available as tip sheets. MEASUREMENTS AND MAIN RESULTS: Implementation of the counseling steps was measured by patient exit interviews (PEI) immediately following the patient visit. The interval between the date of training and the date of the PEI ranged from 6 to 32 months. Special intervention providers were twice as likely as usual care providers to discuss alcohol use with their patients. They carried out every step of the counseling sequence significantly more often than did usual care providers (p < .001). This intervention effect persisted over the 32 months of follow-up. CONCLUSIONS: Physicians and other health-care providers trained in a brief provider-delivered alcohol intervention will counsel their high-risk drinking patients when cued to do so and supported by a primary care office system.     

The Nutrition Attitude Survey: Associations with dietary habits, psychological and physical well-being, and coronary risk factors.

Developed a nutrition attitude survey (NAS) to measure attitudes pertaining to the adoption of a low-fat, low-cholesterol diet. Factor analysis identified 4 primary attitudinal factors: (a) Helpless and Unhealthy, (b) Food Exploration, (c) Meat Preference, and (d) Health Consciousness. For a community sample of 357 healthy men and women, relationships were examined among these attitudinal factors and dietary habits, family food patterns, medical and psychological symptoms (as assessed by the Cornell Medical Index and SCL-90—Revised), and traditional coronary risk factors. Findings provide initial support for the reliability and predictive validity of the NAS and underscore the importance of addressing the attitudes and preferences of participants in dietary intervention programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcome measures for low back pain research. A proposal for standardized use

STUDY DESIGN: An international group of back pain researchers considered recommendations for standardized measures in clinical outcomes research in patients with back pain. OBJECTIVES: To promote more standardization of outcome measurement in clinical trials and other types of outcomes research, including meta-analyses, cost-effectiveness analyses, and multicenter studies. SUMMARY OF BACKGROUND DATA: Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Because back pain is rarely fatal or completely cured, outcome assessment is complex and involves multiple dimensions. These include symptoms, function, general well-being, work disability, and satisfaction with care. METHODS: The panel considered several factors in recommending a standard battery of outcome measures. These included reliability, validity, responsiveness, and practicality of the measures. In addition, compatibility with widely used and promoted batteries such, as the American Academy of Orthopaedic Surgeons Lumbar Cluster were considered to minimize the need for changes when these instruments are used. RESULTS: First, a six-item set was proposed, which is sufficiently brief that it could be used in routine care settings for quality improvement and for research purposes. An expanded outcome set, which would provide more precise measurement for research purposes, includes measures of severity and frequency of symptoms, either the Roland or the Oswestry Disability Scale, either the SF-12 or the EuroQol measure of general health status, a question about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care. CONCLUSION: Standardized measurement of outcomes would facilitate scientific advances in clinical care. A short, 6-item questionnaire and a somewhat expanded, more precise battery of questionnaires can be recommended. Although many considerations support such recommendations, more data on responsiveness and the minimally important change in scores are needed for most of the instruments.     

Primary malignant lymphoma of the bladder: a case report

CONTEXT: Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients. OBJECTIVE: To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff. DESIGN, SUBJECTS, AND SETTING: An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency. MAIN OUTCOME MEASURE: Quantity of drug samples taken for personal or family use. RESULTS: Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples. CONCLUSION: Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.     

Physical therapy management for the patient with HIV. Lower extremity challenges

Disability assessment and rehabilitation intervention have implications for specific stages of HIV disease, with the intention of maximizing overall function and decreasing the burden of care. The AIDS epidemic has challenged communities to develop and to mobilize care networks for persons infected with HIV. A major part of that mobilization has been a push toward community and home-based services. Reliable and valid functional assessment data are necessary to evaluate HIV-related disability changes over time for patients in the hospital and at home. Epidemiologic data also hold implications for rehabilitation healthcare workers in terms of expertise in HIV-specific areas and on the staffing level. Access to rehabilitation services will need to be considered by public policymakers and financial concerns will need to be explored. Because individuals with HIV and AIDS are living longer and with greater levels of health, the chronicity of the disease warrants community support and long-term care. Various functional and quality-of-life measures can assist in the development of resources and medical interventions. As survival increases, rehabilitation professionals can anticipate more referrals for the assessment and management of physical disability in persons with HIV infection. A critical task for health service research is to ensure that HIV healthcare settings deliver optimum services at reasonable costs. Optimal care requires maximizing autonomous functioning and reducing periods of disability and dependence.     

The Future of Health Psychology Interventions.

Progress in health psychology interventions was reviewed to manage chronic illness, treat psychophysiological disorders, and provide complementary treatment for difficult medical symptoms. A closer synergy between research, clinical applications and public policy, and education and training was advocated to guide future work in these areas. Further, the importance of clinical input informing research directions, the need for interventions to focus on a broader range of individual difference and contextual factors, and for effectiveness studies to influence the adoption of treatments in clinical settings was emphasized. In accordance, greater effort should be devoted to disseminating information on treatment effectiveness to professional and lay groups to maximize the public health benefit of established intervention approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sex differences in dependency: a comparison of objective and projective measures

The relationship between scores on two widely used measures of dependency--one objective and one projective--was examined in a sample of 102 undergraduate subjects (60 women and 42 men). Consistent with previous studies in this area, significant sex differences were found on the objective measure of dependency, with women obtaining higher dependency scores than men. However, as predicted, men and women obtained comparable scores on the projective measure of dependency. Additional analyses confirmed that scores on the objective and projective measures of dependency were significantly intercorrelated in both men and women, although the magnitudes of these correlations were somewhat larger in women than in men. Implications of these results for the assessment of dependent personality traits in research and clinical settings are discussed.     

Surgery and the randomised controlled trial: past, present and future

Randomised controlled trials (RCTs), with their prospective definition of methods and outcome measures, double-blind assessment of outcomes and unbiased selection of subjects and controls, provide the best possible evidence for deciding the value of a medical or surgical intervention. Few surgical studies are designed as RCTs, and those that are should be of a higher quality. The lack of good surgical RCTs may be a result of surgeons lacking the necessary training, expertise and desire to perform RCTs, inadequate funding from granting agencies, difficulties in securing patient consent or a lack of sufficient patient numbers. If an RCT is not feasible for a particular study, then alternative research designs, such as prospective matched-pair trials, may need to be better developed and used. If RCTs can be performed, other strategies to increase the number and quality of RCTs may be needed: Education of surgeons in clinical research methods Improved funding of surgical RCTs Compulsory evaluation of new techniques and technology before their general adoption is permitted.     

An Ecological Momentary Assessment of Relapse Crises in Dieting.

Much of the research on relapse crises in dieting has focused on isolated lapse events and relied heavily on retrospective self-report data. The present study sought to overcome these limitations by using ecological momentary assessment (EMA) techniques to examine situations of dietary temptation and lapse with a sample of obese, formerly sedentary, postmenopausal women (N = 37) during the final week of a weight-loss intervention. Mood was associated with reports of dietary lapse. Abstinence-violation effects were more strongly associated with dietary lapses than temptations. Finally, coping responses distinguished dietary temptations from lapses. Education on the factors associated with relapse crises in dieting may be imperative for weight loss success and maintenance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identification, assessment and management of food-related microbiological hazards: historical, fundamental and psycho-social essentials

Microbiological risk assessment aimed at devising measures of hazard management, should take into account all perceived hazards, including those not empirically identified. It should also recognise that safety cannot be "inspected into" a food. Rather hazard management should be the product of intervention strategies in accordance with the approach made mandatory in the EU Directive 93/43 and the USDA FSIS Pathogen Reduction HACCP system; Final Rule. It is essential too that the inherent variability of the biological attributes affecting food safety is recognised in any risk assessment. The above strategic principles may be conceptualised as a four-step sequence, involving (i) identification and quantification of hazards; (ii) design and codification of longitudinally integrated ("holistic") technological processes and procedures to eliminate, or control growth and metabolism of, pathogenic and toxinogenic organisms; (iii) elaboration of microbiological analytical standard operating procedures, permitting validation of "due diligence" or responsible care, i.e. adherence to adopted intervention strategies. This should be supported by empirically assessed reference ranges, particularly for marker organisms, while the term "zero tolerance" is refined throughout to tolerable safety limit; (iv) when called for, the need to address concerns arising from lay perceptions of risk which may lack scientific foundation. In relation to infectious and toxic hazards in the practical context the following general models for quantitative holistic risk assessment are presented: (i) the first order, basic lethality model; (ii) a second approximation taking into account the amount of food ingested in a given period of time; (iii) a further adjustment accounting for changes in colonization levels during storage and distribution of food commodities and the effects of these on proliferation of pathogens and toxin production by bacteria and moulds. Guidelines are provided to address: (i) unsubstantiated consumer concern over the wholesomeness of foods processed by an innovative procedure; and (ii) reluctance of small food businesses to adopt novel strategies in food safety. Progress here calls for close cooperation with behavioural scientists to ensure that investment in developing measures to contain risk deliver real benefit.     

The dieting dilemma in patients with newly diagnosed type 2 diabetes: Does dietary restraint predict weight gain 4 years after diagnosis?

Objective: To examine whether dieting--restriction of food intake for the purpose of weight control--suppresses or promotes excessive food intake and weight gain. Design: A 4-year follow-up study of a dietary intervention in a sample of 97 patients with newly diagnosed Type 2 diabetes. Main Outcome Measures: Weight gain, change in body mass index (measured weight in kilograms divided by measured height squared), and intake of energy, as measured with a food frequency questionnaire, were assessed in relation to dietary restraint and tendency to overeat (emotionally or externally induced overeating), as assessed with the Dutch Eating Behaviour Questionnaire. Results: Tendency to overeat at diagnosis and not dietary restraint was associated with weight gain and intake of energy 4 years after diagnosis. Conclusion: These findings suggest that the success of a dietary intervention can be predicted by a subject's tendency toward overeating. The possibility of matched treatment of obesity is discussed on the basis of the distinction between patients with a low versus a high tendency to overeat. (PsycINFO Database Record (c) 2010 APA, all rights reserved)