Self-management Intervention for Reducing Epilepsy Burden Among Adult Ugandans With Epilepsy (Smart-u), Randomised Clinical Trial Protocol

Background

Epilepsy is a common chronic brain disorder globally affecting people of all ages, with the majority living in developing countries. The introduction of epilepsy self-management approaches to help people with epilepsy is urgently needed to influence epilepsy-related outcomes. This 2-site randomised controlled trial building on promising preliminary data is intended to explore this further.

Methods

A total of 188 adult people with epilepsy (PWE) attending the neurology clinics at Mulago and Mbarara hospitals and consent to participate in the study. They will be randomised into intervention versus enhanced treatment control (eTAU) study groups. The intervention group will receive 12-week "intensive" educational sessions and a 12-week remotely accessed telephone follow-up stage. The controls will continue in their usual care supplemented by written materials on epilepsy in their preferred language and tailored to the reading level of most patients at the clinic. SMART-U consists of 2 main components: a 12-week "intensive" group format stage and a 12-week remotely accessed telephone follow-up stage. SMART-U will be assessed for acceptability, fidelity, and efficacy compared to eTAU. The primary study outcome is the mean change in cumulative past 24-week seizure frequency (24 weeks prior to the study baseline compared to the 24-week follow-up). Seizure frequency will be via self-report with corroboration by family/support system informants whenever possible. Participants will self-report their seizure frequency (numeric count) that they experienced between baseline and 13 weeks and again between 13 and 24 weeks and the mean change from baseline to 24 weeks in QOL.

Discussion

The curriculum-guided Self-Management intervention for Reducing The epilepsy burden among Ugandans (SMART-U) program is anticipated to reduce the epilepsy burden seizure frequency and improve other health outcomes, including depression, functional status and health resource use.

Trial Registration Number TRN

NCT06139198.

Date of registration

14th November 2023.

Challenges to dietary hypertension self-management as described by a sample of African American older adults

BACKGROUND

Hypertension rates are disproportionately higher among Black or African Americans (Black/African American) compared to other racial and ethnic groups in the United States. However, research on self-management strategies to control hypertension through healthy eating such as the Dietary Approaches to Stop Hypertension (DASH), and ketogenic diets has underexplored the use of dietary strategies among older Black/African American adults. In reporting contemporary challenges with implementing dietary strategies targeting blood pressure control among Black/African American older adults living with hypertension, this study addresses a clear need.

AIMS

Prior research has only partially addressed the challenges older Black/African Americans face in implementing and maintaining dietary strategies to control hypertension, therefore the current study aimed to address this gap by reporting contemporary challenges, as reported by a sample of Black/African American older adults living with hypertension.

METHODS

Nineteen Black/African American older adults living with hypertension participated in a focus group. An interview guide with open-ended questions on dietary approaches to self-management hypertension was used to guide data collection. Responses were audio-recorded, transcribed verbatim, and interpreted using qualitative thematic analysis.

RESULTS

Study participants were 71.6 years (SD = 8.3), 87.1% were women, and all were self-identified as Black/African American. Overall, participants shared that they were interested in improving their hypertension self-management skills. They expressed uncertainty about dietary strategies related in part to a lack of knowledge about incorporating or excluding certain foods and adhering to complex dietary recommendations. Participants also related financial concerns about accessing the recommended foods to control hypertension and expressed confusion about how to manage hypertension alongside other comorbidities.

LINKING EVIDENCE TO ACTION

This study highlights several barriers that Black/African American older adults face (lack of dietary knowledge, lack of financial resources, and unique barriers to managing multiple comorbid health conditions), which often pose simultaneous and intersecting barriers to managing hypertension using existing evidence-based dietary strategies.

Using Technology to Support Self-Managing Hypertension in African Americans

The purpose of this study was to examine the effects of a community and technology-based intervention to support self-managing hypertension in African American (AA). Sixty AA with hypertension were randomly assigned to Coachman (a technology-based intervention) or Enhanced Usual Care. COACHMAN is comprised of blood pressure (BP) monitoring with study issued monitor, six-weeks of web-based education, training to use a medication management application, and nurse counseling. Data were collected on contextual factors (demographics, perceived social support), process factors (hypertension knowledge, self-efficacy, technology use/adoption), and proximal health behaviors (medication adherence, diet, exercise) at baseline, and 8 and 12 weeks. While mean difference in BP reduction was not statistically significant, we found that half of the subjects randomized to the intervention group had an average systolic BP reduction of 13.5 mmHg that we would regard as clinically significant. Interventions that incorporate mHealth can support self-managing hypertension in AA, and improve BP.

Intensive vs Standard Blood Pressure Control in Adults 80 Years or Older: A Secondary Analysis of the Systolic Blood Pressure Intervention Trial

OBJECTIVES

To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function.

DESIGN

Secondary analysis.

SETTING

Systolic Blood Pressure Intervention Trial (SPRINT) PARTICIPANTS: Adults 80 years or older.

INTERVENTION

Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment).

MEASUREMENTS

We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4-m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function.

RESULTS

Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] = .66; 95% confidence interval [CI] = .49-.90), mortality (HR = .67; 95% CI = .48-.93), and MCI (HR = .70; 95% CI = .51-.96). There was a significant interaction (P < .001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR = .40; 95% CI = .28-.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI = .87-2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between-group differences in the rate of injurious falls.

CONCLUSION

In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01206062. J Am Geriatr Soc 68:496-504, 2020.

A Power Conundrum: Black Women and Their Sexual Partners in the Midwest

The purpose of this research was to determine the extent to which women of African ancestry manifested power in their relationships regarding sexual activities and to examine the influence that specific variables had on their sexual partnerships. A sample (N = 200) of midlife women aged 40-65, who lived in the Midwest participated in this research. The Sexual Relationship Power Scale was used to examine these relationships. Face-to-face interviews occurred in community settings. Multiple regression equations were used to examine the potential impact of specific variables on sexual functioning. Results of the analysis revealed that variables such as mental quality of life, decision-making, and health promotion were positively associated with sexual relationships. Conversely, depression and life stress scores were negatively linked to sexual relationships. Knowledge gained from this research could be used to explore the phenomena of power as expressed in the daily lives of women of African descent. The research can also be discussed from the perspective of a "Black tax," that has burdened Black women for centuries and is manifested through years of discrimination, bias, and the lack of equity in most domains of American institutions.

Beck Depression Inventory-II: Factor Analyses with Three Groups of Midlife Women of African Descent in the Midwest, the South, and the U.S. Virgin Islands

This research encompasses a factor analysis of the Beck Depression Inventory-II (BDI-II), which involves three groups of midlife women of African descent who reside in the Midwest, the South, and the U.S. Virgin Islands. The purpose of the study was to determine the factor structure of the BDI-II when administered to a sample of women aged 40-65 of African descent who reside in the three distinct geographical regions of the United States. A correlational, descriptive design was used, and 536 women of African descent were invited to participate in face-to-face interviews that transpired in community settings. Results of the factor analysis revealed a two-factor explanation. Factor one included symptoms such as punishment feelings and pessimism (cognitive), and the second factor included symptoms such as tiredness and loss of energy (somatic-affective). The application of the Beck Depression Inventory-II among the three groups of women generated specific information about each group and common findings across the groups. Knowledge gained from the research could help to guide specific intervention programs for the three groups of women, and explicate the common approaches that could be used for the three groups.

Characterizing Frailty Status in the Systolic Blood Pressure Intervention Trial

BACKGROUND

The Systolic Blood Pressure Intervention Trial (SPRINT) is testing whether a lower systolic blood pressure (BP) target of 120 mm Hg leads to a reduction in cardiovascular morbidity and mortality among hypertensive, nondiabetic adults. Because there may be detrimental effects of intensive BP control, particularly in older, frail adults, we sought to characterize frailty within SPRINT to address ongoing questions about the ability of large-scale trials to enroll representative samples of noninstitutionalized, community-dwelling, older adults.

METHODS

We constructed a 36-item frailty index (FI) in 9,306 SPRINT participants, classifying participants as fit (FI ≤ 0.10), less fit (0.10 < FI ≤ 0.21), or frail (FI > 0.21). Recurrent event models were used to evaluate the association of the FI with the incidence of self-reported falls, injurious falls, and all-cause hospitalizations.

RESULTS

The distribution of the FI was comparable with what has been observed in population studies, with 2,570 (27.6%) participants classified as frail. The median FI was 0.18 (interquartile range = 0.14 to 0.24) in participants aged 80 years and older (N = 1,159), similar to the median FI of 0.17 reported for participants in the Hypertension in the Very Elderly Trial. In multivariable analyses, a 1% increase in the FI was associated with increased risk for self-reported falls (hazard ratio [HR] = 1.030), injurious falls (HR = 1.035), and all-cause hospitalizations (HR = 1.038) (all p values < .0001).

CONCLUSIONS

Large clinical trials assessing treatments to reduce cardiovascular disease risk, such as SPRINT, can enroll heterogeneous populations of older adults, including the frail elderly, comparable with general population cohorts.

The associations between diet quality, Body Mass Index (BMI) and Health and Activity Limitation Index (HALex) in the Geisinger Rural Aging Study (GRAS)

OBJECTIVES

To determine the associations between diet quality, body mass index (BMI), and health-related quality of life (HRQOL) as assessed by the health and activity limitation index (HALex) in older adults.

DESIGN

Multivariate linear regression models were used to analyze associations between Dietary Screening Tool (DST) scores, BMI and HALex score, after controlling for gender, age, education, living situation, smoking, disease burden and self-vs. proxy reporting.

SETTING

Geisinger Rural Aging Study, Pennsylvania.

PARTICIPANTS

5,993 GRAS participants were mailed HRQOL and DST questionnaires with 4,009 (1,722 male, 2,287 female; mean age 81.5 ± 4.4) providing complete data.

RESULTS

HALex scores were significantly lower for participants with dietary intakes categorized as unhealthy (<60) (0.70, 95% CI 0.69, 0.72, p<0.05) or borderline (60-75) (0.71, 95% CI 0.70, 0.73, p<0.05) compared to those scoring in the healthy range (>75) (0.75, 95% CI 0.73, 0.77) based on DST scores. HALex scores were significantly lower for underweight (0.67, 95% CI 0.63, 0.72, p<0.05), obese class II (0.68, 95% CI 0.66, 0.71, p<0.05) and class III participants (0.62 95% CI 0.57, 0.67, p<0.05) compared to those with BMI 18.5-24.9.

CONCLUSIONS

Poor diet quality, as assessed by the DST, is associated with lower HRQOL in adults ≥ 74 years of age.

Dietary patterns and relationship to obesity-related health outcomes and mortality in adults 75 years of age or greater

BACKGROUND

The prevalence of obesity-related adverse health outcomes is increasing among older adults. Because it is thought that nutrition plays an important role in successful aging, there has been considerable interest in the association between dietary patterns of older adults and obesity-related health outcomes.

OBJECTIVE

This study examined the association between dietary patterns and mortality and prevalence of obesity-related health outcomes, namely cardiovascular disease (CVD), type 2 diabetes mellitus, hypertension, and metabolic syndrome (MetSyn), over a 5-year follow-up period in adults aged 75 years or greater.

DESIGN

A longitudinal observational study with cross-sectional dietary assessment.

SETTING

Rural Central Pennsylvania.

PARTICIPANTS

Community-dwelling older adults (N = 449; 76.5 years old; 57% female).

MEASUREMENTS

Multiple, unannounced, 24-hour dietary recalls were used to collect dietary intake. Cluster analysis was used to derive dietary patterns. Prevalence of CVD, diabetes mellitus, hypertension, and MetSyn was extracted from outpatient electronic medical records. Logistic regression was used to examine the associations between dietary patterns and health outcomes and mortality.

RESULTS

'Sweets and Dairy', 'Health-Conscious' and 'Western' dietary patterns were identified. Compared to the 'Health-Conscious' pattern, those in the 'Sweets and Dairy' pattern had increased odds of hypertension over the follow-up period; adjusted odds ratio (95% CI) was 2.18 (1.11-4.30). No significant associations were found for CVD, diabetes mellitus, MetSyn or mortality with dietary patterns.

CONCLUSIONS

These findings support the potential value of healthy dietary patterns in the management of hypertension in older adults. We did not observe any other strong associations between dietary patterns and health outcomes or mortality in persons ≥ 75 years of age; thus failing to support the use of overly restrictive diet prescriptions for older persons, especially where food intake may be inadequate.

Antibiotic-associated diarrhoea and pseudomembranous colitis caused by Clostridium difficile. A review of 40 cases

We found antibiotic-associated diarrhoea (AAD) and pseudomembranous colitis caused by Clostridium difficile in 19% of patients with diarrhoea related to antibiotic therapy or with diarrhoea for which no other cause could be found. Ampicillin, cephalosporins and co-trimoxazole appear to be the agents most commonly associated with this complication. The clinical presentation of AAD falls into two categories: (i) an early-onset type characterized by severe diarrhoea with watery stools which may contain mucus; and (ii) a late-onset variety characterized by chronic, persistent diarrhoea with bulky stools. A definitive diagnosis was made in all cases by the detection of the cytotoxin of Cl. difficile in patients' stools using tissue culture assay. Discontinuation of the implicated agent when possible together with a 14-day course of oral vancomycin effected a cure in 90% of patients. The remaining 10% were successfully treated with a similar course of oral bacitracin.