Effectiveness of health education and counseling on stages of change, decisional balance, and smoking cessation self-efficacy: A prospective self-control study

OBJECTIVE

To examine the effectiveness of health education and counseling on the stages of change, decisional balance, and smoking cessations elf-efficacy in smokers with no intention of quitting.

METHODS

A prospective self-controlled design was conducted between December 2020 and December 2022. The research period was divided into a control stage (first to fourth weeks) and an experimental stage (fifth to eighth weeks). Patients with coronary artery disease (CAD) and habitually smoked were recruited. Pearson correlation and a one-factor repeated-measurement analysis were performed to assess the effectiveness of the intervention.

RESULTS

In total, 108 male CAD patients with a mean age of 58.1 years were recruited. After 4 weeks of the intervention, 55 (51%) exhibited behavior change (X 2 = 18.03, p = .001). The decisional balance and smoking cessation self-efficacy scores significantly improved in the experimental stage. No significant differences were observed in the control stage.

CONCLUSIONS

Four weeks of health education and counseling could effectively improve participants' stage of change, decisional balance, and smoking cessation self-efficacy.

PRACTICE IMPLICATION

Healthcare professionals can play key roles in helping CAD patients successfully quit smoking through individual education and counseling.

Nursing Staff Presenteeism Scale: Development and psychometric test

BACKGROUND AND OBJECTIVES

Nurses tend to exhibit higher rates of presenteeism compared to other professions. Presenteeism can cause the work performance of nurses to suffer, jeopardizing their own and their patients' safety and leading to decreased quality of care and increased risks of errors. However, there is a lack of a validated assessment tool for presenteeism in Taiwan. Thus, the purpose of this study was to develop a Nursing Staff Presenteeism Scale (NSPS).

METHODS

To develop questionnaire items, participants from three medical centers in Taiwan were recruited. Through convenience sampling, 500 nurses who met the selection criteria were recruited from November 1, 2022 to January 18, 2023. The scale was developed based on a systematic literature review, a previous study, and expert consultation, and 50 items were initially generated. After removing three items that lacked discriminative power, the reliability and validity of the remaining 47 items were evaluated. An exploratory factor analysis was used to establish the construct validity. A confirmatory factor analysis and structural equation modeling for cross-validation were used to assess relationships of factors with items and the overall NSPS.

RESULTS

The final scale consisted of 44 items assessed on a five-point Likert scale that loaded onto three different factors of physical or mental discomfort (18 items), work performance (15 items), and predisposing factors (11 items). These three factors were found to explain 63.14% of the cumulative variance. Cronbach's alpha for the overall final scale was 0.953. The item-to-total correlation coefficients ranged 0.443 to 0.795.

CONCLUSIONS

The NSPS exhibited satisfactory reliability and validity. It can be applied to assess the level of presenteeism among clinical nurses and provide medical institutions with information regarding the causes of presenteeism, predisposing factors, and the impacts of presenteeism on their work performance to enhance the safety and quality of clinical care.

Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study

AIMS

To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors.

DESIGN

A cross-sectional nationwide study.

METHODS

The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods.

RESULTS

In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001).

CONCLUSIONS

Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment.

IMPACT

What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.

The association between psychological distress and angina pectoris: A population-based study

BACKGROUND

Psychological distress is an undifferentiated combination of symptoms that may be related to the occurrence of angina pectoris (AP). However, few studies have investigated the relationship between psychological distress and AP, particularly in Asian populations. The purpose of this study was to examine the relationship between psychological distress and AP in Taiwanese adults.

METHODS

We adopted a cross-sectional design to explore the data of the 2005-2008 Nutrition and Health Survey in Taiwan. In total, 2080 subjects (aged ≥ 19 years) responded to questionnaire interviews and underwent physical examinations. Each of the five dimensions of psychological distress (sleep disturbance, anxiety, hostility, depression, and feelings of inferiority) were scored (from 0-20) according to the Five-Item Brief Symptom Rating Scale (BSRS-5). A score ≥ 6 points indicated psychological distress. AP was evaluated using a modified Rose questionnaire.

FINDINGS

In total, 102 subjects (3.6%) had AP, and 231 subjects (8.8%) had symptoms of psychological distress. After adjusting for the basic data, metabolism, and lifestyle covariates, the BSRS-5 total score was associated with AP (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.13-1.26, p < 0.001). Subjects with psychological distress had a higher risk of AP (OR = 2.97, 95% CI = 1.76-4.99, p < 0.001).

CONCLUSIONS

The presence of AP is associated with psychological distress. Health care providers should therefore be aware of the impact of psychological distress on AP. Our study findings can serve as a reference for AP assessments. Large scale longitudinal studies are needed to confirm a causal relationship between psychological distress and AP.

Lowered obesity indicator cutoff points more effectively predict 5-year incidence of hypertension in premenopausal women

OBJECTIVE

To compare proposed new cutoff points for four obesity indicators-waist-to-height ratio (WHtR), waist circumference (WC), waist-to-hip ratio (WHR) and body mass index (BMI)-with their current cutoff points to determine which are better standards predicting 5-year incidence of hypertension (HT) and diabetes mellitus (DM) among premenopausal women.

DESIGN

Data were obtained from the 2002 and 2007 Survey on the Prevalence of HT, Hyperglycemia and Hyperlipidemia in Taiwan conducted by the Ministry of Health and Welfare, Taiwan. Premenopausal women were grouped based on the proposed cutoff points versus reference cutoff points for obesity indicators.

PARTICIPANT

A total of 1466 premenopausal women aged between 20 and 57 years old were recruited.

MAIN OUTCOME MEASURE

Five-year incidence of HT and DM.

RESULTS

Our new obesity indicator cutoff points-WHtR 0.49, WC 74.7 cm, WHR 0.79 and BMI 22.3 kg/m2-were better predictors for 5-year HT incidence in premenopausal women compared with those of current standards, but were not significantly different for DM. Among the four obesity indicators, WHtR and WC were optimal for their 5-year predictive ability for HT and DM in premenopausal women.

CONCLUSIONS

To avoid too many cutoff points for practitioners to adopt and memorize, the proposed new cutoff points were recommended preferentially to prevent the incidence of HT and DM in premenopausal women.

A decline in the prevalence of angina pectoris: Data from the Nutrition and Health Survey in Taiwan

BACKGROUND

Angina pectoris (AP) is one of common symptoms of heart disease. The prevalence of AP varies by genders, age and ethnics. This study aimed to estimate the AP prevalence in adults and its change between surveys.

METHODS

Data was derived from the Nutrition and Health Survey in Taiwan (NAHSIT) between 1993 and 1996, and between 2005 and 2008. Participants aged ≥19 years old and grouped according to sex and age range (19-44.9, 45-64.9, and ≥65 years). The national weight prevalence rates in three types of AP (possible, definite, and confirmed) were estimated and we also estimated its change between surveys.

RESULTS

A total of 5031(1993-1996) and 4686 (2005-2008) adults were enrolled for this study. The aged-adjusted prevalence of possible, definite, and confirmed AP was 9.2%, 5.6%, and 2.1%, respectively, in 1993-1996, and 4.7%, 3.5%, and 1.1%, respectively, in 2005-2008. The age-adjusted prevalence of definite AP significantly declined from 5.6 (1993-1996) to 3.5 (2005-2008). Women had greater decline in the prevalence for possible (5.8% vs. 3.2%), definite (2.9% vs. 1.3%) and confirmed (1.6% vs. 0.5%) AP than men in both surveys. All AP prevalence rates increased by age in men in both surveys, however, the positive association between AP prevalence and age groups among women only was in 1993-1996.

CONCLUSIONS

The AP prevalence significantly declined from 1993 to 1996 to 2005-2008. The AP prevalence in women was higher. The prevalence increased with age in men, but not in women. Continuous monitoring of AP prevalence is recommended to better understand the disease burden.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) experiences among COPD patients with comorbid gastrooesophageal reflux disease

AIMS AND OBJECTIVES

To explore perceptions of experience exacerbations of chronic obstructive pulmonary disease among chronic obstructive pulmonary disease patients with comorbid gastrooesophageal reflux disease by focusing on unravelling how patients differentiate and react to symptoms of chronic obstructive pulmonary disease and gastrooesophageal reflux disease.

BACKGROUND

While gastrooesophageal reflux disease has been suggested to be a risk factor for chronic obstructive pulmonary disease exacerbations, no study has explored perceptions of the symptoms leading up to severe exacerbation of chronic obstructive pulmonary disease events among chronic obstructive pulmonary disease patients with comorbid gastrooesophageal reflux disease.

DESIGN

Qualitative design.

METHODS

The analysis was performed in accordance with principles of Grounded Theory methodology. Data were collected via semi-structured interviews from 12 chronic obstructive pulmonary disease patients with endoscopy-diagnosed gastrooesophageal reflux disease who had experienced a chronic obstructive pulmonary disease exacerbation with hospitalisation. Appraisal and analysis using consolidated criteria for reporting qualitative research (COREQ) checklist were undertaken.

RESULTS

The core category of this study was the ineffective management of exacerbation symptoms, which was associated with perceived symptoms pre-exacerbation which contained three overlapping categories of symptom presentation experienced, and chronic obstructive pulmonary disease-related coping strategies, high anxiety and a sense of helplessness in disease management.

CONCLUSIONS

Patients with severe chronic obstructive pulmonary disease with comorbid gastrooesophageal reflux disease presented with some distinctly different atypical symptoms yet used common respiratory symptom management strategies. Patients and practitioners alike need to be more aware of the possibility of other symptoms such as nonspecific symptoms being clues of exacerbation onset for a more effective intervention.

RELEVANCE TO CLINICAL PRACTICE

The medical community needs to educate patients to understand and manage not only chronic obstructive pulmonary disease but also gastrooesophageal reflux disease symptoms so that they are better able to identify the cause of their symptoms, treat them appropriately and seek out medical assistance when necessary.

Patient Transfer Decision Difficulty Scale: Development and psychometric testing of emergency department visits by long-term care residents

Background and objectives

Nurses serve as gatekeepers of the health of long-term care facility (LTCF) residents and are key members deciding whether residents should visit an emergency department (ED). Inappropriate decisions as to ED visits may result in ED overcrowding, excessive medical expenses, and nosocomial infections. Currently, there is a lack of effective tools for assessing the barriers and level of difficulty experienced by LTCF nurses. The purposes of this study were to develop a Patient Transfer Decision Difficulty Scale (PTDDS) and test its effectiveness.

Methods

This study randomly sampled LTCFs in Taiwan and surveyed two or three nurses in every institution selected. Registered return envelopes were provided for participants to return self-completed questionnaires. Three steps were used to develop the scale and items: in step I, the instrument was developed; in step II, psychometric testing was conducted, which entailed performing an exploratory factor analysis (EFA) to verify the construct validity and reliability of the developed items; and in step III, a confirmation study was conducted using a confirmatory factor analysis (CFA) and structural equation modeling to cross-validate the factors and items.

Results

The cumulative sum of variance explained by the measurement models of the three factors in the PTDDS was 63.54%.When deciding whether to transfer LTCF residents to EDs, the most pronounced barrier experienced by nurses were for judging the severity of “clinical episodes”, which had an explanatory power of 37.49%. The second and third pronounced barriers and decision difficulty experienced by nurses were “communication and information” and “timing of the residents’ emergency visits,” which explained 16.81% and 9.24% of the variance, respectively.

Conclusions

The cross-validation results obtained using the EFA and CFA showed favorable reliability and validity of the PTDDS. For future studies, this study recommends performing large-scale investigations of the level of decision difficulty and related factors experienced by nurses in LTCFs of varying levels and types.

Predictors of coronary artery disease in middle-aged Taiwanese women at premenopause, postmenopause and after undergoing hysterectomy

AIMS AND OBJECTIVES

To examine the predictors of coronary artery disease among middle-aged women at various menopausal statuses.

BACKGROUND

Few studies have explored coronary artery disease predictors among middle-aged women at various menopausal statuses, particularly with the inclusion of women who underwent a hysterectomy.

DESIGN

A cross-sectional design was adopted.

METHODS

Two hundred and twenty-five middle-aged women who were waiting for catheterisation examinations because of possible coronary artery disease were selected. These patients were divided into premenopausal (n = 41), postmenopausal (n = 143) and women who had undergone a hysterectomy groups (n = 41). The differences in the risk factors for coronary artery disease between patients with coronary artery disease (catheterisation results showing stenosis of >50% in at least one major coronary artery) and those without coronary artery disease in the three groups were compared.

RESULTS

The participants were aged 56·8 ± 5·9 years. In the premenopausal group, the odds of coronary artery disease among ever or current smokers was 8·46 times the odds of coronary artery disease for the never smokers. In the postmenopausal group, the odds of coronary artery disease among diabetes patients was 2·89 times the odds of coronary artery disease for those without diabetes. Each additional point on the Chinese Beck Depression Inventory-II increased the risk of coronary artery disease by 5%. In the hysterectomy group, each additional increase in 1 mmHg in systolic blood pressure increased the risk of coronary artery disease by 4%.

CONCLUSIONS

Smoking, diabetes, depression and systolic blood pressure are predictors of coronary artery disease in middle-aged women at premenopause, postmenopause and after undergoing hysterectomy respectively.

RELEVANCE TO CLINICAL PRACTICE

These results are beneficial for middle-aged women at various menopausal stages to effectively implement prevention of coronary artery disease. These findings were among women being evaluated for possible coronary artery disease, we suggest the need for further study in lager, longitudinal studies.

An investigation and comparison of the effectiveness of different exercise programmes in improving glucose metabolism and pancreatic β cell function of type 2 diabetes patients

BACKGROUND

Moderately intensive aerobic exercise can improve glucose metabolism and pancreatic β cell function in diabetic patients. To date, there is no evidence to support the long-term effectiveness of home-based exercise interventions on these outcomes.

OBJECTIVE

This study investigated the effectiveness of two moderately intense exercise programmes on glucose metabolism and pancreatic β cell function in type 2 diabetes mellitus (T2DM) patients.

METHODS

A randomised controlled trial of 120 T2DM patients (with a mean age of 55.54 ± 9.09 years) was conducted. Patients were assigned by block randomisation to either an aerobic exercise group (AEG), an accumulated million steps group (AMSG), or a control group (CG); each consisting of 40 patients. Glucose metabolism and pancreatic β cell function of patients were measured at three time intervals for 1 year.

RESULTS

There was no difference in baseline scores, and respective compliance rates for the AEG and AMSG were 94.4% and 99.2%. After generalised estimating equation analysis, the AMSG results for glycated haemoglobin (HbA1c) were significantly lower than those of the CG. The insulinogenic index-acute insulin response (BIGTT-AIR ) of both exercise groups was significantly higher than that of the CG. The AMSG group improved their overall HbA1c and BIGTT-AIR results compared with the AEG group after 3 months exercise programme (T1 ) and 12 months of implementation (T2 ).

CONCLUSION

This study demonstrates that regardless of the type of exercise intervention, it is potentially beneficially effective for glucose metabolism and pancreatic β cell function in T2DM patients. The AMSG had better glucose metabolism and pancreatic β cell function compared with those in the AEG. Nurses can easily integrate exercise interventions into T2DM patient care plans.

Newly diagnosed gastroesophageal reflux disease increased the risk of acute exacerbation of chronic obstructive pulmonary disease during the first year following diagnosis--a nationwide population-based cohort study

BACKGROUND

While prior studies have demonstrated that chronic obstructive pulmonary disease (COPD) is associated with gastroesophageal reflux disease (GERD), and that GERD is associated with acute exacerbations of COPD (AECOPD), no study to date has been able to establish temporality in this relationship. The purpose of this cohort study was to explore the impact of a new diagnosis of GERD on the risk of subsequent AECOPD.

METHODS

We used a retrospective population-based cohort design to analyse the data of 1976 COPD subjects with GERD as an exposure cohort and 3936 COPD subjects without GERD as a comparison group. We individually tracked each subject in this study for 12 months and identified those subjects who experienced an episode of AECOPD. Hazard ratios (HR) were calculated using Cox proportional hazards regression analysis.

RESULTS

The incidence of AECOPD was 4.08 and 2.79 per 100 person-year in individuals with and without GERD, respectively (p = 0.012). Following adjustment for sex, age, ischaemic heart disease, heart failure, atrial fibrillation, hypertension, osteoporosis, anxiety, diabetes mellitus, angina, stroke, anaemia, dementia, occupational category, monthly insurance premium, number of OPD visits and COPD severity. The stepwise Cox regression analysis revealed that GERD was independently associated with an increased risk of AECOPD (HR = 1.48, 95% CI = 1.10-1.99).

CONCLUSION

This study demonstrated that GERD is an independent risk factor for AECOPD. Caution should be exercised when assessing GERD symptoms in patients with COPD.

Lowered cutoff points of obesity indicators are better predictors of hypertension and diabetes mellitus in premenopausal Taiwanese women

INTRODUCTION

In previous study, we found that in order to prevent MS in women aged <65 years, the cutoff points of obesity indicators should be lowered.

OBJECTIVE

To investigate whether our proposed cutoff points of obesity indicators predict the occurrence of hypertension (HT), diabetes mellitus (DM), and hyperlipidemia in premenopausal women with greater sensitivity and specificity compared to reference cutoff points of obesity that are currently being used.

METHODS

Using the database of the "2002 Survey on the Prevalence of Hypertension, Hyperglycemia and Hyperlipidemia in Taiwan" provided by the Bureau of Health Promotion, Taiwan as research material, data from 2270 premenopausal women aged 20-65 years were used for the analyses. The receiver-operating characteristic curves (ROC) of the body-mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) were used to predict HT, DM, and hyperlipidemia.

RESULTS

Obesity is not a good predictor of the occurrence of hyperlipidemia in premenopausal women aged <65 years. However, our proposed cutoff points had greater sensitivity and specificity than did the reference cutoff points. To prevent the risk of HT and DM in premenopausal women, the cutoff points of obesity indicators should be reduced. The proposed values are as follows: a WHR of 0.79; a WC of 74.7 cm; a WHtR of 0.49; and a BMI of 22.3 kg/m(2).

Comparing self-efficacy and self-care behaviours between outpatients with comorbid schizophrenia and type 2 diabetes and outpatients with only type 2 diabetes

People with schizophrenia show higher-than-normal rates of type 2 diabetes mellitus (T2DM); however, research on their understanding of diabetes self-efficacy and self-care behaviours is lacking. This study compared differences in scores of self-efficacy and self-care behaviours between outpatients with comorbid schizophrenia and T2DM and outpatients with T2DM alone. Data were collected using the Diabetes Management Self-Efficacy Scale and Summary of Diabetes Self-Care Activity questionnaire. In total, 105 outpatients with schizophrenia and T2DM and 106 outpatients with T2DM returned completed questionnaires. Results of this study revealed that outpatients with schizophrenia and T2DM had significantly lower total self-efficacy and self-care scores than outpatients with only T2DM. The stepwise regression analysis revealed that self-efficacy, the haemoglobin A1C level and current smoking were significant predictors of self-care behaviours in outpatients with comorbid schizophrenia and T2DM, which explained 33.20% of the variance. These findings help mental health professionals improve patient care through a better understanding of self-care behaviours among outpatients with comorbid schizophrenia and T2DM.

Depression, antidepressants, and the risk of coronary heart disease: a population-based cohort study

BACKGROUND

Evidence supporting a predictive role for depression in the pathgenesis of coronary heart disease (CHD) has mainly come from studies in Western countries. Conflicting data exist regarding the association between antidepressant use and the incidence of CHD. This population-based study tracked the risk of composite coronary events in a cohort with newly diagnosed depression compared to an age- and gender-matched cohort without depression. The association between antidepressant use and risk of coronary events in individuals with depression was also investigated.

METHODS

In total, 39,685 individuals (7937 with depression and 31,748 without depression) aged 20-99 years selected from a random sample of 10(6) beneficiaries of the Taiwan National Health Insurance Program were followed up for up to 9 years with a median follow-up period of 8.76 years. Coronary events were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. Antidepressant use was identified using Anatomical Therapeutic Chemical classification codes.

RESULTS

The multivariable-adjusted hazard ratio (HR) for newly detected coronary events was 1.49 (95% confidence interval (CI)=1.29-1.74, p<0.001) for individuals with depression compared to age- and gender-matched individuals without depression. Use of selective serotonin reuptake inhibitors and tricyclic antidepressants did not significantly impact the risk of the composite coronary events among individuals with depression.

CONCLUSIONS

Depression is associated with an increased risk for CHD. No evidence supporting an association between antidepressants and coronary events was found.

Dietary supplementation and engaging in physical activity as predictors of coronary artery disease among middle-aged women

AIM AND OBJECTIVES

To explore risk factors for coronary artery disease (CAD) among middle-aged women in Taiwan.

BACKGROUND

Coronary artery disease is a leading cause of death among females. Risk factors for CAD vary due to differences in ethnicity, gender and age. However, few studies have documented risk factors among middle-aged women.

DESIGN

We employed a cross-sectional, comparative study design.

METHODS

Sixty-five middle-aged women who were suspected of having CAD and who received cardiac catheterisation were purposively sampled and divided into a CAD group (with at least one coronary artery with > 50% stenosis) and a control group, according to the results of catheterisation. Individual questionnaires regarding their medical history, blood test results, sociodemographic characteristics, metabolism, biomarkers and lifestyle risk factors were administered and quantified.

RESULTS

The mean age of the 65 women (31 CAD and 34 controls) was 56·2 years. Within the CAD group, there was a greater incidence of women with a history of diabetes mellitus (DM), increased fasting blood glucose and increased diastolic blood pressure. Comparatively fewer women within the CAD category used dietary supplements or had a lower level of physical activity. After adjusting for other confounders, it was discovered that women who used dietary supplements (OR = 0·28; p = 0·04) and engaged in physical activities (OR = 0·16; p = 0·02) were less likely to develop CAD.

CONCLUSIONS

Use of dietary supplements and engaging in physical activities can significantly predict the incidence of CAD among middle-aged women in Taiwan.

RELEVANCE TO CLINICAL PRACTICE

Middle-aged women should be encouraged to take appropriate dietary supplements and engage in physical activity in order to prevent CAD.

The relationship between physical activity and heart rate variability in orthotopic heart transplant recipients

AIMS AND OBJECTIVES

To investigate the relationship between physical activity and heart rate variability in orthotopic heart transplant recipients, to compare the difference in heart rate variability between patients one year after orthotopic heart transplant and healthy adults matched to the heart transplant recipients in terms of age, gender and physical activity levels.

BACKGROUND

Although physical activity affects the heart rate variability in patients with heart disease, there is a paucity of literature discussing the correlation between physical activity and heart rate variability among heart transplant recipients.

DESIGN

This was a descriptive and cross-sectional study.

METHODS

A total of 120 eligible subjects were divided into the orthotopic heart transplant recipient group (n = 60) and the healthy adult group (n = 60). The Seven-day Physical Activity Recall questionnaire was used to record the subjects' amount of physical activity per week. Heart rate variety parameters were determined by separate frequency domain components.

RESULTS

Results indicated heart transplant recipients' heart rate variety was significantly lower than that of healthy adults in terms of mean, sdr, total power (ms(2)), low frequency (ms(2)), low frequency (nu), high frequency (ms(2)) and low frequency/high frequency. Heart transplant recipients' heart rate variety including total power (ms(2)), low frequency (ms(2)) and high frequency (ms(2)) was 18·2, 2 and 7·2% of healthy controls, respectively; the amount of absolutely and relatively moderate physical activity was positively related to high frequency (ms(2)) and high frequency (nu), but was negatively related to low frequency/high frequency. High frequency (nu) increases while the total amount of weekly physical activity increases.

CONCLUSIONS

Results confirmed that the more the moderate physical activity performed, the better the patient's heart rate variability.

RELEVANCE TO CLINICAL PRACTICE

We suggest that clinical care providers have to encourage heart transplant recipients to engage in moderate physical activity.

Comparisons of forward and backward gait between poorer and better attention capabilities in early Parkinson's disease

This study compared forward and backward gait between Parkinson's disease (PD) patients with poorer and better attention capabilities. PD and healthy control (HC) participants received a dual-stimuli attention task. The results were assessed using principal component analysis to quantify and rank attention capability. Accordingly, 22 PD and 42 HC subjects were equally divided into poorer (14 PD-P, 18 HC-P) and better (8 PD-B, 24 HC-B) attention capabilities. To analyze the spatiotemporal gait parameters, each participant walked forwards and backwards on a GAITRite(®) walkway. Compared to HC, PD performed worse in the dual task and exhibited slower velocity, less swing, and shorter stride in both walking directions. Notably, PD-P experienced all these gait defects, regardless of directions. PD-B walked worse than HC-B backwards, and displayed comparable gait to HC-P in both directions. In PD and HC, velocity, stride, and swing decreased perceptibly when walking backwards compared to forwards, and the same was true for velocity and stride in PD-P and PD-B. Backward strides were reduced evidently more in PD-P than in PD-B. However, backward swing reductions in PD-P and PD-B were statistically insignificant. Cadence in both directions was similar within the groups and between the groups, and there were little alterations between directions within each group and between groups. These results suggest that attention capability may affect PD gait. Poorer attention exacerbates gait defects and better attention improves gait in both directions. These results may support the application of cuing strategies in PD to enhance attention capability and improve walking gait.

The influence of physical activity level on heart rate variability among asthmatic adults

AIMS

The aim of the study was to evaluate the impact of physical activity levels on heart rate variability among asthmatic patients.

BACKGROUND

In recent years, heart rate variability is frequently used to assess the autonomic nervous system. The pathogenesis of asthma is probably related to autonomic dysfunction. Adequate exercise is considered beneficial to patients who suffer from asthma. However, the relationship between physical activity and the autonomic nervous system of adult asthmatic patients is still unknown.

DESIGN

A cross-sectional survey.

METHODS

A total of 54 subjects (27 healthy persons and 27 asthmatic patients matched by age and gender) were recruited for this study. Heart rate variability was determined by frequency analysis and measured in both resting and active states. The Seven-Day Physical Activity Recall was used to determine the subject's amount of weekly activity.

RESULTS

The results showed that the total power, low frequency (ms(2)), low frequency (nu) and low frequency/high frequency (nu) but not high frequency (nu) were significantly higher in healthy adults compared to asthmatic patients, no matter whether resting or exercising. In both groups, the greater the amount of moderate-to-vigorous physical activity, the higher the TP observed. However, a positive relationship between the amount of moderate-to-vigorous physical activity and low frequency (nu) and a negative relationship with high frequency (nu), respectively, was demonstrated only in asthmatic patients. There was no significant difference in heart rate variability between the asthmatic patients who engaged in more moderate-to-vigorous physical activity and the healthy patients.

CONCLUSIONS

Although the asthmatic patients had poor heart rate variability compared with healthy people, engaging in higher amounts of moderate-to-vigorous physical activity may result in a heart rate variability similar to that of healthy people.

RELEVANCE TO CLINICAL PRACTICE

The results of this study suggest that healthcare professionals should encourage asthmatic patients to take as much physical exercise as they can in their daily lives.

Impact of physical activity on heart rate variability in children with type 1 diabetes

OBJECTIVE

Children with type 1 diabetes are usually associated with cardiovascular autonomic neuropathy. The present study explored the influence of physical activity on their autonomic nervous function by measuring the heart rate variability (HRV).

MATERIALS AND METHODS

A total of 93 type 1 diabetic children and 107 healthy control subjects were enrolled. The Physical Activity Questionnaire for Children (PAQ-C) was adopted to determine the physical activity level as low, moderate, or high activity. HRV was determined by frequency analysis and measured in both resting and active states.

RESULTS

Children with type 1 diabetes had significantly lower HRV than that of healthy control subjects in resting state but not in active state. The decreased HRV in diabetic children was observed only in subjects with low physical activity. The HRV in diabetic children with moderate to high physical activity, however, was not different from that of their healthy controls.

CONCLUSIONS

Diabetic children should be encouraged to engage in physical activity with more intensity, which can benefit their autonomic nervous function. Nevertheless, the potential risk of vigorous activity still needs our concern.

Impact of glycemic control, disease duration, and exercise on heart rate variability in children with type 1 diabetes mellitus

BACKGROUND/PURPOSE

Type 1 diabetes is commonly associated with autonomic neuropathy. The present study investigated the influences of glycemic control, disease duration (DD), and exercise on autonomic nervous function in children with type 1 diabetes by analysis of their heart rate variability (HRV).

METHODS

Seventy-nine type 1 diabetic children were recruited and categorized into four groups by HbA1c of 8% and DD of 4.5 years. HRV parameters as determined by separate frequency domain components (low frequency: LnLF, 0.04-0.15 Hz; high frequency: LnHF, 0.15-0.5 Hz; total power: LnTP, 0.04-0.5 Hz) were measured both at rest and during exercise. Pearson's correlation, one-way ANOVA, and multiple regressions with stepwise method were used for statistical analysis.

RESULTS

While at rest, HbA1c and DD were negatively correlated with all HRV parameters. Both HbA1c and DD were significant predictors in LnTP. However, only HbA1c was a significant predictor in LnLF and LnHF. Type 1 diabetes patients with HbA1c > 8% and DD > 4.5 years had a significantly lower HRV than the other patients. During exercise, HRV reduced significantly and no significant correlation between HbA1c and HRV or between DD and HRV was observed. Also, a significant difference in HRV among the four groups was not demonstrated. The smallest decrement in HRV from resting to exercise were in subjects with HbA1c > 8% and DD > 4.5 years.

CONCLUSION

HbA1c was a more dominant predictor for LnTP, LnHF and LnLF than DD in children with type 1 diabetes at rest. HRV reduced significantly from resting to exercise. However, the responses of HRV during exercise differ from the responses of HRV at rest.

Self-care behavior, hope, and social support in Taiwanese patients awaiting heart transplantation

OBJECTIVE

The purpose of this study was to examine the self-care behavior, hope, and social support in patients awaiting heart transplantation and to explore all the correlative and related factors.

METHODS

In total, 45 participants who met the selection criteria were selected by purposive sampling from four medical centers in Taiwan. The three instruments Self-Care Behavior Scale, Herth Hope Index (HHI), and Social Support Inventory were used for data collection.

RESULTS

Significant, positive correlations among self-care behavior, hope, and social support were observed. Social support was the best predictive factor for both self-care behavior and hope.

CONCLUSION

The outcomes of this study can help medical care personnel better understand the self-care behavior, hope, and social support in patients awaiting heart transplantation and can also serve as a reference when developing relevant interventions for these patients.

Improved haemorrheological properties by Ginkgo biloba extract (Egb 761) in type 2 diabetes mellitus complicated with retinopathy

BACKGROUND & AIMS

Abnormal haemorrheological property changes in erythrocyte deformability, plasma and blood viscosity, and blood viscoelasticity may play very important roles in the development of microangiopathies in diabetes mellitus (DM). In this study, we demonstrate the improvement in abnormal haemorrheological parameters in DM with ingestion of Ginkgo biloba extract 761 (Egb 761).

METHODS

Haemorrheological parameters before and 3 months after Egb 761 oral ingestion were determined in 25 type 2 DM patients with retinopathy. These parameters included lipid peroxidation stress of erythrocytes, erythrocyte deformability, plasma and blood viscosity, blood viscoelasticity, and retinal capillary blood flow velocity.

RESULTS

After taking Egb 761 orally for 3 months, the blood viscosity was significantly reduced at different shear rates, by 0.44 +/- 0.10 (gamma = 400), 0.52 +/- 0.09 (gamma = 150) and 2.88 +/- 0.57 (gamma = 5). Viscoelasticity was significantly reduced in diabetic patients by 3.08 +/- 0.78 (0.1 Hz). The level of erythrocyte malondialdehyde (MDA) was reduced by 30%; however, the deformability of erythrocyte was increased by 20%. And lastly, retinal capillary blood flow rate was increased from 3.23 +/- 0.12 to 3.67 +/- 0.24 cm min(-1).

CONCLUSION

In this preliminary clinical study, 3 months of oral administration of Egb 761 significantly reduced MDA levels of erythrocytes membranes, decreased fibrinogen levels, promoted erythrocytes deformability, and improved blood viscosity and viscoelasticity, which may facilitate blood perfusion. Furthermore, it effectively improved retinal capillary blood flow rate in type 2 diabetic patients with retinopathy.

Fatigue patterns and correlates in male liver cancer patients receiving transcatheter hepatic arterial chemoembolization

Liver cancer is a leading cancer in Taiwan, especially in males. Transcatheter arterial chemoembolization (TACE) is a major treatment for these patients, but research examining their fatigue experiences is limited. The purposes of this longitudinal, correlational study were to identify (1) changes in fatigue, symptom distress, anxiety and depression in cancer patients across four time points during the first week of TACE treatment, and (2) factors predicting changes in fatigue across the four time points. Eligible male inpatients with liver cancer were recruited from a medical center in Taipei. Subjects (n=40) were assessed 1 day before (T1), and during days 2 (T2), 4 (T3) and 6 (T4) of TACE. Data were analyzed by descriptive statistics, Pearson's correlations, repeated measures analysis of variance (ANOVA) and the generalized estimating equation (GEE). Subjects had mild to moderate levels of fatigue that peaked at T2, and showed a decrease at T3 and T4 but were still slightly higher than at T1. The GEE analysis showed that greater symptom distress, anxiety and depression, higher Adriamycin dosage, longer duration of previous fatigue, and less education significantly predicted fatigue changes. The results indicate that the pattern of fatigue in TACE during the first week is similar to fatigue in patients receiving chemotherapy. The results also further indicate that fatigue is associated to several factors. The causal relationships between fatigue and these related factors should be examined. Interventions targeting these factors should also be tested in future studies.

The Influence of Exercise Tolerance on Quality of Life Among Patients with Heart Failure

The purpose of this study was to explore the influence of exercise tolerance on quality of life (QOL) among patients with heart failure (HF). A descriptive correlational design was used to guide the study. Forty-nine participants who met the selection criteria were enrolled at a medical center in Taipei. Data were collected by using the Short-Form 36 and treadmill tests including an exercise intensity-increasing test and duration-increasing test. The results revealed the mean scores of QOL in terms of physical functioning and mental functioning were 66.99 and 68.82, respectively. The average peak VO2 (exercise intensity tolerance) was 4.65 mets. The average exercise duration tolerances were 768.55, 1717.04 and 1923.48 s for reaching 50% heart rate reserve (HRR), 90% HRR, and completing the whole test, respectively. Patients whose exercise intensity tolerance was > or = 5 mets or whose exercise duration tolerance was > or = 1800 s had better physical functioning, but a significant difference in mental functioning was not observed between the two groups. The findings of the study support the view that exercise testing is safe, feasible, and effective in evaluating exercise tolerance, and that both exercise duration and exercise intensity tolerance were important factors in determining QOL, particularly in physical functioning, for HF patients.

Menopausal women: perceiving continuous power through the experience of regular exercise

BACKGROUND

Menopausal women are at high risk for cardiovascular diseases and osteoporosis. However, for so long, women have devoted much of their time and energy to family, children, and work such that they could not regularly exercise. There are few studies addressing the experiences of Taiwanese women who regularly exercise.

OBJECTIVES

The aim of this study was to explore the experiences of regularly exercising, defined as thoughts or actions by menopausal women who did not regularly exercise before menopause, but who now exercise regularly.

DESIGN

A grounded theory research design was used.

METHODS

In-depth interviews were undertaken with a purposive sampling of 12 menopausal women who began to do regular exercises after menopause and who have continued exercising for more than 6 months. The constant comparative method was used to analyse the interview data.

RESULTS

'Perceiving Continuous Power' was the core category during the process of regularly exercising. Every participating woman perceived that her body and mind were filled with continuous power including the subcategories of 'Overcoming the initial discomfort', 'Experiencing Benefits to Body and Mind' and 'Broadening' during the process. 'Awareness of Health Crisis', which included the subcategories of 'Cureless Chronic Disease', 'Mood Swings', and 'Conflict on Medication', was identified as occurring when these women first began regularly exercising. Throughout the process of perceiving continuous power, women experienced the following interactive behaviour categories: 'Exercise Selection' with subcategories of 'Self-Evaluation', 'Seeking and Fitting', 'Comparing' and 'Health Becoming' with the subcategories of 'Releasing Health Crisis', 'Regaining Flowering Life', and 'Self-Fulfilling'.

CONCLUSIONS

Regular exercises provided continuous power for menopausal women.

RELEVANCE TO CLINICAL PRACTICE

The experiences with exercise we uncovered in this study can provide a reference for nurses to guide menopausal women with their regular exercise plans.

Establishment of a Predictive Model of Serum Glucose Changes Under Different Exercise Intensities and Durations Among Patients With Type 2 Diabetes Mellitus

Regular exercise is regarded as one of necessary elements in treating diabetes mellitus (DM). The purpose of this study was to investigate the influence of different exercise intensities and durations on serum glucose changes after exercise in type 2 DM patients and to establish a predictive model of changes in serum glucose under different exercise intensities and durations. Thirty-seven type 2 DM patients were recruited from four teaching hospitals. A total of 12 exercise sessions were scheduled according to the results of a graded treadmill exercise test. The 12 exercise sessions were designed on the basis of different exercise intensities (40%, 60%, and 80% maximal workload) and exercise durations (10, 20, 30, and 40 min). Serum glucose level was measured before and after exercise. The findings indicate that the main effect of exercise intensity and duration was significant, but there was no interaction effect. All four variables, including exercise intensity, exercise duration, pre-exercise serum glucose levels, and gender, explained 37% of the variance in serum glucose changes after exercise. In conclusion, a dose-response relationship between exercise amount and serum glucose changes was demonstrated. This is helpful for health professionals to teach type 2 DM patients how to predict serum glucose response in different exercise situations.

Comparison of oxygen consumption in performing daily activities between patients with chronic obstructive pulmonary disease and a healthy population

OBJECTIVE

The purposes of this study were to compare the daily activity oxygen consumption (VO(2)) and peak oxygen consumption (VO(2peak)) for chronic obstructive pulmonary disease (COPD) patients and healthy individuals; to compare dyspnea levels found in COPD patients and healthy individuals when they performed daily activities and exercise tests; and to establish standard VO(2) values for daily activities for COPD patients.

DESIGN

This was an exploratory and correlative study.

SETTING

The study took place at the Research Center of Sports Medicine at Taipei Medical University, in Taipei, Taiwan.

SUBJECTS

The study included 27 COPD patients and 18 healthy subjects whose ages, weights, and heights were matched.

OUTCOME MEASURES

VO(2peak) and the VO(2) for performing daily activities including sitting, standing, walking, walking with a 2-kg load, and walking upstairs for 2 stories.

INTERVENTION

All data were collected by means of questionnaires and treadmill exercise tests. VO(2) was measured using an AEROSPORT KB1-C metabolic measurement system.

RESULTS

There was no significant difference in VO(2) found between the 2 groups when they were performing daily activities, but the VO(2peak) was significantly lower in the COPD group (13.90 +/- 2.93 mL kg(-1) min(-1)) compared with the healthy control group (16.15 +/- 1.86 mL kg(-1) min(-1)) (P =.01). The dyspnea level of the COPD group when they were performing daily activities and exercise tests was more severe than that of the healthy control group. The mean VO(2) values for daily activities in COPD patients were as follows: sitting 3.41 (+/-0.82), standing 3.67 (+/-0.90), walking 10.06 (+/-2.19), walking with a 2-kg load 10.28, and walking upstairs 8.16 (+/-1.36) mL kg(-1) min(-1).

CONCLUSION

The results of this study reveal that there were no differences in VO(2) values for performing daily activities between COPD patients and healthy individuals. However, an increase in dyspnea level occurred during daily activities, and it was found to be more severe for COPD patients than for healthy individuals. A key factor was probably that COPD patients had an obviously lower VO(2peak) and higher relative exercise intensity for daily activities than did healthy individuals.

Experiences of daily activities within two weeks after hospital discharge among Taiwanese elderly patients with chronic obstructive pulmonary disease

The purpose of this study was to explore the experiences of daily activities among elderly patients with chronic obstructive pulmonary disease (COPD) within 2 weeks after hospital discharge. Seven male and two female COPD patients aged 65-80 were interviewed. Interviews were tape recorded, and then transcribed verbatim within 48 hours. Data were analyzed according to the method of qualitative research through constant comparison and content analysis. The data generated seven themes: (1) expectations beyond one s strength; (2) fear of having another attack; (3) slowing and simplifying activities; (4) acting according one s abilities; (5) protecting oneself; (6) striving for an independent life; and (7) trying to continue living. The findings of this research can help health professionals understand experiences of COPD patients, sensitively and precisely recognize their daily activity needs, and provide suitable interventions during the discharge transition to facilitate a better quality of life for elderly patients.

Effects of arm exercise on serum glucose response in type 2 DM patients

The aims of the study were to examine the influence of upper extremity exercise on glucose response and to establish a predictive model of changes in serum glucose under different exercise intensities and durations. Thirty-three type 2 DM patients who met the selection criteria were selected. An arm cycle ergometer exercise test was conducted, and then 12 arm exercise sessions were arranged based on different exercise intensities (40%, 60%, and 80% of maximal workload) and exercise durations (10, 20, 30, and 40 min). Serum glucose levels were measured before and after each exercise session. Serum glucose levels significantly decreased after arm exercise regardless of different intensities or durations. However, no interaction effect (intensity x duration) or main effect in exercise intensity was observed, but a significant main effect in exercise duration was observed (F = 11.756, p <.0001). Also exercise duration was a significant predictor of serum glucose changes after arm exercise. These results suggest that arm exercise can play a useful role in glycemic control for type 2 DM patients and exercise duration is a key factor in determining serum glucose response under upper-extremity exercise.

Empowering: the experiences of exercise among heart transplantation patients in Taiwan

AIM

To explore the experiences of exercise among Taiwanese heart transplant patients on the basis of a grounded theory.

BACKGROUND

Although studies conducted around the world have proven how important exercise is to heart transplant patients, little information was found about heart transplant patients' exercise experience. In addition, because of different cultural backgrounds, people in Taiwan do not care about 'regular exercise' as much as Americans and Europeans do. Therefore, it is very important to find ways so that they can value 'regular exercise.'

METHODS

In-depth interviews were undertaken with a purposive sample of eight heart transplant patients. Data was analysed by repeated verification.

RESULTS

Eight valid cases were separately and thoroughly interviewed while they were exercising at a sports medical centre. The results revealed that 'empowering the new heart' is the core reason for their exercise. During the exercise training process, every participant felt that his or her new heart was filled with power or energy. The 'hardness and endurance' in terms of feeling discomfort in the body was identified at the beginning of post-surgical exercise training. Throughout the process of empowerment, patients experienced the following five interactive behaviour categories: 'self-protection', 'sharing', 'being watched and cared for', 'being aware of the benefits', and 'strengthening the new heart'.

CONCLUSIONS

Exercise can empower the new heart. After the exercise training, all patients felt that their new hearts were empowered with energy and vigour, and thus were willing to continue exercising. They even expanded their regimen to include folk therapies such as Tai Chi and breathing exercises.

The effects of exercise training on walking function and perception of health status in elderly patients with peripheral arterial occlusive disease

OBJECTIVE

To determine the effects of 12-week exercise programme on ambulatory function, free-living daily physical activity and health-related quality of life in disabled older patients with intermittent claudication.

DESIGN

Prospective, randomized controlled trial.

SETTING

University Medical Center and Veterans Affairs Medical Center, Taipei, Taiwan.

SUBJECTS

Thirty-two of 64 patients with Fontaine stage II peripheral arterial occlusive disease (PAOD) were randomized to exercise training and 32 to usual care control. Five patients from the exercise group and six patients from the control group dropped out, leaving 27 and 26 patients, respectively, completing the study in each group.

INTERVENTIONS

Twelve weeks of treadmill exercise training.

MAIN OUTCOME MEASURES

Treadmill walking time to onset of claudication pain and to maximal claudication pain, 6-min walk distance, self-reported ambulatory ability and perceived health-related quality of life (QOL).

RESULTS

Compliance of exercise programme was 83% of the possible sessions. Exercise training increased treadmill walking time to onset of claudication pain by 88% (P < 0.001), time to maximal pain by 70% (P < 0.001), and 6-min walk distance by 21% (P < 0.001).

SUBJECTS

Perception of health-related QOL improved from 12% to 178% in the exercise group. These improvements were significantly better than the changes in the control group (P < 0.05).

CONCLUSIONS

Significant improvements in claudication following 12-week exercise training in elderly PAOD patients were observed. Increase in treadmill walking time to maximal claudication pain in these patients translated into the improvement of perceived physical health, which enabled the patients to become more functionally independent.

Investigation of the difference between treadmill self-efficacy and actual performance in Taiwanese patients with chronic obstructive pulmonary disease

OBJECTIVE

Because overactivity or underactivity may result in inadequate physical responses among patients with chronic obstructive pulmonary disease (COPD), the purpose of this study was to examine the difference between treadmill self-efficacy and actual treadmill performance. Factors that influence self-efficacy and actual performance were also examined.

DESIGN

The design was a descriptive and correlational study.

SETTING

The study took place at the Research Center of Sports Medicine in University.

PATIENTS

A total of 48 subjects with COPD were recruited from 4 hospitals.

OUTCOME MEASURES

The outcome measures were treadmill self-efficacy and actual treadmill performance.

INTERVENTION

Data were collected by means of treadmill exercise testing and 3 structured questionnaires.

RESULTS

The findings of the study demonstrated that the average maximal functional capacity was 2.94 METs. A positive significant relationship between treadmill self-efficacy and actual performance was observed. However, the majority of subjects (72.9%) underestimated their treadmill performance and only 7 subjects (14.6%) assessed their treadmill performance accurately. Dyspnea was the most common reason for a subject to stop during the exercise testing. The patient's past experience was the most important predictor for both treadmill self-efficacy and actual treadmill performance.

CONCLUSIONS

These results revealed that patients in Taiwan who have COPD have extremely poor functional capacity and most of them underestimated their exercise performance. An assessment of self-efficacy and exercise performance seems imperative in the development of individualized nursing interventions to help COPD patients.

Clinical validation of the related factors and defining characteristics of impaired swallowing for patients with stroke

This exploratory study was conducted to examine the reliability and validity of related factors and defining characteristics of impaired swallowing for stroke patients. Sample of the study included (1) 12 nursing experts, (2) 52 nurses who work in neurological wards, and (3) 107 stroke patients who were divided into a BDST (Burks Dysphagia Screening Test)-positive group (n = 51) and a BDST-negative group (n = 56). Data were collected and validated based on expert validity, diagnostic content validity (DCV), construct validity, and discriminate validity. Results showed that the DCV scores of 17 related factors and 12 defining characteristics were all greater than 0.5. The internal consistency of the 12 defining characteristics was demonstrated by a Cronbach alpha coefficient of 0.89. Two factors were extracted from the 12 defining characteristics after factor analysis; these were "high risk of aspiration with speech disorder" and "ineffectiveness of swallowing". Five major defining characteristics, i.e. pocketing of food, signs of acute aspiration, burning or tickling at the back of the throat, spitting food or food leaking from the mouth, and weak or hoarse cough, were determined by logistic regression. The findings of this study suggest that the 17 related factors and 12 defining characteristics are reliable and valid in diagnosing the problem of impaired swallowing for stroke patients.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: a middle-term clinical follow-up

HYPOTHESES/PURPOSE

The medial displacement calcaneal osteotomy has recently become a popular addition to flexor digitorum longus transfer for stage II posterior tibial tendon dysfunction. We reviewed the results of 26 patients who had undergone the procedure at an average of 32 months prior to follow-up (range 12 to 70 months) with particular attention to objective functional parameters.

CONCLUSIONS/SIGNIFICANCE

FDL transfer and medial displacement calcaneal osteotomy provides good functional and symptomatic results in the middle-term. The operation preserves the majority of subtalar motion and is objectively durable as assessed by the continued ability to perform a single-leg toe rise. Although moderate radiographic improvement in the arch is frequent, often patients fail to notice this clinically. A prolonged period of steady improvement in symptoms after surgery is common.

SUMMARY OF METHODS/RESULTS

Between 1993 and 1998, 26 patients underwent flexor digitorum longus transfer and medial displacement calcaneal osteotomy performed by the senior author. Sixteen returned for the study and were seen for physical exams. Three were included on the basis of chart review including one who was deceased and two who could not be contacted. Five further patients included on the basis of chart review were also contacted for telephone interviews. For the survival analysis, however, their last physical examination was used as the follow-up date. Two patients who had early technical failures were not interviewed but were counted as early failures of the procedure in the survival analysis. Functionally, all patients except three could perform a single-leg toe rise at follow-up, a maneuver none could perform preoperatively. Of these three, two cases were technical failures with loss of fixation of the FDL transfer early in the postoperative course, ultimately requiring revision procedures including one subtalar fusion. Another patient was a late failure after developing increasing pain and weakness during a pregnancy 69 months after the procedure. Clinically assessed subtalar motion remained 81 +/- 15% of the contralateral side in those patients with unilateral disease. Although improvement in the radiographic alignment of the foot was commonly noted, only 50% of patients felt the conformation of their foot had noticeably changed, and only one (4%) felt the improvement to be significant. Pain relief was rated excellent by 75% and good by 16%; the average AOFAS Hindfoot pain subscale score was 35.2 (out of 40 possible). Function was felt to be markedly improved by all patients except the three who were unable to perform a single-leg toe rise. The average score for the four functional symptom categories of the AOFAS score was 26.8 (out of 28 possible). Most patients noted that although they were able to perform daily activities after their postoperative immobilization was liberalized, there was a prolonged period of steady improvement in symptoms and function after surgery. The median length of time to self-rated maximal medical improvement was 10 months.

[Impact of different activity modes and durations on immediate serum glucose response among type 2 diabetes mellitus patients]

The purpose of this study was to examine the influence of different activity modes and durations on glucose response among type 2 Diabetes Mellitus patients. Twenty-one subjects who met the selection criteria were selected by purposive sampling. A subject's serum glucose level was determined by using the mini Accutrend monitor before, and then 10 minutes, 20 minutes, 30 minutes, and 40 minutes after three kinds of activities, which included rest, hospital routines (such as registering, getting medication, waiting in line, etc.), and aerobic exercise. The results of this study demonstrated that the decrease in serum glucose was greater after performing aerobic exercise than after rest or hospital routines. Also, a greater decrease in serum glucose was found after 20, 30, and 40 minutes aerobic exercise than after 10 minutes aerobic exercise. Subjects who took sulfonylurea had a larger decrease in serum glucose after 10 minutes aerobic exercise than subjects who took metformin. A greater decrease in serum glucose was found in males than females after aerobic exercise.

Alstrom syndrome in two siblings

Alstrom syndrome is a very rare autosomal recessive inherited disorder. Only 50 cases have been reported since the syndrome was first described in 1959. This syndrome is characterized by obesity, impaired glucose tolerance with insulin resistance, retinal degeneration, neurosensory deafness, acanthosis nigricans, hepatic dysfunction, and some endocrine disorders. The index case of this report was a 12-year-old girl who became blind at the age of 6 years as the result of progressively impaired vision. At the age of 12, diabetes mellitus was diagnosed and acanthosis nigricans presented in the neck, axilla, and groin regions. Her 10-year-old brother had similar symptoms. Electroretinography and audiometry disclosed generalized pigmentary epithelial change, decreased to absent cone and rod responses, and moderate sensorineural hearing loss in both siblings. Biochemistry and oral glucose tolerance tests showed diabetes mellitus, dyslipidemia, and hepatic dysfunction in the index case. Elevations of insulin, C-peptide, and leptin concentrations were found in both siblings. Insulin resistance was also demonstrated in both siblings using the modified insulin suppression test with constant infusion of somatostatin and exogenous insulin.

Sensory thresholds of normal human feet

HYPOTHESES/PURPOSE

Although several studies in the literature have evaluated the abnormal sensory thresholds of diabetic feet to Semmes-Weinstein monofilament testing, there is very limited data on the sensory thresholds of individuals without diabetes or peripheral neuropathy. The purpose of this study was to assess the dorsal and plantar sensation of the feet from 40 healthy, college-aged volunteers using Semmes-Weinstein monofilaments.

CONCLUSIONS/SIGNIFICANCE

Semmes-Weinstein testing is a useful tool in predicting which diabetic patients may be at risk for ulceration of the feet. Several studies have determined 5.07 to be the threshold for protective sensation. Based on the normal values derived in this study, the inability to feel a Semmes-Weinstein monofilament of 5.07 (as in diabetic neuropathy) represents a sensory threshold that is more than 50 times greater than normal. This means that roughly 98% of the sensory ability has been lost.

METHODS

20 male and 20 female volunteers between the ages of 18 to 22 years old were selected. None had a history of any significant injury or previous surgery to the foot or ankle. There were no known medical conditions associated with decreased foot sensation, (e.g.- diabetes, syphilis, leprosy, myelomeningocele, syringomyelia, or hereditary neuropathy). Volunteers were also questioned regarding participation in athletic activities. The subjects were blindfolded with the leg resting comfortably on a chair as 14 plantar and 5 dorsal locations were tested on each foot. The right foot was always tested first. Each site on the foot had the Semmes-Weinstein monofilaments applied to it first, in an order of increasing stiffness, then repeated in decreasing order, using all twenty monofilaments in the set. A positive threshold response was recorded when the subject could feel the filament and could accurately locate where on the foot the stimulus had been applied. The left foot was then tested in an identical fashion.

RESULTS

The mean sensitivity for all sites was 3.63 (0.0075 SEM). There were significant differences between sites, between using increasing or decreasing monofilament stiffness, between subjects, and in some instances, between right foot and left foot values. When testing was performed from the higher to lower monofilament stiffness, subjects were found to have significantly better sensitivity, which indicates the importance of a consistent testing protocol (either all up or all down). Sensation in the lesser toes and the arch were the most sensitive followed by the hallux and the plantar metatarsal heads. The least sensitive site was the heel, with 1/6th the sensitivity of the most sensitive toes.

Effects of lovastatin and gemfibrozil in subjects with high ratios of total cholesterol to high-density lipoprotein cholesterol

Insulin resistance is associated with hypertriglyceridemia, low serum high-density lipoprotein cholesterol (HDL-C) concentrations and high serum total cholesterol (TC) to HDL-C ratios. Several reports have demonstrated that either lovastatin or gemfibrozil may favorably lower serum lipid concentrations. However, their effects on insulin sensitivity are unknown. The primary aim of this study was to compare the effects of lovastatin and gemfibrozil on insulin sensitivity and serum leptin concentrations in subjects with high TC/HDL-C ratios. We enrolled 25 nondiabetic patients, similar in terms of age and weight with TC/HDL-C ratios greater than 5. Thirteen subjects were treated with lovastatin 20 mg per day, and 12 received gemfibrozil 300 mg twice per day. Plasma lipids, glucose, and leptin were measured, and a 75-g oral glucose tolerance test (OGTT) and a modified insulin suppression test were performed before and after 3 months of treatment. The study showed the mean plasma TC, low-density lipoprotein cholesterol (LDL-C) concentrations, and TC/HDL-C ratio were significantly reduced in the lovastatin-treated group, but no obvious effects on plasma triglyceride (TG) and HDL-C were noted. In the gemfibrozil group, plasma TG and HDL-C were markedly lowered, but no significantly different effects in other plasma lipids were found. Gemfibrozil did not affect steady-state plasma glucose (SSPG) concentrations, whereas lovastatin significantly increased SSPG concentrations. Neither drug affected the serum leptin concentration during the OGTT. We conclude that lovastatin significantly lowers plasma TC and LDL-C ratio, and TC/HDL-C concentrations and adversely affects insulin sensitivity, while gemfibrozil markedly reduces plasma TG concentrations without altering insulin sensitivity in subjects with high TC/HDL-C ratios.

Subtrochanteric femoral fractures in children. Alignment after 90 degrees-90 degrees traction and cast application

Fifteen children younger than 10 years of age with subtrochanteric fractures treated by a uniform method were evaluated. These patients had been treated with femoral skeletal traction, with the hip and knee flexed to 90 degrees until radiographic callus appeared, then with a hip spica cast. True neck to shaft and anteversion angles were calculated bilaterally using a biplanar method. Leg lengths were measured radiographically and clinically. Mean age at injury was 4.5 years, and mean followup was 6.5 years. Overgrowth averaged 10 mm after fracture. Anteversion at final followup differed only by a mean of 2 degrees from the contralateral side (range, -3 degrees to +4 degrees), and the mean neck shaft angle differed by only 1 degree. Remodeling of coronal angulation was 50% or more in all cases.

The influence of self-efficacy on exercise intensity, compliance rate and cardiac rehabilitation outcomes among coronary artery disease patients

Self-efficacy is increasingly used as a predictor of health behavior. The purpose of this study was to examine the impact of exercise self-efficacy on exercise behaviors and outcomes. A one-group pre-test/post-test design was used. The treatment, a 12-week exercise training program, was executed between the pre- and post-tests. Exercise self-efficacy was measured prior to training and at the 4th, 8th and 12th weeks of training. Estimated VO2max, fatigue, anxiety, depression, and quality of life (QOL) were assessed prior to exercise training and after 12 weeks of training. Compliance rate and exercise intensity were computed at the 4th, 8th and 12th weeks of training. Results of this study revealed no relationship between exercise self-efficacy and compliance rate, nor between exercise self-efficacy and exercise intensity. The change in exercise self-efficacy after exercise training, rather than the initial self-efficacy level, was significantly related to exercise outcomes. Exercise intensity was more important in predicting the improvement of VO2max than was compliance rate. In contrast, compliance rate was more important in predicting the improvement of QOL than was exercise intensity.

Bandura's self-efficacy theory: a guide for cardiac rehabilitation nursing practice

To help patients achieve the greatest benefit from cardiac rehabilitation programs, nurses must assist them to modify unhealthy behaviors. Many cardiac rehabilitation programs, however, lack a theoretical foundation; therefore, interventions are usually executed without accounting for the complexities of human behavior, and little consideration is given to the difficulties encountered in altering unhealthy behavior patterns. Bandura's self-efficacy theory is considered a suitable model for cardiac rehabilitation because it provides a systematic direction which allows one to interpret, modify, and predict patients' behaviors. This article describes the development of and conceptual framework for Bandura's theory, how it provides a basis for measurement of self-efficacy, and how it may be applied to the study of cardiac rehabilitation. Finally, some research issues, which are related to applications of self-efficacy theory in cardiac rehabilitation are discussed.

Ablation of stimulation of a cAMP-responsive promoter in CHO cell lines defective in their cAMP-dependent protein kinase system

We have studied the requirement for an intact cAMP-dependent protein kinase (PKA) system to regulate cAMP-mediated gene transcription in Chinese hamster ovary (CHO) cells. Wild-type CHO cells and mutant CHO cell lines selected for their resistance to the growth inhibitory effect of 8-Br-cAMP and defective in their PKA system were transiently transfected with reporter plasmids containing 2.5 and 3.0 kb of the 5'-flanking sequence of the rat tyrosine aminotransferase (TAT) gene promoter. This segment of DNA contains no CRE-like sequences, yet wild-type transfectants exhibited a specific increase in TAT promoter activity following growth in medium containing 8-Br-cAMP. In CHO cell lines defective in their PKA, the transfected TAT promoter failed to respond to cAMP treatment. We conclude that an intact PKA system is necessary for the cAMP-mediated increase in TAT promoter activity in CHO cells and that there is no requirement for a CRE to see this effect.

Point mutational analysis of the hamster dihydrofolate reductase minimum promoter

We have shown previously that 48 base pairs (bp) of 5'-flanking sequence are necessary for correct initiation at the major transcriptional start site of the Chinese hamster dihydrofolate reductase (dhfr) gene (Ciudad et al., 1988). As an upstream element, this sequence alone confers 25% of maximum promoter activity. The 5' half of this sequence is particularly well conserved among mammalian species; it contains one Sp1 binding site (GC box) and one CAA element. In the present work, we have analyzed the role of this region by extensive point mutational analysis. Twenty-three dhfr minigene constructs containing 1- or 2-base substitutions in this region of the promoter were tested by measuring their ability to transfect DHFR-deficient Chinese hamster ovary cells to a DHFR+ growth phenotype. Eight mutants, all in or near the GC box, exhibited reduced transfection efficiency. Promoter disfunction in these mutants was confirmed by RNase protection analysis of stable transfectants. Gel retardation experiments showed that mutants affected in the consensus sequence for Sp1 binding were deficient in binding a protein found in nuclear extracts of Chinese hamster ovary cells. Purified human transcription factor Sp1 was also unable to bind a promoter sequence bearing one of these single base substitutions, suggesting that Sp1 itself is involved in dhfr transcription in vivo. We conclude that most single base mutations in the GC box severely cripple or eliminate promoter function by inhibiting binding of transcription factors to this regulatory sequence and that Sp1 is likely to be involved in dhfr transcription in vivo. We also found that the well conserved CAA element is not absolutely necessary for transcription.

[Shift of placental alkaline phosphatase isoenzymes in the course of pregnancy]

It is generally accepted that every placental protein shows its characteristics vicissitude pattern during pregnancy and that alkaline phosphatases (ALP) are subdivided into three kinds of isoenzymes, i.e.: tissue-unspecific, intestinal and termplacental ALPs. In this study, the changes in ALP isoenzyme profile throughout the course of pregnancy was studied by biochemistry, enzyme- and immuno-histochemistry, and the following results were obtained. In early pregnancy, ALP activity was composed mostly of tissue-unspecific ALP isoenzyme, and its activity revealed a peak value around 10 weeks of pregnancy as in the case of the hCG serum concentration. At the end of the second trimester of pregnancy, instead of tissue-unspecific isoenzyme, ALP activity was mainly composed of term placental ALP isoenzyme, but a very small amount of the isoenzyme was proved to exist in the villi at the 6th week of gestation. The above results were confirmed by morphological studies such as enzyme-cytochemistry and immuno-cytochemistry. It was therefore concluded that at least two genes of ALP isoenzymes existed in the villi and that the regulation of gene activity changed during the course of pregnancy. Furthermore, since tissue-unspecific ALP isoenzyme showed a pattern of change similar to that of serum hCG, the existence of a developmental phase-specific gene set was postulated.