Erica Schorr

The PADQOL: development and validation of a PAD-specific quality of life questionnaire.

Understanding the impact of peripheral artery disease (PAD) requires broad evaluation of how functional limitations of PAD affect patients’ perceptions of health-related quality of life (HRQL). The objective of this study was to describe the development, testing, and psychometric properties of the PAD Quality of Life Questionnaire (PADQOL). The PADQOL was developed in three steps: (1) interviews of symptomatic PAD patients provided content of the initial questionnaire; (2) co-administration with the SF-36 (a 36-item short-form health survey), Walking Impairment Questionnaire, and Profile of Mood States examined construct validity; and (3) a three-phased factor analysis identified factors and shortened the questionnaire. Data analyses from 297 symptomatic PAD patients resulted in a 38-item questionnaire of five factors: Social relationships and interactions, Self-concept and feelings, Symptoms and limitations in physical functioning, Fear and uncertainty, and Positive adaptation (α = 0.92–0.73) and items related to sexual function, intimate relationships and employment. Between-instrument correlations established construct validity. In conclusion, PADQOL is a validated measure to assess the disease-specific physical, psychosocial and emotional effects of PAD for research and practice.

Methods of symptom evaluation and their impact on peripheral artery disease (PAD) symptom prevalence: A review

Peripheral artery disease (PAD) is a common progressive atherosclerotic occlusive disease that causes insufficient blood flow to the lower extremities. The symptom that health care professionals most often associate with PAD is claudication. However, patient reporting of claudication is highly variable. A structured literature review was conducted to evaluate how PAD symptoms are identified, defined, and categorized. This review focuses on the development and performance characteristics of PAD symptom questionnaires and the identification of a spectrum of leg symptoms beyond classic claudication. Additionally, potential confounders of PAD symptom reporting and strategies for a more comprehensive assessment of PAD symptoms are discussed. Overall, there is a lack of consistency in the utilization of PAD claudication questionnaires which impacts PAD symptom reporting and categorization. Based on this review, atypical symptoms are commonly reported, but poorly understood. Additional research is needed to gain a better understanding of the presentation of atypical symptoms, as well as the role of age, gender, race, and comorbid conditions on the symptom experience of patients with PAD.

Effects of fasting on tissue contents of coenzyme A and related intermediates in rats.

Exposure of rats and mice to hyperoxia decreases lung coenzyme A (CoASH) contents, with a decrease of 50% observed in adult male Fischer-344 rats exposed to >95% O2 for 48 h. Decreases in lung CoASH levels are not accompanied by increases in contents of the mixed glutathione disulfide of CoA, as might be expected of a primary oxidative stress on CoASH status. Animals exposed to hyperoxia exhibit decreased food intake, and the present studies were to test the hypothesis that fasting would decrease lung CoASH contents, thereby suggesting a mechanism for the effects of hyperoxia. Adult male Fischer-344 rats were examined after 0, 24, or 48 h of fasting (n = 5, 6, and 6, respectively). Fasting for 24 or 48 h did not affect lung CoASH levels or lung weights, despite 6 and 12% losses in body weight. Lung glutathione concentrations (nanomoles per gram of tissue) and contents (nanomoles per whole organ) and glutathione disulfide contents were 10 to 20% lower in rats fasted for 48 h than in fed rats. Liver weights and glutathione and glutathione disulfide contents and concentrations were 30 to 70% lower in rats fasted for 24 or 48 h than in fed rats. Hepatic CoASH concentrations increased during fasting, but hepatic contents of CoASH remained remarkably constant. Liver protein contents (milligrams of protein per whole organ) decreased after 24 and 48 h of fasting, but protein concentrations (milligrams of protein per gram of tissue) were higher in rats fasted 48 h than in fed rats. Overall, glutathione, glutathione disulfide, and protein contents in liver and skeletal muscle decreased with fasting, but significant changes in CoASH contents were not observed. Diminished food intake in animals does not explain the effects of hyperoxia on lung CoASH contents. CoASH and derived thioesters participate in many cellular functions, and if depletion of lung CoASH during hyperoxia proves to be relevant to mechanisms of lung injury, support of mechanisms needed to sustain CoA levels could be helpful in prematurely born infants and in adults.

Characterization of the peripheral artery disease symptom experience

Claudication is the most commonly recognized peripheral artery disease (PAD) symptom, but not the most prevalent. Only 7.5%-33% of patients report claudication as being part of their symptom experience. However, there is little evidence supporting atypical symptom reporting. The study purpose was to describe the full spectrum of symptoms experienced by older and younger individuals with PAD. Semistructured interviews were conducted with a purposive sample of 38 community-dwelling adults aged 49-83 years; transcripts were analyzed using content analysis. Six themes emerged: symptom descriptors (claudication and atypical), maintaining equilibrium, temporal fluctuations, the role of exercise, perceived impact on quality of life, and disease presence and treatment. Results suggest heavy reliance on claudication can result in mis- or under-diagnosis of PAD. Further research is needed to validate the correspondence of atypical symptoms with ischemic changes during exercise to broaden currently accepted symptom locations and descriptors associated with PAD.

Peer Group and Text Message–Based Weight-Loss and Management Intervention for African American Women:

About 80% of African American (AA) women are overweight or obese. Accessible and effective weight management programs targeting weight loss, weight maintenance and the prevention of weight regain are needed to improve health of AA women. A feasibility study was conducted to examine the feasibility, acceptability, and potential efficacy of a 16-week intervention protocol for weight loss and management that combined daily text messages and biweekly peer group sessions. Modest but statistically significant reductions were detected in weight and body mass index from baseline to 16 weeks. At baseline, 36% of participants were in action and maintenance stages in measures of the stages of change for weight loss and management; this percent increased to 82% at 16 weeks. Findings of this feasibility study provide preliminary evidence of an educational intervention that could motivate women and lead to successful behavior change, and successful weight loss and management for AA women.

The Relationship between Peripheral Artery Disease Symptomatology and Ischemia

Background Fewer than half of individuals with peripheral artery disease (PAD) experience classic claudication, and the relationships between PAD typical or atypical symptom intensity, location, and description (classic or atypical) with ischemic changes have not previously been reported. Objective The primary purpose of this study was to evaluate the relationship between self-reported PAD symptom intensity and calf tissue ischemia measured using the tissue saturation index (TSI) during treadmill exercise. The location and descriptors of atypical PAD symptoms in the presence of calf tissue ischemia were also identified. Methods Adults with PAD with exercise-limiting ischemic symptoms were asked to (a) rate symptom intensity using a numerical rating scale (NRS) from 0 to 5 (0 = no pain, 1 = onset of pain, 5 = maximal pain), (b) provide symptom locations and descriptors, and (c) wear a near-infrared spectroscopy device to obtain calf TSI values during treadmill exercise. Multilevel models with TSI as the outcome variable were estimated during exercise and recovery. Covariates included were exercise time, recovery time, baseline TSI, exercise rating, recovery rating, ankle-brachial index (ABI), age, race, gender, body mass index, diabetes, neuropathy, and smoking. Results During three successive bouts of treadmill exercise for 40 participants (80% Caucasian men; average age = 68 years, SD = 9.2), the most rapid decline in TSI occurred between the start of exercise and symptom onset (when NRS = 1). The TSI nadir was often reached prior to report of maximum discomfort (when NRS = 5), and changes in TSI were related to exercise time (p < .001), baseline TSI (p < .001), exercise ratings (p < .001), and ABI (p < .05). During recovery, TSI increased steadily for most participants as pain eased. In the recovery model, changes in TSI were associated with recovery ratings (p < .001) and ABI (p < .03). Of 120 treadmill exercise tests, 69.2% were stopped due to discomfort in the calf with classic descriptors reported only half the time (55.4%). Discussion Exploratory analyses revealed ischemic symptoms extended beyond classic claudication locations and descriptors. Future research should evaluate changes in TSI relative to atypical locations and descriptors to improve understanding of the full range of ischemic symptoms experienced by individuals with PAD.

Variability in Individual Response to Aerobic Exercise Interventions Among Older Adults

Although a plethora of evidence supports the benefits of exercise among older adults, a majority of studies have emphasized group differences, while giving little, if any, attention to individual differences. Given the lack of data on variability in response, the present review examined how nonresponse to aerobic exercise has been defined in older adult populations and characteristics associated with nonresponse among older adults. The results of this review suggest that interindividual variability in response of maximal oxygen consumption to aerobic exercise interventions is prevalent among older adults (1.4-63.4%); age, sex, race, and body mass index may not be critical determinants of nonresponse; whereas health status, baseline fitness, and exercise dose appear important. Future intervention studies should evaluate and report the variability in individual response of older adults to exercise; investigators should develop programs that allow for modification of components to assist older adults in achieving optimal benefit from exercise programs.

Social Determinants Documentation in Electronic Health Records With and Without Standardized Terminologies

In 2014, the Institute of Medicine (IOM) urged documentation of 12 social and behavioral determinants of health (SBDH) across all electronic health records (EHRs). The American Academy of Nursing (AAN) urged EHR vendors to provide mechanisms for documenting SBDH using standardized terminologies. Twelve terminologies are recognized by the American Nurses Association. The purpose of this study was to examine SBDH documentation in EHRs with and without standardized nursing terminologies. Data-Information-KnowledgeWisdom framework guided this informatics-policy study to advance knowledge management and action related to SBDH. This pilot study surveyed key informants regarding SBDH documentation in nine EHRs (six acute/ambulatory care and three community care). Three graduate nursing students reviewed SBDH literature, compiled SBDH items, and interviewed informants. For each of 107 SBDH items, they recorded documentation methods, documenter roles, and EHR screens. Data analysis used standard descriptive and inferential statistics. SBDH items were documented using free text, structured text, and clinical terminologies in diverse screens and by multiple clinicians and others. The clinical terminologies were Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) (M = 1), International Classification of Diseases 9th/10th Edition (ICD 9/10) (M = 1), and the Omaha System (M = 79). Most often, clinical terminology data were documented by nurses versus receptionists or other non-clinical personnel. Documentation “unknown” differed significantly between EHRs with and without the Omaha System (M = 26.0, SD = 8.7 vs. M = 74.5, SD = 16.5; p = .005). Mapping 107 SBDH items and the Omaha System yielded 12 problems in four domains. Harmonizing the 12 IOM-recommended measures with the Omaha System yielded 17 signs/symptoms of eight problems in two domains. SBDH documentation differed vastly based on presence of a nursing terminology. The Omaha System enabled a more comprehensive, holistic assessment of interoperable SBDH data. EHRs 658208WJNXXX10.1177/0193945916658208Western Journal of Nursing ResearchMonsen et al research-article2016

Review of an article: Gardner AW, Parker DE, Montgomery PS, Scott KJ, Blevins SM. Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication: A randomized controlled trial. Circulation 2011;123(5):491-98

Medically supervised exercise has been shown to effectively improve exercise performance, including increased claudicationonset time and peak walking time in patients afflicted with peripheral artery disease (PAD). Although supervised exercise is currently a treatment recommended by the American College of Cardiology and the American Heart Association, reimbursement by health insurance companies is not yet provided. Therefore, patients experiencing PAD-associated claudication could benefit from an exercise alternative in the community setting, such as a home-based walking program. In this study, 119 participants with PAD experiencing intermittent claudication were randomized into 1 of 3 groups: nonexercise as the usual care, supervised exercise, or home-based exercise. There were no significant differences among the groups in baseline characteristics. The study was strengthened by utilizing a randomized, controlled design and a step-activity monitor to directly measure exercise adherence and to quantify the amount of exercise completed. The purpose of the study was to compare the changes among the 3 groups with regard to exercise performance and daily ambulatory activity. Patients were followed for 12weeks, duringwhich time supervised and home-based participants exercised 3 times per week, at 2 miles per hour or at a self-selected pace, respectively. The initial

Documentation of social determinants in electronic health records with and without standardized terminologies: A comparative study:

Background: Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH. Objective: We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies. Methods: We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases. Results: In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): ICD-9/10 (N = 1); SNOMED CT (N = 1); Omaha System (N = 79). Most often, standardized terminology data were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ differed significantly between EHRs with and without the Omaha System (mean = 26.0 (standard deviation (SD) = 8.7) versus mean = 74.5 (SD = 16.5)) (p = .005). SBDH documentation in EHRs differed based on the presence of a nursing terminology. Conclusions: The Omaha System enabled a more comprehensive, holistic assessment and documentation of interoperable SBDH data. Further research is needed to determine SBDH data elements that are needed across settings, the uses of SBDH data in practice, and to examine patient perspectives related to SBDH assessments.