Susan J. Bartlett

Patient adherence in COPD

Patient adherence to treatment in chronic obstructive pulmonary disease (COPD) is essential to optimise disease management. As with other chronic diseases, poor adherence is common and results in increased rates of morbidity, healthcare expenditures, hospitalisations and possibly mortality, as well as unnecessary escalation of therapy and reduced quality of life. Examples include overuse, underuse, and alteration of schedule and doses of medication, continued smoking and lack of exercise. Adherence is affected by patients’ perception of their disease, type of treatment or medication, the quality of patient provider communication and the social environment. Patients are more likely to adhere to treatment when they believe it will improve disease management or control, or anticipate serious consequences related to non-adherence. Providers play a critical role in helping patients understand the nature of the disease, potential benefits of treatment, addressing concerns regarding potential adverse effects and events, and encouraging patients to develop self-management skills. For clinicians, it is important to explore patients’ beliefs and concerns about the safety and benefits of the treatment, as many patients harbour unspoken fears. Complex regimens and polytherapy also contribute to suboptimal adherence. This review addresses adherence related issues in COPD, assesses current efforts to improve adherence and highlights opportunities to improve adherence for both providers and patients.

Exercise in the Treatment of Obesity Effects of Four Interventions on Body Composition, Resting Energy Expenditure, Appetite, and Mood

This study investigated changes in body composition, resting energy expenditure (REE), appetite, and mood in 128 obese women who were randomly assigned to 1 of 4 treatment conditions: diet alone, diet plus aerobic training, diet plus strength training, or diet combined with aerobic and strength training (i.e., combined training). All women received the same 48-week group behavioral program and were prescribed the same diet. Exercising participants were provided 3 supervised exercise sessions per week for the first 28 weeks and 2 sessions weekly thereafter. Participants across the 4 conditions achieved a mean weight loss of 16.5 +/- 6.8 kg at Week 24, which decreased to 15.1 +/- 8.4 kg at Week 48. There were no significant differences among conditions at any time in changes in weight or body composition. Women who received aerobic training displayed significantly smaller reductions in REE at Week 24 than did those who received strength training. There were no other significant differences among conditions at any time on this variable or in changes in appetite and mood.

Can inexpensive signs encourage the use of stairs? Results from a community intervention.

The American Heart Association recently added a sedentary lifestyle to its list of modifiable risk factors [1]. Reports suggest that only 22% of the U.S. adult population are active enough to derive health benefits from their physical activity and that one in four Americans are completely sedentary [2]. This finding may parallel the sharp increase in the prevalence of overweight persons over the past 12 years, from 25% in the National Health and Nutrition Examination Survey (NHANES II) in 1976-1980 to 33% in phase I of NHANES III in 1988-1991 [3]. The Centers for Disease Control and Prevention and the American College of Sports Medicine recently revised their recommendation regarding exercise to suggest that all Americans should accumulate 30 minutes or more of moderate-intensity physical activity on most or all days of the week [4]. Inactive people who increase their levels of physical activity are less likely to die of all causes and of cardiovascular disease than those who remain sedentary [5, 6]. Walking and taking the stairs instead of escalators or elevators may be two easy ways for seemingly healthy sedentary adults to become more moderately active [7-10]. In 1980, Brownell and associates [11] examined the effects of placing a sign that encouraged stair use for health benefits at the base of an escalator that was adjacent to a flight of stairs in a mall, train station, and bus terminal in Philadelphia. They reported that the sign resulted in statistically significant increases in stair use among 45 694 commuters. They also noted that overweight persons did not use the stairs as often as leaner persons before or after the sign was erected. Blamey and colleagues [12] recently examined the effects of encouraging stair use for health benefits in a Scottish train station and also found that a low-cost sign could result in statistically significantly increases in stair use by adults. We examined the trends among shoppers of different ages, ethnicities, sexes, and body weights in a shopping mall in which escalators and stairs were adjacent. We also observed the differential effects of adding signs at the base of the escalator that promoted stair use for health benefits or weight control. Methods Participants We observed 17 901 adult patrons of a mall located in a Baltimore suburb while they used the stairs or escalators. Because of the potential for artifactual influence on the decision process, persons carrying items larger than a briefcase were excluded. We also excluded persons carrying a baby or child and those judged to be younger than 18 years of age. Participants were unaware that they were part of a study investigating physical activity patterns. Design This observational study involved an initial baseline phase and two subsequent intervention phases that incorporated motivational signs displayed at the base of the escalator and stairs. Each of the three phases lasted 1 month. During the baseline phase, the frequency of stair use compared with use of the adjacent escalator was recorded. During the first interventional phase (health benefits), a 22 28 sign was placed on an easel beside the escalator and stairs. The sign featured a caricature of a heart at the top of a flight of stairs and the statement, Your heart needs exercise, use the stairs. During the second interventional phase (weight control), a similar-sized sign was placed on an easel. The sign featured a caricature of a woman at the top of a flight of stairs; she had a thin waistline and was wearing pants with a waist that was too large. The caption on the sign read, Improve your waistline, use the stairs. Setting In this suburban Baltimore mall, participants could use the escalator or the stairs to get to the second floor. A stairway was adjacent to ascending and descending escalators. The stairway consisted of 10 stairs, a 6-foot landing, and 10 more stairs. Observations were made during June, July, and August between 10:30 a.m. and 9:00 p.m. on all days of the week. Procedures Observations were made by one of the authors. A previous physical activity study [11] used many observers to ensure valid observation of all persons. However, the volume of mall traffic was never so heavy that more than one observer was needed to code the characteristics and choice of each person. Before the study began, the observer and the senior author spent one full day in the mall classifying shoppers by age and weight status to be sure that observations were as accurate as possible. The observer sat in an inconspicuous spot at the foot of the steps that allowed for clear observation. Frequency of stair use was recorded in the same way during each of the three phases. Each persons sex and ethnicity (black, white, or other) was recorded. In addition, persons were judged to be 40 years of age or older or younger than 40 years of age. Finally, the observer noted whether the person appeared overweight. Statistical Analysis The change in proportions of persons using the stairs from the baseline to the intervention phases of the study was analyzed by using the chi-square test and by computing 95% CIs around the differences in proportions between the comparison groups. The same procedure was used to examine intergroup differences (normal weight or overweight) within a given phase of the study. We also computed the number needed to treat (NNT), the number of shoppers who needed to be exposed to the sign to get one shopper to use the stairs, as 1/RD, where RD is expressed as the difference in proportions between the two comparison groups. Results are presented as the proportion of persons who opted to use the stairs rather than the escalator; 95% CIs are presented with associated P values and the NNT. Data were analyzed by using the SPSS for Windows (version 8.0) statistical package [13]. Results A total of 17 901 observations were made. Overall, the use of stairs at baseline was 4.8%. During the intervention period when the health benefits sign was displayed, stair use increased significantly to 6.9% (difference, 2.1 percentage points [CI, 1.3 to 2.8 percentage points]; NNT, 48). Compared with the baseline value, stair use also increased significantly to 7.2% when the weight-control sign was displayed (difference, 2.4 percentage points [CI, 1.5 to 3.2 percentage points]; NNT, 42). Stair use did not differ between the health benefits (6.9%) and the weight-control (7.2%) signs (difference, 0.3 percentage points [CI, 0.5 to 1.2 percentage points]; NNT, 333). Sex Table 1 and Table 3 shows the percentage of persons who used the stairs during the studys three phases as a function of age, sex, race, and body weight. Table 2 shows the change in stair use with the two signs and the change from the health benefits sign to the weight-control sign. A similar pattern emerged among men and women: Compared with baseline levels of stair use, both the health benefits sign and the weight-control sign increased stair use from 4.9% to 7.2% and 7.4%, respectively, among women and from 4.8% to 6.4% and 7.0%, respectively, among men). No sex-related differences were found when no sign or either type of sign was present. Table 1. Stair Use before and during Placement of Two Different Motivational Signs Table 3. Table 1 Continued Table 2. Changes in Stair Use among Groups of Shoppers in Response to Signs Promoting Stair Use Age At baseline, 4.6% of persons judged to be younger than 40 years of age used the stairs. Six percent took the stairs with the display of the health benefits sign (difference, 1.4 percentage points [CI, 0.3 to 2.4 percentage points]; NNT, 71), and 6.1% took the stairs in response to the weight-control sign (difference, 1.5 percentage points [CI, 0.3 to 2.7 percentage points]; NNT, 66), significantly increasing stair use relative to the baseline value (P = 0.015). No statistically significant difference in stair use was found between the health benefits sign and weight-control sign (difference, 0.1 percentage points [CI, 3.4 to 3.6 percentage points]). A similar pattern emerged among persons judged to be 40 years of age or older. At baseline, 5.1% of persons took the stairs; when the health benefits sign was erected, 8.1% chose to climb the stairs (difference, 3.0 percentage points [CI, 1.7 to 4.3 percentage points]; NNT, 33), and the weight-control sign increased stair use to 8.7% (difference, 3.6 percentage points [CI, 2.1 to 5.1 percentage points]; NNT, 28). Stair use did not significantly differ between the two signs (difference, 0.6 percentage points [CI, 0.8 to 2.1 percentage points]). Older shoppers were more likely than younger shoppers to take the stairs in response to both the health benefits sign (difference, 2.1 percentage points [CI, 0.9 to 3.2 percentage points]) and the weight-control sign (difference, 2.6 percentage points [CI, 1.1 to 4.1 percentage points]) (Figure 1). Figure 1. Patterns of stair use among shoppers judged to be younger than 40 years of age (white bars) or 40 years of age or older (striped bars). Body Weight Persons were stratified by body weight (not overweight or overweight). At baseline, 5.4% of shoppers judged to be not overweight used the stairs. The health benefits sign increased stair use to 7.2% (difference, 1.8 percentage points [CI, 1.2 to 4.7 percentage points]; NNT, 55), and the weight-control sign increased stair use to 6.9% (difference, 1.5 percentage points [CI, 0.3 to 2.6 percentage points]; NNT, 66). The same pattern emerged among persons judged to overweight: The health benefits sign significantly increased stair use from 3.8% to 6.3% [difference, 2.5 percentage points (CI, 1.2 to 3.7 percentage points); NNT, 40], and the weight-control sign increased stair use from 3.8% to 7.7% (difference, 3.9 percentage points [CI, 1.2 to 7.0 percentage points]; NNT, 40). In persons judged not to be overweight, stair use did not differ significantly between the health benefits sign (7.2%) and the weight-control sign (6.9%) (difference

Impact of weight loss on Health-Related Quality of Life

To examine the effect of treatment-induced weight loss on Health-Related Quality of Life (HRQL), 38 mildly-to-moderately overweight persons recruited to participate in a study to examine the efficacy of a lifestyle modification treatment program completed a sociodemographic questionnaire, the Beck Depression Inventory (BDI), the Medical Outcomes Study Short-Form Health Survey (SF-36, as an assessment of HRQL), and underwent a series of clinical evaluations prior to treatment. After baseline evaluations, participants were randomly assigned to either a program of lifestyle physical activity or a program of traditional aerobic activity. Participants again completed the SF-36 and BDI after the 13-week treatment program had ended. Weight loss averaged 8.6 ± 2.8 kg over the 13-week study. We found that weight loss was associated with significantly higher scores (enhanced HRQL), relative to baseline, on the physical functioning, role-physical, general health, vitality and mental health domains of the SF-36. The largest improvements were with respect to the vitality, general health perception and role-physical domains. There were no significant differences between the lifestyle and aerobic activity groups on any of the study measures. These data indicate that, at least in the short-term, weight loss appears to profoundly enhance HRQL.

Health-related quality of life among obese persons seeking and not currently seeking treatment

OBJECTIVE To compare sociodemographic characteristics and health-related quality of life (HRQL) between groups of obese persons who sought and did not seek university-based treatment for overweight. METHOD Three-hundred twelve consecutive obese persons sought outpatient university-based weight management treatment. The sample of obese persons (N = 89) who indicated that they were not currently trying to lose weight was derived from a larger convenience sample (N = 232) of persons surveyed in a hospital setting. Both groups completed sociodemographic and brief medical history questionnaires and the HRQL as measured by the Medical Outcomes Study Short-Form-36 Health Survey (SF-36). RESULTS Obese persons who had sought treatment tended to be heavier, older, Caucasian, married, in white collar employment, and reported a higher prevalence of diabetes, hypertension, and pain. In multivariate analyses, both adjusted and unadjusted for these differences, obese persons who had sought treatment were significantly more impaired on the bodily pain, general health, and vitality HRQL domains than those who were not trying to lose weight. DISCUSSION Although differences on sociodemographic and medical variables between the two groups may attenuate the obesity-HRQL relationship somewhat, obesity appears to have a pronounced impact on important dimensions of HRQL independent of whether or not the person is attempting to lose weight

Abnormal body composition phenotypes in older rheumatoid arthritis patients: association with disease characteristics and pharmacotherapies.

OBJECTIVE To compare measures of body fat and lean mass and the prevalence of abnormal body composition phenotypes (sarcopenia, overfat, and sarcopenic obesity) in men and women with rheumatoid arthritis (RA) versus matched controls, and to explore the disease-related predictors of abnormal body composition in patients with RA. METHODS A total of 189 men and women with RA and 189 age-, sex-, and race-matched non-RA controls underwent dual-energy x-ray absorptiometry for measurement of total and regional body fat and lean mass. Continuous and categorical measures of body composition were compared between RA and control subjects by sex and according to categories of body mass index (BMI). Within the group of RA patients, demographic, lifestyle, and RA disease and treatment characteristics were compared for RA patients with healthy body composition versus those with abnormal body composition phenotypes. RESULTS Compared with non-RA controls, RA status was significantly associated with greater odds of sarcopenia, overfat, and sarcopenic obesity in women, but not in men. Relative differences in body composition phenotypes between RA and control subjects were greatest for patients in the normal weight BMI category (<25 kg/m(2)). Among RA characteristics, increasing joint deformity, self-reported disability scores, C-reactive protein levels, rheumatoid factor seropositivity, and a lack of current treatment with disease-modifying antirheumatic drugs were significantly associated with abnormal body composition. CONCLUSION Abnormal body composition phenotypes are overrepresented in patients with RA, particularly in those in the normal weight BMI range. RA-associated disease and treatment characteristics contribute to this increase in abnormal body composition.

The Scleroderma Patient-centered Intervention Network (SPIN) Cohort: protocol for a cohort multiple randomised controlled trial (cmRCT) design to support trials of psychosocial and rehabilitation interventions in a rare disease context

Introduction Psychosocial and rehabilitation interventions are increasingly used to attenuate disability and improve health-related quality of life (HRQL) in chronic diseases, but are typically not available for patients with rare diseases. Conducting rigorous, adequately powered trials of these interventions for patients with rare diseases is difficult. The Scleroderma Patient-centered Intervention Network (SPIN) is an international collaboration of patient organisations, clinicians and researchers. The aim of SPIN is to develop a research infrastructure to test accessible, low-cost self-guided online interventions to reduce disability and improve HRQL for people living with the rare disease systemic sclerosis (SSc or scleroderma). Once tested, effective interventions will be made accessible through patient organisations partnering with SPIN. Methods and analysis SPIN will employ the cohort multiple randomised controlled trial (cmRCT) design, in which patients consent to participate in a cohort for ongoing data collection. The aim is to recruit 1500–2000 patients from centres across the world within a period of 5 years (2013–2018). Eligible participants are persons ≥18 years of age with a diagnosis of SSc. In addition to baseline medical data, participants will complete patient-reported outcome measures every 3 months. Upon enrolment in the cohort, patients will consent to be contacted in the future to participate in intervention research and to allow their data to be used for comparison purposes for interventions tested with other cohort participants. Once interventions are developed, patients from the cohort will be randomly selected and offered interventions as part of pragmatic RCTs. Outcomes from patients offered interventions will be compared with outcomes from trial-eligible patients who are not offered the interventions. Ethics and dissemination The use of the cmRCT design, the development of self-guided online interventions and partnerships with patient organisations will allow SPIN to develop, rigourously test and effectively disseminate psychosocial and rehabilitation interventions for people with SSc.

Enhancing Medication Adherence Among Inner-City Children with Asthma: Results from Pilot Studies

Despite the availability of effective treatments that aid in controlling asthma symptoms, inner-city children with asthma have high rates of morbidity and are frequent users of emergency department services. The goal of these studies was to pilot test an intervention that used social learning strategies (e.g., goal-setting, monitoring, feedback, reinforcement, and enhanced self-efficacy) and targeted known barriers to individualize a family-based asthma action plan. Participants were 15 children with asthma, aged 7–12 years, who had been prescribed at least one daily inhaled steroid. The children and their mothers lived in inner-city Baltimore and all were African-American. Participants received up to five visits in their home by a nurse. Electronic monitors were installed on the childrens MDI to provide immediate feedback on medication adherence to the families and validate medication use. At baseline, only 28.6% of the children were using their medications as prescribed. Within four weeks, the number of children who were using their medications appropriately doubled from 28.6% at baseline to 54.1% (90% increase; p = 0.004), while underutilization decreased from 51.2% to 25.4% (100% decrease; p = 0.02). The number of children with no medication use at all dropped from 28.3% at baseline to 15.1% by week 5 (87% decrease; p = 0.009). Thus, within four weeks, more than half the children were using their inhaled steroids appropriately. In addition, the rate of underutilization decreased and that of nonutilization was cut in half. Our initial data suggest that an individualized, home-based intervention can significantly enhance adherence to the daily use of inhaled steroids in inner-city children with asthma. Nevertheless, adherence to daily inhaled steroid therapy remains a significant problem in this group.

Association of autoimmunity to peptidyl arginine deiminase type 4 with genotype and disease severity in rheumatoid arthritis

OBJECTIVE Protein citrullination is an important posttranslational modification recognized by rheumatoid arthritis (RA)-specific autoantibodies. One of the citrullinating enzymes, peptidyl arginine deiminase type 4 (PAD-4), is genetically associated with development of RA in some populations, although the mechanism(s) mediating this effect are not yet clear. There have been descriptions of anti-PAD-4 autoantibodies in different rheumatic diseases. This study was undertaken to investigate whether anti-PAD-4 antibodies are specific to RA, are associated with disease phenotype or severity, and whether PAD-4 polymorphisms influence the anti-PAD-4 autoantibody response. METHODS Sera from patients with established RA, patients with other rheumatic diseases, and healthy adults were assayed for anti-PAD-4 autoantibodies by immunoprecipitation of in vitro-translated PAD-4. The epitope(s) recognized by PAD-4 autoantibodies were mapped using various PAD-4 truncations. PAD-4 genotyping was performed on RA patients with the TaqMan assay. Joint erosions were scored from hand and foot radiographs using the Sharp/van der Heijde method. RESULTS PAD-4 autoantibodies were found in 36-42% of RA patients, and were very infrequent in controls. Recognition by anti-PAD-4 autoantibodies required the 119 N-terminal amino acids, which encompass the 3 nonsynonymous polymorphisms associated with disease susceptibility. Strikingly, the anti-PAD-4 immune response was associated with the RA susceptibility haplotype of PADI4. Anti-PAD-4 antibodies were associated with more severe joint destruction in RA. CONCLUSION Our findings indicate that anti-PAD-4 antibodies are specific markers of RA, independently associated with more severe disease, suggesting that an anti-PAD-4 immune response may be involved in pathways of joint damage in this disease. Polymorphisms in the PADI4 gene influence the immune response to the PAD-4 protein, potentially contributing to disease propagation.

Behavioral treatment of obese binge eaters: do they need different care?

This study investigated the relationship between binge eating and the outcome of weight loss treatment. Participants in a 48-week trial of a structured diet combined with exercise and behavior therapy were classified into one of four groups: no overeating; episodic overeating; subthreshold binge-eating disorder(BED); and BED. Binge eating status was not associated with either dropout or adherence to the diet, but did affect weight loss and mood. The BED group lost significantly more weight at the end of treatment than all other groups, even when adjusting for initial weight. At 1-year follow-up, there were no differences among groups in weight loss or weight regain. The BED group began treatment with significantly higher BDI scores, but improvement in mood occurred by week 5. On the basis of these findings, and a review of the recent literature, we conclude that obese binge eaters respond as favorably to standard dietary and behavioral treatments as do obese nonbingers.