Setting Treatment Goals Research Articles

Factors affecting the discharge destination of hip fracture patients who live alone and have been admitted to an inpatient rehabilitation unit.

[Purpose] (1) The aim of this study was to examine relations between clinical and functional assessment and discharge destination and (2) to identify the optimal cutoff point for estimating discharge to home after inpatient rehabilitation. [Subjects] The subjects were 54 hip fracture patients (15 males, 39 females; mean age 81.3 ± 7.4 years) living alone. [Methods] The patients were classified into two groups: those discharged to home and those admitted to an institution. Age, gender, side of fracture, fracture type, number of comorbidities, Functional Independence Measure motor score, and Functional Independence Measure cognitive score were compared between groups. Multiple logistic regression analysis was conducted with discharge to home as the dependent variable and age, gender, side of fracture, fracture type, number of comorbidities, Functional Independence Measure motor score, and Functional Independence Measure cognitive score as independent variables. A receiver operating characteristic curve analysis was used to identify a cutoff point for classification of the patients into the two groups. [Results] Multiple logistic regression analysis showed that the Functional Independence Measure cognitive score was a significant variable affecting the discharge destination. The receiver operating characteristic curve analysis revealed that discharge to home was predicted accurately by a Functional Independence Measure cognitive score of 23.5. [Conclusion] Information from this study is expected to be useful for determining discharge plans and for the setting of treatment goals.

Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience.

Patients with psoriatic arthritis (PsA) may not be optimally treated. The impact of the disease extends beyond skin and joint symptoms, impairing quality of life. This indicates that the adoption of a patient‐focused approach to PsA management is necessary. An expert multidisciplinary working group was convened, with the objective of developing an informed perspective on current best practice and needs for the future management of PsA. Topics of discussion included the barriers to current best practice and calls to action for the improvement of three areas in PsA management: early and accurate diagnosis of PsA, management of disease progression and management of the impact of the condition on the patient. The working group agreed that, to make best use of the available of diagnostic tools, clinical care recommendations and effective treatments, there is a clear need for healthcare professionals from different disciplines to collaborate in the management of PsA. By facilitating appropriate and rapid referral, providing high quality information about PsA and its treatment to patients, and actively involving patients when choosing management plans and setting treatment goals, management of PsA can be improved. The perspective of the working group is presented here, with recommendations for the adoption of a multidisciplinary, patient‐focused approach to the management of PsA.

An informed shared decision making programme on the prevention of myocardial infarction for patients with type 2 diabetes in primary care: protocol of a cluster randomised, controlled trial.

BackgroundInternational and national societies claim a patient centred approach including shared decision making (SDM) in diabetes care. In a previous project, a SDM programme on the prevention of myocardial infarction has been developed. It is aimed at supporting patients with type 2 diabetes to make informed choices on preventive options, to share the decision making process with the health care team, and to improve adherence to the chosen treatment. In this study, the programme will be implemented and evaluated in primary care practices.Methods/DesignA cluster randomised, controlled trial will be conducted to compare the SDM programme with standard care enrolling patients with type 2 diabetes (N = 306) from primary care practices (N = 24). The intervention programme comprises a six hours provider training, a patient decision aid including evidence-based information, a 90 minutes structured teaching session provided by medical assistants, a sheet to document the patients’ individual treatment goals, and a structured consultation with the general practitioner for sharing information, setting treatment goals, and for adapting treatment regimens if necessary. Patients in the control group receive a brief extract of recommendations of the German National Disease Management Guideline on the treatment of patients with type 2 diabetes. Primary outcome measure is adherence to blood pressure treatment and statin treatment at 6 months follow-up. Secondary outcome measures comprise informed choice and the achievement of patients’ treatment goals. Analyses will be carried out on intention-to-treat basis. Concurrent qualitative methods will be used to explore the implementation processes.DiscussionAt the end of this study, information on the efficacy of the SDM programme in the primary care context will be available. In addition, processes that might interfere with or that might promote a successful implementation will be identified.Trial registrationISRCTN77300204.

Introducing the Concept of the Minimally Important Difference to Determine a Clinically Relevant Change on Patient-Reported Outcome Measures in Patients with Intermittent Claudication.

PurposeThe minimally important difference (MID) represents the smallest change in score on patient-reported outcome measures that is relevant to patients. The aim of this study was to introduce the MID for the Vascular Quality of Life Questionnaire (VascuQol) and the walking impairment questionnaire (WIQ) for patients with intermittent claudication (IC).MethodsIn this multicenter study, we recruited 294 patients with IC between July and October 2012. Patients completed the VascuQol, with scores ranging from 1 to 7 (worst to best), and the WIQ, with scores ranging from 0 to 1 (worst to best) at first visit and after 4 months follow-up. In addition, patients answered an anchor-question rating their health status compared to baseline, as being improved, unchanged, or deteriorated. The MID for improvement and deterioration was calculated by an anchor-based approach, and determined with the upper and lower limits of the 95 % confidence interval of the mean change of the group who had not changed according to the anchor-question.ResultsFor the MID analyses of the VascuQol and WIQ, 163 and 134 patients were included, respectively. The MID values for the VascuQol (mean baseline score 4.25) were 0.87 for improvement and 0.23 for deterioration. For the WIQ (mean baseline score 0.39), we found MID values of 0.11 and −0.03 for improvement and deterioration, respectively.ConclusionIn this study, we calculated the MID for the VascuQol and the WIQ. Applying these MID facilitates better interpretation of treatment outcomes and can help to set treatment goals for individual care.Electronic supplementary materialThe online version of this article (doi:10.1007/s00270-015-1060-0) contains supplementary material, which is available to authorized users.

Effect of an Evidence-Based Mobility Intervention on the Level of Function in Acute Intracerebral and Subarachnoid Hemorrhagic Stroke Patients on a Neurointensive Care Unit

ObjectivesTo explore the effect of an evidence-based mobility intervention on the level of function (LOF) achieved by patients with intracerebral hemorrhage (ICH) stroke and subarachnoid hemorrhage (SAH) stroke and to identify clinical characteristics and measures associated with walking distances >15.24m. DesignRetrospective pre- and postintervention study. SettingRegional neurointensive care unit. ParticipantsAdult patients with ICH and SAH (N=361). InterventionDaily mobility intervention based on patient's current LOF. Main Outcome MeasureWalking >15.24m (LOF 5) by neurointensive care unit discharge. ResultsElectronic health records for 361 patients (52.6% women; mean age, 62.1y; ICH stroke, 63.2%; aphasia, 35%; hemiplegia, 33%) were included. There was a 2.3-fold increase in patients with hemorrhagic stroke achieving a LOF of 5 by neurointensive care unit discharge after introduction of a mobility intervention. In the multivariable logistic regression model including neurointensive care unit length of stay (LOS) as a covariate, the intervention, LOF of 5 at admission, SAH stroke type, third (vs lowest) quartile of neurointensive care unit LOS, and absence of aphasia and/or hemiplegia were associated with higher likelihood of achieving a LOF of 5 (odds ratio [OR]=5.28; 95% confidence interval [CI], 2.52–11.06; OR=6.02; 95% CI, 1.45–24.96; OR=3.78; 95% CI, 1.83–7.80; OR=2.94; 95% CI, 1.16–7.47; OR=17.77; 95% CI, 6.59–47.92, respectively). ConclusionsA mobility intervention was strongly associated with increased distance walked by neurointensive care unit patients with acute hemorrhage at discharge and can be applied in any intensive care unit setting to promote stroke recovery. Future studies directed at building predictive models for walking achievement in patients with acute hemorrhagic stroke may provide insight into individualized treatment goal setting and discharge planning.

Demonstrating mood repair with a situation-based measure of self-compassion and self-criticism.

ObjectivesThe clinical significance of self‐criticism and self‐compassion has prompted the development of questionnaires assessing these constructs. However, there is a lack of measures assessing their interaction within specific contexts and potential involvement in mood repair processes.DesignTo rectify this, we developed the Self‐Compassion and Self‐Criticism Scales (SCCS), based on responses to specific scenarios, and examined its psychometric properties in an online survey and an experimental situation.MethodIn study 1, standard psychometric procedures were used to investigate the reliability and validity of the SCCS. In study 2, an experimental challenge involving a difficult language task was used to test its sensitivity to change.ResultsIn study 1, exploratory factor analysis (n = 413) showed a clear two‐factor structure of the SCCS denoting two orthogonal scales, with high internal validity (α ≥ .87). Correlations between the SCCS and existing measures also demonstrated appropriate convergent validity. Study 2 (n = 90) provided preliminary evidence that the SCCS can detect changes in self‐appraisals. Participants receiving no performance feedback from the challenge task showed reduced state self‐criticism and increased state self‐compassion, demonstrating mood repair.ConclusionsThe SCCS has promise as a situational measure of self‐compassion and self‐criticism.Practitioner points In the context of specific problem situations, clients' levels of self‐criticism and self‐compassion may well be orthogonal and can be assessed with the SCCS.In setting treatment goals and assessing treatment outcome, it may be helpful to target both self‐compassion and self‐criticism separately.

3D image superimpositions for orthodontic diagnostics and therapy

Orthodontists and maxillofacial surgeons have always been interested to quantify the influence of orthodontic and/or orthognathic surgery treatment on craniofacial morphology. Historically, superimpositions of cephalometric radiographs have been used to study growth and treatment effects. In recent years advances in 3D imaging techniques have led to their widespread use for setting treatment goals, choosing treatment modalities, predicting treatment results and evaluating treatment and/or growth changes. Various different techniques have been reported for superimposition of 3D datasets derived from either conventional computed tomography (CT) or lower radiation cone beam CT (CBCT) images. This lecture presents the main 3D superimposition techniques that are currently available and discuss their unique specifications and inherent limitations.

Differential effects of the working alliance in family therapeutic home‐based treatment of multi‐problem families

Families with a low socioeconomic status play an increasingly significant role in health services, research and social policy. The present outcome research study is a pre/post naturalistic study of home‐based therapeutic work with multi‐problem families (MPF), as conducted by Therapeutisch Ambulante Familenbetreung, an integrative family therapy with a structure‐related, mentalization‐based, psychoanalytic orientation. With a mean treatment duration of 75.7 weeks, 379 families showed significant psychological improvement on 10 scales concerning patient–therapist collaboration, treatment expectancy and psycho‐social outcome measures with a medium to large effect size for all parameters (range: .35–1.49). About two‐thirds of the sample improved by two SD on individually set treatment goals, further supporting the clinical significance of the therapeutic effect of home‐based family treatment. Improvements in goal‐directed collaboration and treatment expectancy are shown to be related to clinical improvement. Structural family therapy interventions for families with multiple problems thus benefit from individually setting goals and improving their self‐efficacy and problem‐solving by means of improved treatment expectancy.Practitioner's points MPF constitute a significant problem in healthcare and costs (burden of disease). The treatment of MPF is considered relatively difficult. Improvements to the process quality (working alliance, treatment expectancy) increase the quality of the results of home‐based treatment of MPF.

The Nurse-Based Age Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome (NAILED ACS) Risk Factor Trial: Protocol for a Randomized Controlled Trial.

BackgroundSecondary prevention after acute coronary syndrome (ACS) is essential to reduce morbidity and mortality, but related studies have been fairly small or performed as clinical trials with non-representative patient selection. Long-term follow-up data are also minimal. A nurse-led follow-up for risk factor improvement may be effective, but the evidence is limited.ObjectiveThe aims of this study are to perform an adequately sized, nurse-led, long-term secondary preventive follow-up with inclusion of an unselected population of ACS patients. The focus will be on lipid and blood pressure control as well as tobacco use and physical activity.MethodsThe study will consist of a randomized, controlled, long-term, population-based trial with two parallel groups. Patients will be included during the initial hospital stay. Important outcome variables are total cholesterol, low-density lipoprotein (LDL) cholesterol, and sitting systolic and diastolic blood pressure. Outcomes will be measured after 12, 24, and 36 months of follow-up. Trained nurses will manage the intervention group with the aim of achieving set treatment goals as soon as possible. The control group will receive usual care. At least 250 patients will be included in each group to reliably detect a difference in mean LDL of 0.5 mmol/L and in mean systolic blood pressure of 5 mmHg.ResultsThe study is ongoing and recruitment of participants will continue until December 31, 2014.ConclusionsThis study will test the hypothesis that a nurse-led, long-term follow-up after an ACS with a focus on achieving treatment goals as soon as possible is an effective secondary preventive method. If proven effective, this method could be implemented in general practice at a low cost.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 96595458; http://www.controlled-trials.com/ISRCTN96595458 (Archived by WebCite at http://www.webcitation.org/6RlyhYTYK).

Modeling factors predictive of functional improvement following acute stroke

BackgroundPredicting functional improvement at an early stage after stroke is critical to setting treatment goals and strategies. The aim of this study was to identify factors that can predict motor function improvement at 3 months and 6 months poststroke. MethodsForty-four patients with stroke were included in the study. We recorded age, interval between stroke onset and initiation of physical therapy, stroke type, history of diabetes or cardiovascular disease, functional status prior to stroke, cognition, motivation, walking ability, eating ability, hemineglect, sensory function, and brain lesion site as predictive factors. The Stroke Rehabilitation Assessment of Movement, Berg Balance Scale, Timed Up & Go Test, and the 6-Minute Walk Test were conducted upon intake and at 3 months and 6 months poststroke. Patients were assigned to a progressive group or a nonprogressive group based on their improvement in four functional measures. Variables for which there were significant group differences were used for stepwise discriminant analysis as determining factors and for setting the prediction model. ResultsPatient age, history of diabetes, functional status prior to stroke, and motivation were predictive factors of functional progress at 3 months poststroke. Motivation and functional status prior to stroke predicted functional progress at 6 months poststroke. By comparing the discriminant function values of the progressive and nonprogressive groups, functional improvement can be predicted. ConclusionFunctional status prior to stroke and motivation are predictive of functional outcome at 3 months and 6 months poststroke. We have provided a formula that can be used to predict a patient’s progress and then set treatment goals and programs accordingly.

Managing recent-onset diabetes: choosing durable, well-tolerated therapies and understanding the role of incretin-based therapies.

Management of recent-onset diabetes offers osteopathic physicians the opportunity to work with patients to set treatment goals and expectations for this progressive yet manageable disease, as well as intervene early to reduce the risk of diabetes-related complications. Starting effective therapy early--and intensifying therapy appropriately--to achieve and maintain glycemic goals has been shown to reduce microvascular risks and produce legacy effects that may have macrovascular benefits. Metformin remains a cornerstone of therapy for those patients who can tolerate it. Early combination therapy that is well tolerated reduces risks of hypoglycemia or unwanted weight gain, improves patient adherence, and addresses the multifactoral pathophysiology of even recent-onset diabetes. Incretin-based therapies have been shown to be effective across the spectrum of type 2 diabetes mellitus, including recent-onset diabetes. The present article reviews the use of incretin-based therapies early in the disease process of type 2 diabetes mellitus.

Treatment targets in patients with type 2 diabetes set by primary care physicians from Central and Eastern Europe

Background: Primary care physicians have an important role in the care of patients with Type 2 diabetes but little is known about this issue in Central and Eastern European countries.Objectives: To investigate the treatment goals of patients with type 2 diabetes mellitus (type 2 DM) set by primary care physicians in Central and Eastern European countries and illustrate inter-country variation.Methods: A cross-sectional survey of primary care physicians randomly chosen in nine countries. A validated questionnaire was used. Physicians reported treatment goals for patients with type 2 DM.Results: A total of 44.1% of physicians, reported the acceptance of HbA1c < 6.5% (48 mmol/mol) as a treatment goal, whilst 40% chose lower levels (< 6.1%; 43 mmol/mol). In all countries, 62% of physicians set FPG at a level of < 6.0 mmol/l. Most respondents set low BP levels as a goal of therapy (47% of physicians in all countries: BP < 130/80 mmHg and 48% < 120/80 mmHg). A TC level < 4.5 mmol/l and a LDL-C level < 2.5 mmol/l were reported as the targets for patients with diabetes by 51% and 69% of all respondents, respectively. The overall differences between all the countries were statistically significant (P < 0.01).Conclusion: For patients with diabetes approximately half of physicians set treatment goals at levels that were recommended within the international guidelines. Most of them set treatment goals for HbA1c and BP at very low levels. Educational efforts to raise awareness about new treatment goals are needed.

Role of premixed insulin analogues in the treatment of patients with type 2 diabetes mellitus: a narrative review.

Because of the progressive nature of type 2 diabetes mellitus (T2DM), insulin therapy will eventually become necessary in most patients. Recent evidence suggests that maintaining optimal glycemic control by early insulin therapy can reduce the risk of microvascular and macrovascular complications in patients with T2DM. The present review focuses on relevant clinical evidence supporting the use of premixed insulin analogues in T2DM when intensifying therapy, and as starter insulins in insulin-naïve patients. Our aim is to provide relevant facts and clinical evidence useful in the decision-making process of treatment selection and individualized treatment goal setting to obtain sustained blood glucose control.

A unified protocol for the transdiagnostic psychodynamic treatment of anxiety disorders: An evidence-based approach.

Although there is evidence for the efficacy of psychodynamic therapy (PDT) in anxiety disorders, results are not yet satisfactory, for example, if rates of remission and response are considered. To address this problem, a unified psychodynamic protocol for anxiety disorders (UPP-ANXIETY) is proposed that integrates the treatment principles of those methods of PDT that have proven to be efficacious in anxiety disorders. In addition, this protocol is transdiagnostic, implying that it is applicable to various forms of anxiety disorders and related disorders (generalized anxiety disorder, social phobia, panic disorders, avoidant personality disorder). Based on supportive-expressive therapy, the UPP-ANXIETY represents an integrated form of psychodynamic therapy that allows for a flexible use of empirically supported treatment principles. UPP-ANXIETY encompasses the following 9 treatment principles (modules): (1) socializing the patient for psychotherapy, (2) motivating and setting treatment goals, (3) establishing a secure helping alliance, (4) identifying the core conflict underlying anxiety, (5) focusing on the warded-off wish/affect, (6) modifying underlying internalized object relations, (7) changing underlying defenses and avoidance, (8) modifying underlying response of self, and (9) termination and relapse prevention. Some principles are regarded as core components to be used in every treatment (principles 3-8). A unified protocol for the psychodynamic treatment of anxiety disorders has several advantages, that is (1) integrating the most effective treatment principles of empirically supported psychodynamic treatments for anxiety disorders can be expected to further improve the efficacy of PDT; (2) using a unified protocol in efficacy studies has the potential to enhance the evidence-based status of PDT by aggregating the evidence; (3) a unified protocol will facilitate both training in PDT and transfer of research to clinical practice; and (4) thus, a unified protocol can be expected to have a significant impact on the health care system. We are planning to test the UPP-ANXIETY in a multicenter randomized controlled trial.

Age Specific Normative Data of Deep Neck Flexor Endurance for Asymptomatic Young Adults

Background and purpose : Decreased deep neck flexor endurance has been found to be a causative as well as a contributory factor of neck pain. But it is less common to, for therapists to perform endurance testing in clinical setting. One of the main constraints for this is that literature contains little age specific data concerning normal values of deep neck flexor endurance. Lack of baseline age specific reference values is a limitation in quantification of physical performance of deep neck flexor muscles. The purpose of the study is to establish age specific normative data of deep neck flexor endurance for asymptomatic young adults using deep neck flexor endurance test. Study design : A normative research study design. Subject and method : This study involved 400 asymptomatic subjects aged between 20-40 years (young adults), deep neck flexor endurance test was used to quantify static endurance. The mean and standard deviation scores were determined. Results : Age specific normal values of deep neck flexor endurance time (mean±SD) for 20-40 years(young adults), 20-29 years(males), 30-40years(males), 20-29years(females) and 30-40 years(females) were 22.8±3.7sec., 27.5±2.4sec., 22.9±1.4sec., 21.5±2.6sec., 19.4±1.8sec. respectively. We found that overall static endurance of deep neck flexor muscles declined with advancing age among both genders. Conclusion : This study established a set of age specific normative data of deep neck flexor endurance for young adults using deep neck flexor endurance test. These values can be used to compare patient's endurance score at intake to recognize muscle dysfunction, provide benchmarks for setting treatment goals to increase endurance capacity and provide outcome measure for evaluating success of an intervention in clinical practice.

복합틱장애 증상이 있는 딸을 둔 부부에 대한 가족치료 사례연구

This study deals with a counseling case in which a mother requested counseling due to the problems of her daughter, who suffers from multiple tic disorder. The participants of this study included five family members (grandmother, father, mother and two female children) and a total of 23 sessions were held from September 2006 to December 2007. Additional counseling (<TEX>$24^{th}$</TEX> counseling session) was conducted on April 1st, 2009. The data was based on recorded transcripts and notes from 24 family therapy sessions. The study used a constant comparative analysis, which uses matrix and network display as an analysis method suggested by Miles&Huberman(1994). The characteristics of the family of origin and the indifference of the husband had caused the wife stress. The couple had frequent conflicts due to dysfunctional communication methods, a clash of values, sexual dissatisfaction, and a lack of communication. This marital conflict became the primary factor of the daughter's multiple tic disorder. Intervention of the family therapist resulted in the setting of treatment goals based on MRI's communication theory and Bowen's family systems theory in order to solve the problem of the daughter's multiple tic disorder. Also, the therapist's intervention techniques included exploring experiences with the family of origin, shedding light on the multigenerational transmission process, exploring dysfunctional attempts at solutions, the therapist's self-disclosure, providing similar cases, dealing with resistance, and suggesting a new communication method. To solve the problem, the therapist helped the family separate the daughter spatially from her parents. Therefore, the therapist's intervention helped reduce the daughter's tics and improve relationships among the family.

Long-term follow-up on continuous intrathecal Baclofen therapy in non-ambulant children with intractable spastic Cerebral Palsy

BackgroundLittle is known about the long-term effects of Continuous intrathecal Baclofen (CITB) therapy in non-ambulant children with intractable spastic Cerebral Palsy (CP). AimTo determine whether short-term beneficial effects of CITB therapy are present at the long-term, and whether caregivers would choose CITB therapy for their child again considering the advantages and disadvantages encountered over the years. MethodsLong-term follow-up data were obtained of the children whom had previously participated in a RCT on CITB by the Dutch Study Group on Spasticity. Quality of life (QoL) was assessed by the Child Health Questionnaire (CHQ), current satisfaction with CITB was measured by use of a Visual Analogue Scale regarding previously set treatment goals, functioning in daily living was determined by a questionnaire concerning functioning of the child, and possible detrimental effects of CITB therapy encountered over the years were noted. All data were acquired via interview of the caregivers. ResultsAll 17 children of the former trial participated in this study. Previously identified significant positive effects on pain (CHQ 46.8 vs. 74.38, p = 0.002; VAS 2.4 vs. 8.01, p = 0.02), ease of care (VAS 2.0 vs. 7.26, p = 0.00), and mental health (CHQ 67.2 vs. 75.94, p = 0.010) were still present at the end of the trial. Novel significant positive effects were noted at six to nine years follow-up, i.e. significantly improved scores on the Parent Impact – Emotional subscale (CHQ 66.0 vs. 78.2, p = 0.008), Parent Impact – Time subscale (CHQ 68.9 vs. 91.72, p = 0.002), and the Physical Summary (CHQ 17.6 vs. 27.4, p = 0.019) compared to baseline. Ninety-four percent of the caregivers would choose CITB treatment again for their child again. ConclusionThe beneficial effects of CITB are present at the long term and caregiver satisfaction is high.

Patient–provider communication and diabetes medication adherence: where do we go from here?

185 ISSN 1758-1907 10.2217/DMT.13.9 © 2013 Future Medicine Ltd Diabetes Manage. (2013) 3(3), 185–188 For several decades, researchers have explored how patient–provider relationships can influence chronic illness care and outcomes. The domains of patient–provider communication – such as shared decision-making, trust and/or respect, and mutual understanding regarding treatment plans – are increasingly central to patient-centered models of care delivery. For example, new diabetes treatment guidelines call for individualizing clinical control targets, taking into consideration patient health status and risk factors, as well as psychological, social and economic conditions [1]. Actively engaging patients in setting treatment goals by assessing and incorporating their capacities, desires and values inherently requires effective patient–provider communication strategies. While much of the research on patient–provider communication among diabetes patients has focused on its influence on intermediate outcomes, such as control of cardiometabolic risk factors for complications (i.e., HbA1c, blood pressure and cholesterol), fewer studies have focused on the pathways between communication and diabetes self-management, such as medication adherence. Medication adherence among diabetes patients is theorized to be a proximal outcome of effective patient–provider communication, linked by such potential mechanisms as advancing patient understanding/knowledge, increasing the quality of medical decision-making and/or increasing patient self-efficacy or empowerment [2]. Improving medication adherence among diabetic patients is an important healthcare priority, given that nonadherence rates for medication regimens range from 10 to 40% depending on the study and pharmacological agent of interest [3]. In the longer term, poor adherence can lead to poorer clinical control and, in turn, higher rates of macroand micro-vascular complications. Moreover, poor adherence can jeopardize patient safety, when unsuspecting clinicians escalate dosages or intensify regimens, instead of addressing barriers to adherence. This editorial summarizes some of the most relevant literature on patient–provider communication and medication adherence among diabetes patients, raises important

Assessing and treating functional impairment in poststroke spasticity

Poststroke spasticity (PSS) is associated with significant consequences for a patient's functional status and quality of life. Nonetheless, no uniform definition of spasticity exists that can be utilized across clinical research settings, and difficulties in validating proper assessment tools--both clinical and nonclinical--complicate the ability to evaluate and appropriately treat spasticity. Consequently, the current state of defining, assessing, and treating spasticity requires improved consistency and ongoing validation as clinical research efforts advance. When selecting clinical measures for PSS assessment (e.g., the Modified Ashworth, Tone Assessment, Tardieu, Modified Rankin, and Disability Assessment scales, and the Barthel Index), it is critical to understand the levels of impairment or functional limitation each tool assesses as well as their benefits and limitations. The use of quantitative methods--such as electrophysiologic, biomechanical, and imaging techniques--adjunctive to traditional clinical measures also allows for sensitivity in quantifying the abnormal muscle activity associated with spasticity. In addition to accurate evaluation and assessment of PSS, realistic treatment goal setting for patients as well as family members and caregivers is critical, because it promotes motivation and cooperation as well as proper management of expectations and can favorably affect recovery. Goal attainment scaling has been shown to help organize, focus, and clarify the aims of treatment, thereby enhancing the PSS rehabilitative process. Furthermore, integration of therapeutic modalities and treatment strategies, including both nonpharmacologic intervention and pharmacotherapy, is also important for improved outcomes.

The NAILED stroke risk factor trial (nurse based age independent intervention to limit evolution of disease after stroke): study protocol for a randomized controlled trial.

BackgroundSecondary prevention after stroke and transient ischemic attack (TIA) is essential in order to reduce morbidity and mortality. Secondary stroke prevention studies have, however, been fairly small, or performed as clinical trials with non-representative patient selection. Long-term follow-up data is also limited. A nurse-led follow-up for risk factor improvement may be effective but the evidence is limited. The aims of this study are to perform an adequately sized, nurse-led, long-term secondary preventive follow-up with a population-based inclusion of stroke and TIA patients. The focus will be on blood pressure and lipid control as well as tobacco use and physical activity.MethodsA randomized, controlled, long-term, population-based trial with two parallel groups. The patients will be included during the initial hospital stay. Important outcome variables are sitting systolic and diastolic blood pressure, LDL cholesterol and total cholesterol. Outcomes will be measured after 12, 24 and 36 months of follow-up. Trained nurses will manage the intervention group with a focus on reaching set treatment goals as soon as possible. The control group will receive usual care. At least 200 patients will be included in each group, in order to reliably detect a difference in mean systolic blood pressure of 5 mmHg. This sample size is also adequate for detection of clinically meaningful group differences in the other outcomes.DiscussionThis study will test the hypothesis that a nurse-led, long-term follow-up after stroke with a focus on reaching set treatment goals as soon as possible, is an effective secondary preventive method. If proven effective, this method could be implemented in general practice at a low cost.Trial registrationCurrent Controlled Trials ISRCTN23868518