Melanie Harrison

INTRODUCTION: The use of patient reported outcome measures to support routine inflammatory bowel disease (IBD) care is not widespread and suggests that existing questionnaires lack relevance to day-to-day decisions or are too cumbersome to administer. We developed a simple, generic tool for capturing disease control from the patient's perspective to address these barriers. METHODS: Development based on literature review, patient focus groups/interviews and a steering group, defining a limited set of generic questions. The 'IBD-Control' questionnaire comprises 13 items plus a visual analogue scale (VAS) (0-100). Prospective validation involved baseline completion of IBD-Control, quality of life (QoL) questionnaire (UK-IBD-Q), EuroQol (EQ-5D), Hospital Anxiety and Depression Score; and clinician assessment (blinded to questionnaire; recording Harvey-Bradshaw Index or Simple Clinical Colitis Activity Index; Global Clinician Rating; treatment outcome). RESULTS: 299 patients returned baseline surveys (Crohn's disease, n=160; ulcerative colitis, n=139) and 138 attended for repeat visits. Completion time (mean; SD): 1 min 15 s; 25 s; Internal consistency: Cronbach's α for all 13 items (0.85); for subgroup of eight questions ('IBD-Control-8'; 0.86). Strong correlation between IBD-Control-8 and IBD-Control-VAS (r=0.81). Test-retest reliability (2 week repeat): intra-class correlation=0.97 for IBD-Control-8 and 0.96 for IBD-Control-VAS. Construct validity: Moderate-to-strong correlations between IBD-Control-8 and IBD-Control-VAS versus activity indices, UK-IBD-Q and EQ-5D (utility) with r values 0.52-0.86. Discriminant validity (mean instrument scores for remission, mild, moderate or severe): p<0.001 (analysis of variance (ANOVA)). Sensitivity to change: Effect sizes: 0.76-1.44. CONCLUSIONS: The IBD-Control is a rapid, reliable, valid and sensitive instrument for measuring overall disease control from the patient's perspective. Unlike existing patient reported outcome measures, its simplicity, ease-of-use and generic applicability make it a candidate for supporting routine care.

OBJECTIVE: This study explored the perspectives of hypertensive African-American patients, in 2 primary care practices, regarding the factors they perceived as barriers or facilitators of adherence to prescribed antihypertensive medications. DESIGN: This qualitative study used a grounded theory methodology with data collection occurring through in-depth individual patient interviews. SETTING AND PARTICIPANTS: One hundred and six hypertensive African-American patients followed at 2 urban primary care practices participated in the open-ended interviews. METHODS: During interviews, patients' experiences taking antihypertensive medications and their perceptions of the challenges they face in adhering to their medications as prescribed were explored. Patients were also asked about the situations that make it easy or difficult for them to take their antihypertensive medications as prescribed and the skills they thought were necessary for patients to adhere to their medications as prescribed. All responses were recorded verbatim and analyzed using grounded theory methodology. RESULTS: Fifty-eight percent of participants were women, mean age was 56 years, and 60% had uncontrolled hypertension. Four categories of barriers and 5 categories of facilitators were identified. The barriers included patient-specific, medication-specific, logistic, and disease-specific barriers. The facilitators included use of reminders, having a routine, knowledge about hypertension, its treatment and complications, having social support and good doctor-patient communication. CONCLUSION: This study provides a framework for investigating issues of medication adherence in hypertensive African Americans by describing a taxonomy of barriers and facilitators of adherence identified by patients.

When nursing home residents with dementia are unable to locate their own rooms, it often creates problems for staff and other residents. The impact of placing two external memory aids outside participants' bedrooms was evaluated by using a multiple-baseline design experiment. Three female special care unit (SCU) residents with severe Alzheimer's disease (MMSE = 5.7) participated in the study. Results showed that a combination of a portrait-type photograph of the participant as a young adult and a sign stating the resident's name increased room finding by over 50 percent with all three participants. Room finding stabilized at 100 percent accuracy for all participants within a few days of implementing the environmental intervention.

BACKGROUND: Because of the relatively large surface area of metaphyseal cancellous bone, the majority of distal femur fractures heal reliably. Nonunions of the distal femur do rarely occur, however, and the associated bone loss and soft tissue scarring can make successful treatment difficult. Few reports in the literature exist regarding the clinical and functional outcome after treatment of distal femoral nonunions. The purpose of this study was to evaluate the outcome of patients who underwent treatment of a distal femoral nonunion using a standardized treatment plan that included open reduction, internal fixation, supplemental bone graft, lag screw placement, and arthrolysis. METHODS: Thirty-one patients with a distal femoral nonunion were treated by a single surgeon from 1992 to 2002, and their clinical and radiographic outcomes were assessed. The average age was 57.6 years, and four patients (13%) had sustained open fractures. The average time from injury to diagnosis of the nonunion was 15.9 months and the average time of follow-up was 41.5 months after the definitive nonunion surgery. In all cases a fixed-angle implant was used. Lag screw and bone graft augmentation was used in all patients; 71% received iliac crest bone graft and 29% received demineralized bone matrix. Outcomes were analyzed using radiographs and the Knee Society Rating Score (KSRS). RESULTS: At final follow-up the union rate was 97%, and the average time to heal was 15.9 weeks. A complete return to preinjury functional status was achieved in 84%. The KSRS Knee Assessment subsection score improved from 43.0 to 78.3 after surgical treatment of the nonunion (p < 0.001). The KSRS Knee Function subsection score also improved from 11.1 to 61.2 at final follow-up (p < 0.001). CONCLUSIONS: Distal femoral nonunions may be treated successfully with correction of deformity, stable fixed-angle internal fixation, lag screw placement, and supplemental bone grafting. Knee joint manipulation and arthrolysis are important components of the treatment plan if knee motion is limited because of fibrosis. This yields predictable functional outcome after the surgical intervention.