Responsiveness of self-reported and objective measures of disease severity in carpal tunnel syndrome

Responsiveness, the ability to detect meaningful clinical change, is a critical attribute of instruments used to evaluate outcomes of treatments. The authors hypothesized that self-administered symptom severity and functional status questionnaires are more responsive to clinical improvement after carpal tunnel release than traditional physical examination measures of strength and sensibility. Data were obtained from a randomized clinical trial of endoscopic versus open carpal tunnel release conducted in four university medical centers. Patients were evaluated before surgery and 3 months after surgery. Seventy-four patients indicating that they were more than 80% satisfied with the results of surgery were assumed to have clinically meaningful improvement and were the focus of the analysis. Evaluations included questionnaires assessing symptom severity, functional status, and activities of daily living as well as measurement of grip, pinch, and abductor pollicus brevis strength, and 2-point discrimination and Semmes-Weinstein pressure sensibility. Responsiveness was calculated with the standardized response mean (mean change/standard deviation of change) as well as the effect size (mean change/standard deviation of baseline values). The symptom severity scale was four times as responsive, and the functional status and activities of daily living scales were twice as responsive, as the measures of strength and sensibility. Self-administered symptom severity and functional status scales are much more responsive to clinical improvement than measures of neuromuscular impairment and should severe as primary outcomes in clinical studies of therapy for carpal tunnel syndrome.     

The use of objective measures of asthma severity in primary care: a report from ASPN

This study compared the use of 2 1/2-hour multimedia workshop with distribution of an algorithm on the ability of fourth-year medical students to present a stop-smoking plan to a simulated patient. Results showed that students who participated in the workshop performed statistically significantly better on the skill areas of providing information, eliciting and responding to feeling and on content areas of past experience with quitting, resources available for change and negotiating a plan. There were no significant differences in the skill area of eliciting information and the content areas of motivation to stop smoking, factors that inhibit change and problems affecting the plan. Neither of the groups performed very well. The highest number of available points obtained by both groups was in eliciting information (53% in the algorithm group and 64% in the formal training group); however, most of the values were in the range of 10%-25% of possible points. Suggested reasons for the low values may be due to the specific items rated, the teaching methods or the time needed to assimilate new skills.     

Validation of objective measures for facial paralysis

A shift from subjective scales to objective measures of facial paralysis requires physical models against which to validate and calibrate the new objective techniques. The purpose of this report was to demonstrate such a model and to test the capacity of an objective computer system to accurately measure physical change. The physical model consisted of an advancing edge of a spreading gelatin film. The model was measured in submillimeter increments. Concurrent measurements were made using the computed system. Ten trials were conducted. The objective system proved to be exquisitely sensitive (0.03 mm) and highly correlated with the physical criterion model (Pearson's product moment correlation coefficient [r]=0.9849). Sensitive and calibrated objective methods of analysis of facial motion are crucial to the design of clinical trials, clinical studies of nerve regeneration, and comparisons of reanimation techniques.     

Pulsus paradoxus: an objective measure of severity in croup

We used a noninvasive monitor of arterial pressure to determine the utility of pulsus paradoxus (PP) as an objective severity measure in croup. We performed a prospective, blinded comparison of PP in children with croup versus healthy control subjects, analyzed the relationship between PP and Westley croup score (WCS), and observed the effect of racemic epinephrine (RE) on PP and WCS in a subgroup of patients with severe croup. The PP and WCS were measured at presentation and in severe patients after treatment with RE. Mean PP was 6.1 +/- 1.8 (SD) mm Hg (n = 29) in control subjects compared with a mean of 17.8 +/- 11.2 (SD) mm Hg (n = 28) in patients with croup (p < 0.00001). There was significant concordance between baseline WCS and PP (Spearman's rho: 0.68; p = 0.0001). The mean decrease in PP after RE was 7.5 +/- 11.8 (SD) mm Hg (p = 0.05; n = 12). The magnitude of decrease in PP after RE has significant concordance with the concurrent decrease in WCS (Spearman's rho: 0.73; p < 0.007). PP is elevated in children with croup, and the magnitude of elevation correlates with severity as measured by the WCS. PP may have utility as a research tool to objectively measure the severity of upper airway obstruction in croup.     

Advent of objective measures of the transference concept.

Reviews research on measurement of transference that has used Q-sort questionnaires and psychotherapy process measures. The 1st type of measure, although reliable, has lacked validity information. The newer psychotherapy process measures, such as the 1st author's (1976) core conflictual relationship theme (CCRT) method, provide evidence for their reliability and validity. A study of 8 patients showed considerable comparability between data from the CCRT method and operationalized propositions from 9 of Freud's observations about transference, which concerned such issues as the uniqueness, origins, and consistency of the transference pattern. The CCRT is compared with other methods, and methodological issues and proposals that could further advance research on transference are examined. (61 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Casemix adjustment of managed care claims data using the clinical classification for health policy research method

OBJECTIVES: The objective of this study was to explore the use of the Clinical Classification for Health Policy Research (CCHPR) as a casemix adjustment method for examining physician practice patterns. METHODS: The data source was 2 years of administrative claims from an 86,000 member health maintenance organization in southeastern Michigan. The CCHPR version 2 algorithm, which is in the public domain, was used to assign each claim to one of 260 clinical categories. CCHPR and age-sex categories were used as explanatory variables in multiple linear regression models with approved claims payments in dollars as the outcome variable. Regressions were performed retrospectively for 1994 and 1995, and with 1994 claims' history to predict 1995 utilization. Similar regressions were performed with age-sex categories alone, and also with the ambulatory diagnostic groups. RESULTS: The adjusted R2 value of the retrospective regression models for total approved dollars was 0.42 for both study years when CCHPR categories were used. In contrast, age-sex explanatory variables alone achieved an R2 of 0.02. CONCLUSIONS: The CCHPR method appears to be a promising tool to understand variability in physician resource utilization in managed care.     

Statistical analysis of repeated measures data using SAS procedures

Mixed linear models were developed by animal breeders to evaluate genetic potential of bulls. Application of mixed models has recently spread to all areas of research, spurred by availability of advanced computer software. Previously, mixed model analyses were implemented by adapting fixed-effect methods to models with random effects. This imposed limitations on applicability because the covariance structure was not modeled. This is the case with PROC GLM in the SAS System. Recent versions of the SAS System include PROC MIXED. This procedure implements random effects in the statistical model and permits modeling the covariance structure of the data. Thereby, PROC MIXED can compute efficient estimates of fixed effects and valid standard errors of the estimates. Modeling the covariance structure is especially important for analysis of repeated measures data because measurements taken close in time are potentially more highly correlated than those taken far apart in time.     

Sex differences in dependency: a comparison of objective and projective measures

The relationship between scores on two widely used measures of dependency--one objective and one projective--was examined in a sample of 102 undergraduate subjects (60 women and 42 men). Consistent with previous studies in this area, significant sex differences were found on the objective measure of dependency, with women obtaining higher dependency scores than men. However, as predicted, men and women obtained comparable scores on the projective measure of dependency. Additional analyses confirmed that scores on the objective and projective measures of dependency were significantly intercorrelated in both men and women, although the magnitudes of these correlations were somewhat larger in women than in men. Implications of these results for the assessment of dependent personality traits in research and clinical settings are discussed.     

A comparison of some objective measures of expectancy.

4 measures of expectancy were compared. "Similarities of results in the four groups indicate that all four methods are tending to measure the same thing… There appears to be a close relationship between previous training in a specific situation and expectations for future performance." 26 references. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do severity measures explain differences in length of hospital stay? The case of hip fracture

OBJECTIVE: To examine whether judgments about hospital length of stay (LOS) vary depending on the measure used to adjust for severity differences. DATA SOURCES/STUDY SETTING: Data on admissions to 80 hospitals nationwide in the 1992 MedisGroups Comparative Database. STUDY DESIGN: For each of 14 severity measures, LOS was regressed on patient age/sex, DRG, and severity score. Regressions were performed on trimmed and untrimmed data. R-squared was used to evaluate model performance. For each severity measure for each hospital, we calculated the expected LOS and the z-score, a measure of the deviation of observed from expected LOS. We ranked hospitals by z-scores. DATA EXTRACTION: All patients admitted for initial surgical repair of a hip fracture, defined by DRG, diagnosis, and procedure codes. PRINCIPAL FINDINGS: The 5,664 patients had a mean (s.d.) LOS of 11.9 (8.9) days. Cross-validated R-squared values from the multivariable regressions (trimmed data) ranged from 0.041 (Comorbidity Index) to 0.165 (APR-DRGs). Using untrimmed data, observed average LOS for hospitals ranged from 7.6 to 23.9 days. The 14 severity measures showed excellent agreement in ranking hospitals based on z-scores. No severity measure explained the differences between hospitals with the shortest and longest LOS. CONCLUSIONS: Hospitals differed widely in their mean LOS for hip fracture patients, and severity adjustment did little to explain these differences.     

Predicting outcome in very low birthweight infants using an objective measure of illness severity and cranial ultrasound scanning

AIM: To investigate the feasibility of developing an objective tool for predicting death and severe disability using routinely available data, including an objective measure of illness severity, in very low birthweight babies. METHOD: A cohort study of 297 premature babies surviving the first three days of life was made. Predictive variables considered included birthweight, gestation, 3 day cranial ultrasound appearances and 3 day CRIB (clinical risk index for babies) score. Models were developed using regression techniques and positive predictive values (PPV) and likelihood ratios (LR) were calculated. RESULTS: On univariate analysis, birthweight, gestation, 3 day CRIB score and 3 day cranial ultrasound appearances were each associated with death. On multivariate analysis, 3 day CRIB score and 3 day cranial ultrasound appearances remained independently associated. A 3 day CRIB score > 4 along with intraventricular haemorrhage (IVH) grade 3 or 4 was associated with a PPV of 64% and an LR of 9.8 (95% confidence limits 3.5, 27.9). Only 3 day CRIB score and 3 day cranial ultrasound appearances were associated with severe disability on univariate analysis. Both remained independently associated on multivariate analysis. A 3 day CRIB score > 4 along with an IVH grade of 3 or 4 was associated with a PPV of 60% and an LR of 24.2 (95% CI 4.4, 133.3). CONCLUSION: Incorporating objective measures of illness severity may improve current prediction of death and disability in premature infants.     

Respiratory allergy in laboratory animal workers: a retrospective cohort study using pre-employment screening data

OBJECTIVES: To study the role of exposure, atopy, and smoking in the development of laboratory animal allergy (LAA) in a retrospective cohort study. METHODS: Between 1977 and 1993, 225 people received a pre-employment screening when they started a job at a Dutch research institute where they were going to work with laboratory animals. After active follow up 136 of them (60.4%) could be traced and were sent a questionnaire with extensive questions on allergic symptoms, smoking habits, and job history. 122 people (89.7%) sent back a completed questionnaire. Those who were accepted for a job at the institute and did not have allergic symptoms at the start of the job were selected as cohort members. After selecting people with complete data on start and end date of jobs, exposure intensity, atopy, and smoking, the cohort consisted of 99 people with an average time of follow up of 9.7 years. LAA was defined as a positive response to a set of questions in the questionnaire. The mean number of hours a week a person was exposed to laboratory animals at entry of the cohort was used as a surrogate for exposure, and was divided into four categories. RESULTS: 19 cohort members (19.2%) reported LAA. More people with asthmatic symptoms were found in the high exposure categories. More atopic than non-atopic people reported asthmatic symptoms (13% v 6%). The mean time until development of symptoms of LAA was about 109 months in non-atopic people (n = 9), and 45 months in atopic people (n = 10) (t test; P < 0.05). Time until development of symptoms of LAA was shorter at a higher intensity of exposure, except for those exposed for less than two hours a week. A proportional hazard regression analysis showed that exposure and atopy were significant determinants of LAA. An increased relative risk (RR) was found for non-atopic people exposed to laboratory animal allergens for more than two hours a week. Atopic people had an even higher risk when exposed to laboratory animals for more than two hours a week (RR above 7.3). Sex, smoking, and age were not risk factors. More atopic than non-atopic people were absent from work or transferred because of allergies. CONCLUSIONS: This study showed that exposure and atopy are significant predictors of LAA and that the risk of developing LAA remained present for a much longer period (> 3 y) than considered before.     

Clinical and laboratory findings associated with the severity of community-acquired pneumonia

To clarify the clinical features of severe community-acquired pneumonia, we retrospectively studied 121 patients treated at our hospital. We divided the patients into three groups, based on the severity, of their disease. Patients were put in the "mild" group (n = 56) if they recovered after treatment with antimicrobial agents only, they were put in the "moderate" group (n = 34) if the required oxygen therapy and recovered, and they were put in the "severe" group (n = 31) if they required mechanical ventilation. Age and underlying disease were recorded, as well as signs, symptoms, and laboratory data obtained during the first 24 hours after admission. The data indicated that the following nine findings were associated with the severity of disease: age of at least 65 years, an underlying disease of (31) the respiratory or central nervous system, dyspnea, a pulse rate of at least 90 beats per minute, a respiratory rate of at least 25 breaths per minute, an albumin concentration no greater than 3.5 g/dl, a blood urea nitrogen level of at least 20 mg/dl, a PaO2 no greater than 60 mmHg or an SaO2 no greater than 90%, and a high score on a scale of the extent of roentgenographic evidence of pulmonary infiltrates. Patients in whom these are found be managed carefully.     

Onset of action of eformoterol by dry powder inhaler: objective and subjective measures

Fluorescence microscopy of caudal epididymal spermatozoa stained with 3, 3' dihexyloxacarbocyanine iodide (DiOC6(3)) showed intense fluorescence along the concave surface of the apical hook of spermatozoa of Rattus species and along the upper concave margin of the sperm head in Mus musculus. In the spermatozoa of Hydromys chrysogaster, Melomys cervinipes, and Pseudomys australis, the two ventral processes also fluoresced brightly. In P. australis, fluorescence in the apical hook of sperm heads was largely localized to its upper and lower surfaces. The sperm of N. alexis did not show consistent positive fluorescence. The localization of fluorescence in these spermatozoa after staining with DiOC6(3) was mainly restricted to regions where a large accumulation of perinuclear theca material lies beneath the plasmalemma. The reason for this remains to be determined, but DiOC6(3) may be useful for quickly demonstrating areas of abundant perinuclear thecal material in sperm heads of eutherian mammals by light microscopy.     

Common measures of asthma severity lack association for describing its clinical course

BACKGROUND AND OBJECTIVE: To address the problems of increasing asthma morbidity and mortality rates, reliable severity measures must be identified. Accordingly, we compared three measures and their relationship to beclomethasone compliance. METHODS: Three clinical measures (symptom scores, morning peak expiratory flow rates, and number of as needed albuterol inhalations with Nebulizer Chronologs [Forefront Technologies, Inc., Lakewood, Colo.]) were assessed daily in 13 adults with asthma for 8.9 +/- 2.1 weeks. The relationships among these three variables were analyzed in terms of Pearson correlation coefficients. These were evaluated for each of the three possible pairs of the three clinical measures for each of the 13 patients. The relationship between inhaled beclomethasone compliance and the pairwise correlations was studied with the use of nonparametric statistical procedures. RESULTS: In four of the 13 patients, no pairwise correlations between any of the three severity measures were observed. The peak expiratory flow rate-symptom score relationship was observed in eight patients, whereas peak expiratory flow rate-albuterol use and albuterol use-symptom score correlations were each seen in four patients. Mean beclomethasone compliance was 64% and was greatest in those patients whose albuterol use increased concurrently with symptom scores (94% vs 50%, p = 0.02). CONCLUSIONS: The commonly used measures of asthma severity, symptom scores, peak flow rate, and beta-agonist use may not be interchangeable in describing the clinical course. Patients whose beta-agonist use is driven by symptoms tend to be more compliant with use of inhaled corticosteroids.     

An objective validation of factual interview data.

How valid is information obtained from interviews? 91 physically handicapped individuals were interviewed by 5 female interviewers, each having a 3-hour training period. The information for some was obtained by talking directly to the handicapped person; for others, it was obtained from an adult relative. These data were checked against agency records and employer questionnaires. "It is indefensible to assume the validity of purportedly factual data obtained by interview." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing the severity of posttraumatic stress disorder: Relation between dichotomous and continuous measures.

Both the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) and the Impact of Event Scale (IES) assess distress following trauma. This article assesses the interrelation between these two instruments for soldiers who suffered from combat stress reactions (N?=?382) and for a matched group (N?=?334). Results indicated that subjects suffering from posttraumatic stress disorder (PTSD) according to the DSM-III yielded higher scores of the Intrusion and Avoidance factors of the IES. Furthermore, the Intrusion factor was predominantly associated with each of the criteria of the DSM-III diagnosis. Although the IES and the DSM-III overlap, they may tap different aspects of battle-related PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multiphase mixed-effects models for repeated measures data.

Behavior that develops in phases may exhibit distinctively different rates of change in one time period than in others. In this article, a mixed-effects model for a response that displays identifiable regimes is reviewed. An interesting component of the model is the change point. In substantive terms, the change point is the time when development switches from one phase to another. In a mixed-effects model, the change point can be a random coefficient. This possibility allows individuals to make the transition from one phase to another at different ages or after different lengths of time in treatment. Two examples are reviewed in detail, both of which can be estimated with software that is widely available. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Tobacco withdrawal and nicotine replacement influence objective measures of sleep.

Research has not adequately characterized the impact of tobacco withdrawal on objectively assessed sleep parameters despite the recent inclusion of insomnia as a nicotine withdrawal sign in the Diagnostic and Statistical Manual of Mental Disorders. Moreover, whether 24-hr nicotine replacement aids or interferes with sleep during withdrawal is unknown. In a double-masked, randomized clinical trial, 34 cigarette smokers who were motivated to quit received either active nicotine patches or placebo patches while quitting. Sleep was polysomnographically monitored for 2 precessation nights and 3 postcessation nights. The study demonstrates that among dependent smokers tobacco withdrawal increases objectively assessed sleep disturbance (sleep fragmentation) and nicotine replacement results in postcessation improvements in important polysomnographic measures of sleep quality (sleep fragmentation, Stage 3 and Stage 4 sleep). (PsycINFO Database Record (c) 2010 APA, all rights reserved)