Development and evaluation of a standardized questionnaire for identifying adverse events in vaccine clinical trials

In vaccine trials, diary questionnaires or vaccination report cards (VRCs) are used extensively to collect complaints reported by subjects or guardians following vaccination. These have not been evaluated for accuracy or standardized to facilitate tolerability comparisons among vaccines.Objectives -(1) Develop standardized, age-specific VRCs for collecting self-reported adverse events (AEs) in trials; (2) Evaluate whether complaints elicited by nurse examinations or telephone interviews were missed by VRCs.Methods -Vaccine-trial databases, focus groups, experts and experienced nurses were used to develop paediatric and adolescent/adult VRCs. VRCs were evaluated at four sites. The primary outcome was subjects with AEs missed on the VRC and reported in nurse examinations (for injection-site reactions) or telephone interviews (for systemic complaints).Results -Of 855 subjects, 96.5% completed VRCs. For systemic complaints, 1.5% (12/812) reported both no complaint on VRCs and at least one complaint in telephone interviews. For injection-site reactions, 5.1% (53/1030) of injection sites had both no reaction reported on VRCs and had reactions noted by nurse examination. No missed AEs were rated as severe.Conclusion -The data suggest VRCs provide a practical and reasonably complete method of eliciting complaints following vaccination. Copyright (c) 2000 John Wiley & Sons, Ltd.

NHS Diabetes guideline for the perioperative management of the adult patient with diabetes

These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.

The beliefs which motivate young male and female drivers to speed: a comparison of low and high intenders

In Australia, young drivers aged 17-24 years, and particularly males, have the highest risk of being involved in a fatal crash. Investigation of young drivers' beliefs allows for a greater understanding of their involvement in risky behaviours, such as speeding, as beliefs are associated with intentions, the antecedent to behaviour. The theory of planned behaviour (TPB) was used to conceptualise beliefs using a scenario based questionnaire distributed to licenced drivers (N=398). The questionnaire measured individual's beliefs and intentions to speed in a particular situation. Consistent with a TPB-based approach, the beliefs of those with low intentions to speed ('low intenders') were compared with the beliefs of those with high intentions ('high intenders') with such comparisons conducted separately for males and females. Overall, significant differences in the beliefs held by low and high intenders and for both females and males were found. Specifically, for females, it was found that high intenders were significantly more likely to perceive advantages of speeding, less likely to perceive disadvantages, and more likely to be encouraged to speed on familiar and inappropriately signed roads than female low intenders. Females, however, did not differ in their perceptions of support from friends, with all females reporting some level of disapproval from most friends and all females (i.e., low and high intenders) reporting approval to speed from their male friends. The results for males revealed that high intenders were significantly more likely to speed on familiar and inappropriately signed roads as well as having greater perceptions of support from all friends, except from those friends with whom they worked. Low and high intending males did not differ in their perceptions of the advantages and disadvantages of speeding, with the exception of feelings of excitement whereby high intenders reported speeding to be more exciting than low intenders. The findings are discussed in terms of how they may directly inform the content of mass media and public education campaigns aimed at encouraging young drivers to slow down.

Young and unlicensed: risky driving before entering the licensing system

OBJECTIVE

On-road driving before gaining a valid license (prelicense driving) represents a risk for all road users. Prelicense driving among young people who obtained a provisional license within an enhanced graduated driver licensing program in Queensland, Australia, was investigated.

METHODS

Recently licensed drivers (n = 1032) aged 17 to 19 years (M = 17.54) completed a survey exploring their driving experiences while on their learner's license. Six months later, 355 of these drivers completed the same survey exploring their experiences on their provisional (intermediate) license.

RESULTS

Twelve percent of participants reported prelicense driving. Prelicense drivers reported significantly more risky driving as learners and provisional drivers.

CONCLUSIONS

Prelicense drivers not only place themselves and other road users at risk at the time but also continue to do so through their subsequent risky driving. Prelicense driving should be discouraged, and parents should be encouraged to monitor car use and the driving behavior of their children.

Varicella in infants after implementation of the US varicella vaccination program

OBJECTIVE

To describe varicella disease in infants since implementation of the varicella vaccination program in the United States.

PATIENTS AND METHODS

From 1995 to 2008, demographic, clinical, and epidemiologic data on cases of varicella in infants were collected prospectively through a community-based active surveillance project. We examined disease patterns for infants in 2 age groups: 0 to 5 and 6 to 11 months.

RESULTS

Infant varicella disease incidence declined 89.7% from 1995 to 2008. Infants aged 0 to 5 months had milder clinical disease than those aged 6 to 11 months: ≥50 lesions, 49% vs 58% (P = .038); fever (body temperature > 38°C), 12% vs 21% (P = .014); and varicella-related complications, 6% vs 14% (P = .009), respectively. Age was an independent predictor of the occurrence of complications.

CONCLUSIONS

The varicella vaccination program has resulted in substantial indirect benefits for infants, who are not eligible for vaccination. Presence of maternal varicella-zoster virus antibodies might explain attenuated disease in very young infants likely born to mothers with history of varicella. Although varicella disease incidence has declined, exposure to varicella-zoster virus continues to occur. Improving varicella vaccination coverage in all age groups will further reduce the risk of varicella exposure and protect those not eligible for varicella vaccination.

Mileage, car ownership, experience of punishment avoidance, and the risky driving of young drivers

OBJECTIVE

Young drivers are at greatest risk of injury or death from a car crash in the first 6 months of independent driving. In Queensland, the graduated driver licensing (GDL) program was extensively modified in July 2007 in order to reduce this risk. Increased mileage and car ownership have been found to play a role in risky driving, offenses, and crashes; however, GDL programs typically do not consider these variables. In addition, young novice drivers' experiences of punishment avoidance have not previously been examined. This article explores the mileage (duration and distance), car ownership, and punishment avoidance behaviors of young newly licensed intermediate (provisional) drivers and their relationship to risky driving, crashes, and offenses.

METHODS

Drivers (n = 1032) aged 17 to 19 years recruited from across Queensland for longitudinal research completed survey 1 exploring prelicense and learner experiences and sociodemographic characteristics. survey 2 explored the same variables with a subset of these drivers (n = 341) after they had completed their first 6 months of independent driving.

RESULTS

Most young drivers in survey 2 reported owning a vehicle and paying attention to police presence. Drivers who had their own cars reported significantly greater mileage and more risky driving. Novices who drove more kilometers, spent more hours each week driving, or avoided actual and anticipated police presence were more likely to report risky driving. These drivers were also more likely to report being detected by police for a driving-related offense. The media, parents, friends, and other drivers play a pivotal role in informing novices of on-road police enforcement operations.

CONCLUSIONS

GDL programs should incorporate education for the parent and novice driver regarding the increased risks associated with greater driving, particularly when the novice driver owns a vehicle. Parents should be encouraged to delay exclusive access to a vehicle. Parents should also consider whether their young novices will deliberately avoid police if they are aware of their location. This may reinforce not only the risky behavior but also young novices' beliefs that their parents condone this behavior.

How the immune response to vaccines is created, maintained and measured: addressing patient questions about vaccination

This article gives an overview of the immune response to vaccines, including ways in which it is measured and/or augmented to enhance its effectiveness. A brief description is given of the immune response, adaptive immunity, immunologic memory, antibodies, and adjuvants. Given that many young parents and physicians have never witnessed the ravages of vaccine-preventable diseases, it is hoped this article will aid the many people involved in the prevention of infectious disease to understand better the concepts and practicalities of immunization and vaccine development.

STUDIES ON THE MECHANISM OF RECOVERY IN PNEUMOCOCCAL PNEUMONIA : IV. THE MECHANISM OF PHAGOCYTOSIS IN THE ABSENCE OF ANTIBODY

1. Evidence has been presented in previous publications that the phagocytosis of pneumococci in the pneumonic lung during chemotherapy is due neither to specific opsonins nor to capsular injury (1, 2). The present studies have shown that the phagocytosis taking place in the lung is independent of any sort of intermediary factor and results from a direct action of the phagocytic cells upon the pneumococci. 2. Phagocytosis in the absence of antibody has been demonstrated not only in the lungs of living rats but in formalin-fixed lungs, on the surfaces of a variety of tissues (both freshly removed from the animal and previously "killed" with heat), and on the surfaces of such inert materials as moistened filter paper, cloth, and fiber glass. On the other hand, smooth materials such as glass, cellophane, albumin, and paraffin have failed to support the phagocytic reaction. This latter observation indicates that the physical character of the surface to which the leucocytes have access constitutes a determining factor in the non-antibody mechanism of phagocytosis. 3. Further experiments have defined the relationship of "surface phagocytosis" to that induced by specific opsonins. The non-antibody mechanism was found to operate only upon surfaces of suitable physical properties, whereas opsonins enabled phagocytes floating freely in a fluid medium to engulf the fully encapsulated organisms. 4. Direct visualization of the surface phenomenon in the lung revealed that leucocytes phagocyte the virulent organisms in the absence of antibody only after having trapped them against the alveolar walls. Once the encapsulated pneumococci have been ingested, they can be seen to undergo digestion within a few hours. The discovery of the phenomenon of surface phagocytosis affords clarification of previously unanswered problems concerning the mechanism of recovery in pneumococcal pneumonia.

Response efficacy: the key to minimizing rejection and maximizing acceptance of emotion-based anti-speeding messages

This study sought to improve understanding of the persuasive process of emotion-based appeals not only in relation to negative, fear-based appeals but also for appeals based upon positive emotions. In particular, the study investigated whether response efficacy, as a cognitive construct, mediated outcome measures of message effectiveness in terms of both acceptance and rejection of negative and positive emotion-based messages. Licensed drivers (N=406) participated via the completion of an on-line survey. Within the survey, participants received either a negative (fear-based) appeal or one of the two possible positive appeals (pride or humor-based). Overall, the study's findings confirmed the importance of emotional and cognitive components of persuasive health messages and identified response efficacy as a key cognitive construct influencing the effectiveness of not only fear-based messages but also positive emotion-based messages. Interestingly, however, the results suggested that response efficacy's influence on message effectiveness may differ for positive and negative emotion-based appeals such that significant indirect (and mediational) effects were found with both acceptance and rejection of the positive appeals yet only with rejection of the fear-based appeal. As such, the study's findings provide an important extension to extant literature and may inform future advertising message design.

Identifying infants at increased risk for late initiation of immunizations: maternal and provider characteristics

OBJECTIVE

We identified maternal, provider, and community predictors among infants for late initiation of immunizations.

METHODS

We performed a retrospective cohort study of infants born between January 1, 2002, and December 31, 2004, in Philadelphia, Pennsylvania. Primary outcomes were age in days at first office-based immunization and status as a late starter (i.e., initiating office-based immunizations after 90 days of age). Candidate predictors included sociodemographic and prenatal characteristics, immunization provider practice type and size, and neighborhood factors. We performed hierarchical logistic regression and Cox regression models to identify independent predictors for being a late starter and prolonged time to first immunization.

RESULTS

Of the 65,519 infants from this birth cohort in Philadelphia's immunization registry, 54,429 (88.1%) were included in analysis and 12.6% of these were late starters. Infants whose mothers were younger, received less than five prenatal visits, had less than a high school education, had more than two children, and who smoked cigarettes prenatally were significantly more likely to be late starters. Receiving care at hospital/university-based or public health clinics was also significantly associated with likelihood of being a late starter. Neither distance between infant's residence and practice nor neighborhood socioeconomic indicators was independently associated with the outcomes. Common risk factor profiles based on practice type and four maternal characteristics were found to reliably identify infant risk.

CONCLUSIONS

Maternal receipt of fewer prenatal care visits, younger maternal age, higher birth order, and receiving care at public health clinics were the strongest predictors of being a late starter and time to first immunization. Risk factor profiles based on information already collected at birth can be used to identify higher-risk infants. Early intervention and potentially partnering with prenatal care providers may be key strategies for preventing underimmunization.

Validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated children, adolescents, and young adults in the post-vaccine licensure era

OBJECTIVES

We assessed the validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated persons 1 to 29 years of age, and we examined varicella disease characteristics associated with varicella zoster virus immunity among those reporting positive histories.

METHODS

We conducted a cross-sectional study at 7 community-based sites in Philadelphia, Pennsylvania, between June 2004 and May 2006 and recruited 1476 participants 1 to 29 years of age who had not been vaccinated against varicella. Sensitivity, specificity, and positive predictive value were determined by comparing self-reported or parent-reported varicella histories from a standardized study interview with varicella zoster virus immunoglobulin G serological results for each participant. We performed multivariate logistic regression analyses to determine which disease characteristics best predicted seropositivity.

RESULTS

The sensitivity of reported varicella history was highest (81%-89%) among participants > or =10 years of age, whereas specificity was highest among participants 1 to 4 years of age (99%) and > or =20 years (88%). Reported varicella history was highly predictive of seropositivity (>95%) only among participants > or =15 years of age. For participants 10 to 14 years of age, parental reports of a generalized itchy rash with 1 of the following were highly predictive of seropositivity: varicella transmission to another household member or being raised in a household with no other children. Among participants < or =9 years of age, no combination of disease characteristics was both highly predictive of seropositivity and common.

CONCLUSIONS

The validity of reported varicella history varies according to age, and a reported history is no longer highly predictive of seropositivity among cohorts born since 1994 (participants < or =9 years of age). Universal varicella vaccination, regardless of history, for these children should be considered, as should simplified criteria for varicella zoster virus immunity among unvaccinated persons born before 1994.

Professionals delivering palliative care to people with COPD: qualitative study

This article describes health and social care professionals' perceptions of palliative care and facilitators and barriers to the delivery of such care for patients with advanced chronic obstructive pulmonary disease. Health professionals participated in semi structured interviews and focus groups which were analysed using content analysis. According to participants, care of patients with chronic obstructive pulmonary disease is focused upon the management of symptoms, with emphasis focused predominately on an acute model of care. Key barriers towards the delivery of palliative care included the reluctance to negotiatie end-of-life decisions and a perceived lack of understanding among patients and carers regarding the illness trajectory. Consequently the delivery of palliative care was viewed as a specialist role rather than an integral component of care. There is a need for education and training for health and social care professions to plan and provide high quality end-of-life care.

I can not get a breath: experiences of living with advanced chronic obstructive pulmonary disease

This study aims to explore the potential for palliative care among people living with advanced chronic obstructive pulmonary disease (COPD). Individual semi-structured interviews (n=13) were conducted with people who had a diagnosis of advanced COPD and were on optimal tolerated drug therapy, with their breathing volume (forced expiratory volume at less than 30%) or were on long-term oxygen therapy or non-invasion ventilation. Participants raised concerns about the uncertain trajectory of the illness and reported unmet palliative care needs with poor access to palliative care services. For most people, palliative care was associated with end of life; therefore, they were unwilling to discuss the issue. There was a wide acceptance that, medically, nothing more could be done. Findings also suggest that patients had unmet palliative care needs, requiring information and support. The research suggests the need for palliative care to be extended to all (regardless of diagnosis), with packages of care developed to target specific needs.

Drink driving deterrents and self-reported offending behaviours among a sample of Queensland motorists

PROBLEM

The efficacy of drink driving (driving under the influence, DUI) countermeasures to deter motorists from driving over the legal limit is extremely important when considering the personal and economic impact the offending behavior has on the community. This paper reports on an examination of 780 Queensland motorists' perceptions of legal and non-legal sanctions and their deterrent impact on self-reported offending behavior.

METHOD

The data were collected via a telephone survey of motorists recruited from a random sample of all listed telephone numbers in the state, adjusted according to district population figures.

RESULTS

The results indicated that there were a range of legal and non-legal factors that were significantly associated with self-reported DUI including: the perceived risk of apprehension and license loss (legal factors); and concerns relating to the possibility of being involved in a crash and hurting another person (non-legal factors). However, additional multivariate analyses indicated that while both legal and non-legal factors significantly predicted self-reported DUI, higher alcohol consumption levels and more favorable attitudes to the behavior also appear to increase the likelihood of DUI.

DISCUSSION

The paper will outline the direct implications of the research project such as the development and promotion of countermeasures that both effectively deter motorists and address pro-offending attitudes.

IMPACT ON INDUSTRY

The findings also highlight that DUI remains a relatively common behaviour among some motoring groups and that there is a need to extend current levels of enforcement as well as adopt innovative strategies to enhance the impact of these operations on the offending behaviour.

Experiences and needs of bereaved carers during palliative and end-of-life care for people with chronic obstructive pulmonary disease

AIM

This study explored the experiences of palliative care that bereaved carers had while providing care to a dying loved one with chronic obstructive pulmonary disease (COPD).

METHOD

Semi-structured interviews were undertaken with nine carers who had lost a loved one in the preceding 6 to 24 months. These interviews explored levels of satisfaction with disease management, symptom management, and end-of-life care. With permission, interviews were tape recorded, transcribed, and subjected to content analysis.

FINDINGS

Three themes emerged from the data: the impact of the caring experience, the lack of support services, and end-of-life and bereavement support. Carers experienced carer burden, lack of access to support services, a need for palliative care, and bereavement support.

CONCLUSION

The findings provide a first insight into the experiences of carers of patients with advanced COPD. Bereaved carers of patients who had suffered advanced COPD reported that they had received inadequate support and had a range of unmet palliative care needs. Special attention should be paid to educating and supporting carers during their caring and bereavement periods to ensure that their quality of life is maintained or enhanced.