WWW accessible system for national/regional registries of clinical results of cord blood transplants: a tool to facilitate cooperative clinical research

A system, accessible via internet, has been developed to support the Spanish Registry of Cord Blood Transplants (RETSCU). The system includes a database of clinical results directly accessible by transplant centers (TCs) and cord blood banks (CBBs) (restricted to own cases regarding primary data and unrestricted regarding statistics derived from validated data) and gives open access to Web pages containing results approved for publication. It also includes internal mail for two-way and broadcast messages. Patients' data are essentially those included in Eurocord forms. Additional features of the system are: confidentiality; inalterability of validated primary data; identifiability of data sources. The Unix central computer is accessible via the WWW. For security, data transmission is encrypted and passwords are required for access. Copies are regularly updated. Data can be loaded from CBBs and TCs. The procedure for creating and updating records is user-friendly, with the possibility of errors being minimized by extensive automated checks. Validation of patients' records by a manager is required before making data available for general statistical analysis. TCs and CBBs may retrieve data on their own cases, regardless of validation, as individual records or in tables directly transferable to common statistical programs. Statistical analysis may be done on validated data from all the patients in the Registry or from groups selected according to HLA compatibility and disease, type of transplant (related/unrelated), or protocol. Several similarly designed and managed national/regional Registries might be networked and their data integrated into a multinational Registry. Our system would require some additional developments to be used in this way.

Effects of the type of meniscal lesion on knee function

The relationship between the type of meniscal lesion (bucket-handle, flap or degenerative tears) and preoperative knee function (5.1 +/- 6.2 days before arthroscopic meniscectomy) was studied in 35 patients. Patients with bucket-handle tears (group B, n = 12) had large knee extension work deficits during maximal voluntary contractions at 30 degrees and 180 degrees/s (Kin-Com dynamometer). These work deficits were accompanied by proportional decreases in the prime mover or agonist-EMG levels (VM: vastus medialis and/or VL: vastus lateralis). These patients had smaller deficits during flexion movements at 30 degrees/s. Moreover, a larger number of negative clinical signs and symptoms (pain at rest and during tests, locking, thigh atrophy, extension and flexion movement deficits larger than 10 degrees) were found with an equal or a higher prevalence in group B than in the other groups. Patients with flap tears (group F, n = 15) had deficits in work and agonist-EMG activity (VM and VL) only during the extension tests. In contrast, patients with degenerative tears (group D, n = 8) had a work deficit and a concomitant decrease in the EMG level of the medial gastrocnemius (MG), only during the flexion test at 30 degrees/s. Comparable mean knee function scores, as measured by the Lysholm and Gillquist questionnaire [35], were obtained for the three groups of patients, suggesting that this measure was not sensitive enough to discern functional differences related to types of meniscal tears. The results of this study have demonstrated a link between the type of meniscal lesion and the consequent preoperative knee joint disability profile as defined by comparison with the sound leg. These results emphasize the need to consider meniscal lesion type and an individual's preoperative strength deficit when group comparisons of patients are made or the effects of therapy (arthroscopic surgery and rehabilitation) are evaluated.

The protective action of amlodipine on cardiac negative inotropism caused by prolonged incubation in vitro

The mechanism of the antihypertensive action of the 1,4-dihydropyridine Ca2+ antagonist amlodipine was studied in isolated ventricular strips and aortic rings from Wistar rats after oral treatment with amlodipine 15 mg/kg/day for one week. The contractions evoked by electrical stimulation of isolated strips from right ventricles pretreated with amlodipine (5 nM) were unaffected during the first hour after mounting, but they decreased in magnitude after prolonged incubation (4 hr). However, the decrease in response of these preparations after prolonged incubation was less than that observed in strips prepared from untreated rats. A negative inotropic effect of amlodipine was observed at concentrations higher than 300 nM. In the presence of lower concentrations of amlodipine (5 nM-30 nM) after prolonged incubation, the contractions of ventricular strips were significantly more sustained than in the absence of amlodipine. Likewise, the decrease in contractility evoked by increasing the stimulation frequency from 1 to 3 Hz was reduced in amlodipine treated rats. The recovery of contractility was improved when stimulation frequency was returned to 1 Hz. On the other hand, when rat ventricular strips pretreated with amlodipine (5 nM) were exposed to isoprenaline (3 microM), the contractions evoked by isoprenaline were enhanced. The isoprenaline effect was not altered with 300 nM amlodipine, but with 3 microM became weak and was significantly lower than in strips treated with isoprenaline alone. In addition, treatment with amlodipine produced a marked decrease in the contractions evoked by 100 mM KCl solution in isolated aortic rings when compared to untreated rats. This inhibition was produced in a time-dependent manner with an IC50 equal to 30 and 3 nM after 2 and 45 min of contraction, respectively. Ex vivo results show that amlodipine treatment decreased aortic contractility without producing a negative inotropic effect although there was an occupation of cardiac Ca2+ channels. These results suggest that a protective effect of amlodipine on cardiac negative inotropism is produced by prolonged incubation in vitro.

Pituitary tumors and gamma knife surgery. Clinical experience with more than two years of follow-up

30 patients with pituitary tumors were treated in our unit and followed for 26-45 months. 14 patients had nonsecreting adenomas, 7 had acromegaly, 5 had prolactinomas, 3 had Cushing's disease. One patient had a choristoma of the pituitary stalk. The patient with a choristoma, 7 patients with nonsecreting adenomas, 4 with acromegaly, 1 prolactinoma and 3 with Cushing's disease had been operated by transsphenoidal microsurgery prior to Gamma Knife (GK) treatment. From this group, one patient with a nonsecreting adenoma and two with acromegaly had undergone fractional external radiotherapy after surgery. Stereotactic MRI localization had been used in all cases. All the tumors showed either a reduction in volume or cessation of growth; 85% of the patients with acromegaly showed normalization of growth hormone (GH) levels. Normalization of ACTH levels occurred in the 3 patients with Cushing's disease. All the patients with prolactinomas showed reduction of prolactin levels but normalization did not occur. However, in 3 cases the bromocriptine could be withdrawn. Deterioration of vision was not observed. One patient suffered transient paresis of the third cranial nerve that improved with steroids. Panhypopituitarism appeared in one case of Cushing's disease two years after the treatment. In the remaining cases there were no changes in their previous physiological pituitary function. We conclude that GK radiosurgery in pituitary tumors is an effective alternative to transsphenoidal microsurgery when compression of surrounding structures does not exist, and it can efficiently replace conventional irradiation.

Combining studies using effect sizes and quality scores: application to bone loss in postmenopausal women

This article presents a random effects model that uses effect sizes (ES) and quality scores to integrate results from investigations. An empirical example is given with data obtained from a meta-analysis on the effectiveness of physical activity in the prevention of bone loss in healthy postmenopausal women. A Medline search was performed to locate relevant studies published in French or English between January 1966 and May 1996. Three independent reviewers extracted data from studies. Effect sizes were calculated according to the method of Hedges and Olkin. A modified version of Chalmers' scale was utilized to calculate quality scores. DerSimonian and Laird's method with incorporation of the quality scores was used to estimate the overall effect size. Quality scores and the inverse of the variances were included as weights when combining studies. The overall estimate and standard error (SE) of the effect of physical activity on spinal bone mineral density loss in healthy postmenopausal women was ESoverall = 0.4263 (1.1361). When compared to other meta-analysis methods such as the fixed effects model and the model of DerSimonian and Laird without the quality score (DL), the new model generated comparable estimators (fixed effects model's ESoverall (SE) = 1.2724 (0.0139), DLs ESoverall (SE) = 0.3958 (1.2370)). Due to the heterogeneity that existed between studies, a random effects model was more appropriate then a fixed effects model. However, it resulted in wider confidence intervals, as expected. It was shown empirically that the model using quality scores generated narrower confidence intervals than the model of DL alone. The inclusion of covariates such as quality scores in meta-analyses permits the quantification of the variation between studies.

Comparison of cross-sectional and longitudinal designs in the study of aging of upper extremity performance

The purpose of the study was to compare two research designs, namely the cross-sectional design and the longitudinal design, in the context of upper extremity performance and age-related changes. Upper extremity performance of 360 randomly recruited healthy, community-dwelling elderly persons was evaluated with reliable and valid sensori-motor tests. Three years later, survivors (n = 264) were reevaluated with the same tests. In many tests, cross-sectional and longitudinal designs were comparable for estimating the changes in upper extremity performance with age. However, in some tests, the decline with age using a cross-sectional design was underestimated. The upper extremity performance decline observed with the longitudinal design was larger than the decline predicted with the cross-sectional design. The withdrawal and survivor biases related to the longitudinal design and the cohort bias associated with the cross-sectional design may, in part, explain these results.

Profile of residents in unlicensed homes for the aged in the eastern townships of Quebec

BACKGROUND

The number of unlicensed homes for the aged in Quebec has increased rapidly over the last decade. Because these homes are not linked in any formal way to the Quebec Ministry of Health and Social Services, little is known about their residents. The objective of this study was to describe the sociodemographic characteristics and disability profile of elderly residents in unlicensed homes for the aged. Comparisons were made to a sample of residents drawn from licensed long-term facilities.

METHODS

The target population was restricted to residents aged 65 years and over in facilities in the Eastern Townships of Quebec who had some difficulties with at least 2 activities of daily living. This population included 94% of elderly people in licensed facilities and 64% of those in unlicensed homes. The study population comprised 301 impaired people in 88 residential care facilities (36 licensed, 52 unlicensed). They were selected using a 2-stage sampling scheme: stratified sampling of the primary units (homes) and simple random sampling of the secondary units (residents). Facility managers were interviewed to collect descriptive information about themselves and their facilities. Residents were assessed with regard to their cognitive abilities (using the Modified Mini-Mental State [3MS] Examination) and their functional autonomy (using the Functional Autonomy Measurement System [Système de mesure de láutonomie fonctionnelle (SMAF)].

RESULTS

Although residents without impairment were excluded from the study, the unlicensed facilities were found to house people who were, on average, less cognitively and physically impaired than their counterparts in the licensed facilities (p < 0.001). Nonetheless, a substantial proportion of the residents in the unlicensed homes had severe cognitive disabilities (38.5% had 3MS score of less than 60) and functional disabilities (17.0% had an SMAF score of more than 40). The corresponding figures for residents in the licensed facilities with these scores were 65.3% and 66.7%. Of the managers of the unlicensed facilities 31.9% had no training and 58.8% had no previous experience in caring for the elderly people. The staff-resident ratio was lower among the unlicensed homes than among the licensed facilities (mean 0.05 [standard error of the mean (SEM) 0.01] v. 0.39 [SEM 0.03], p < 0.001). In addition, only 26.0% of the unlicensed homes employed qualified staff, as compared with 63.0% of the licensed facilities (p < 0.001).

INTERPRETATION

This study provides evidence that many residents of unlicensed homes have considerable care needs. These homes appear ill-equipped to address their needs, which raises doubts about their ability to deliver high-quality care.

Prolactin and interleukin-6 in neuropsychiatric lupus erythematosus

We investigated the levels of prolactin (PRL) and interleukin-6 (IL-6) in the cerebrospinal fluid (CSF) and serum of systemic lupus erythematosus patients with central nervous system involvement (CNS-SLE), and examined whether PRL and IL-6 have a relationship. Serum and CSF PRL and IL-6 were measured in the following groups of patients and controls: group I: seven patients with CNS-SLE; group II: three SLE patients without CNS involvement (non CNS-SLE); group III: 10 patients with neurocysticercosis; and group IV: six healthy women. The patients were clinically assessed. CSF PRL and IL-6 were elevated in group I (CNS-SLE) in comparison with all other groups (p<0.001). In addition, four of seven patients had higher levels of IL-6 and PRL in CSF than in serum. A positive correlation between PRL and IL-6 in CSF of SLE was observed (r=0.88, p<0.001). The mean serum PRL concentrations were not significantly different in all groups, but high levels of IL-6 were found in the serum of group I in comparison with groups II and IV (p<0.001). The serum levels of group III were not different from those of group I. These results demonstrate the presence of intrathecal synthesis and elevations of CSF PRL and IL-6 in active CNS-SLE involvement and indicate that measurements of CSF PRL and IL-6 may be useful in the evaluation of neuropsychiatric lupus erythematosus.

Age- and education-specific reference values for the Mini-Mental and modified Mini-Mental State Examinations derived from a non-demented elderly population

MAIN OBJECTIVE

To report age- and education-specific reference values for the Mini-Mental State Examination (MMSE) and Modified Mini-Mental State (3MS) Examination.

DESIGN

Cross-sectional study.

SETTING

Community and institutional settings in five regions across Canada.

PARTICIPANTS

7754 subjects aged 65 and over randomly chosen to take part in the Canadian Study of Health and Aging. Subjects classified as cognitively impaired or demented following a clinical and neuropsychological examination were excluded.

MEASUREMENTS

Total scores on the MMSE and 3MS, and the degree to which they are influenced by the age, sex, education, mother tongue and living environment of the subject.

RESULTS

Reference values on the two tests are reported through various descriptive statistics for five age groups and four education levels. These values decrease with age and increase with years of schooling. Test scores are also influenced by the subject's sex and mother tongue, albeit to a lesser extent. These observations led to the development of predictive equations of the performance to be expected from a 'normal' elderly subject, given his/her socio-demographic characteristics.

CONCLUSION

The use of the reference values and related predictive equations will allow the clinician to interpret a patient's performance on two widely used cognitive tests, in light of the value expected from a group of 'normal' subjects with the same sociodemographic profile.

A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being

OBJECTIVE

To evaluate the effects of a weight-bearing, water-based, exercise program designed for women with low bone mass.

DESIGN

A test-retest cross-sectional, prospective study.

SETTING

Community-dwelling women from a Canadian city.

PARTICIPANTS

Seventy-seven postmenopausal women, 50 to 70 years of age, with spinal or femoral bone density below the fracture threshold.

INTERVENTION

Subjects exercised in a pool with waist-high water for 60 minutes, 3 days a week, over a 12-month period. Forty minutes of each session were devoted to successive jumps and muscular exercises designed to promote bone accretion, strength, and endurance.

MAIN OUTCOME MEASURES

Spinal and femoral bone mineral density (BMD) measured by dual-energy X-ray absorptiometry, functional fitness (flexibility, coordination, agility, strength/endurance, and cardiorespiratory endurance) assessed with the American Alliance for Health, Physical Education, Recreation and Dance battery, and psychological states evaluated with Dupuy's General Well-Being Schedule.

RESULTS

Spinal BMD decreased significantly (p < .001), whereas there was no change in femoral neck BMD (p = .90). Four of the parameters chosen to assess functional fitness, namely, flexibility, agility, strength/endurance, and cardiorespiratory endurance, were affected positively by the exercise program (all p values < .001). Psychological well-being also improved significantly after participation in the exercise program (p < .001).

CONCLUSION

The intervention was successful in improving the functional fitness and psychological well-being of the participants, despite a lack of effect on the skeletal system. Future studies are needed to identify water exercises that are safe yet exert enough stress on the bones to initiate a bone response.

Age- and education-specific reference values for the Mini-Mental and modified Mini-Mental State Examinations derived from a non-demented elderly population

MAIN OBJECTIVE

To report age- and education-specific reference values for the Mini-Mental State Examination (MMSE) and Modified Mini-Mental State (3MS) Examination.

DESIGN

Cross-sectional study.

SETTING

Community and institutional settings in five regions across Canada.

PARTICIPANTS

7754 subjects aged 65 and over randomly chosen to take part in the Canadian Study of Health and Aging. Subjects classified as cognitively impaired or demented following a clinical and neuropsychological examination were excluded.

MEASUREMENTS

Total scores on the MMSE and 3MS, and the degree to which they are influenced by the age, sex, education, mother tongue and living environment of the subject.

RESULTS

Reference values on the two tests are reported through various descriptive statistics for five age groups and four education levels. These values decrease with age and increase with years of schooling. Test scores are also influenced by the subject's sex and mother tongue, albeit to a lesser extent. These observations led to the development of predictive equations of the performance to be expected from a 'normal' elderly subject, given his/her socio-demographic characteristics.

CONCLUSION

The use of the reference values and related predictive equations will allow the clinician to interpret a patient's performance on two widely used cognitive tests, in light of the value expected from a group of 'normal' subjects with the same sociodemographic profile.

Long-term improvement in patients with severe Parkinson's disease after implantation of fetal ventral mesencephalic tissue in a cavity of the caudate nucleus: 5-year follow up in 10 patients. Clinica Puerta de Hierro Neural Transplantation Group

Different groups worldwide have observed in recent years that stereotactic implantation of fetal tissue can ameliorate the clinical symptoms of Parkinson's disease. The authors therefore investigated whether implantation of fetal ventral mesencephalic (FVM) tissue via open surgery is also capable of producing an improvement and whether this improvement is transient or long lasting. The authors report their findings in a 5-year follow-up study in 10 patients with Hoehn and Yahr Grade IV or V Parkinson's disease in whom a single FVM graft was implanted in a cavity created in the right caudate nucleus. The results indicate that the implants improved motor function and that clinical recovery persisted in seven of the 10 patients 5 years after implantation. Amelioration was observed in both the on and off phases and was accompanied by a 64% reduction in the levodopa dose and withdrawal of the dopamine agonist. The on phase was prolonged from 39% of the waking day to 72%, with reduced intensity and duration of dyskinesias. All symptoms that were analyzed showed improvement, although they differed in intensity and time of onset. The course of improvement seemed to be stepwise, with significant improvement between 5 and 7 months postimplantation followed by two waves of progress peaking in Months 15 and 36. Withdrawal of cyclosporine in three patients after more than 2 years of administration produced a decline in the patients' clinical conditions. In conclusion, the results indicate that open surgery implantation of FVM tissue in the caudate nucleus improves the clinical condition of parkinsonian patients and that this improvement can persist for at least 5 years. In comparison with two earlier series reported by the authors, which involved implants of perfused adrenal medulla and coimplantation of adrenal medulla and peripheral nerve, the course and pattern of improvement in these implant recipients suggests that their recovery can be attributed to more than one factor.

Meta-analysis of the effectiveness of physical activity for the prevention of bone loss in postmenopausal women

A meta-analysis was done to measure the effect of physical activity on the bone mass of healthy postmenopausal women. All studies published between 1966 and 1996, in French or English, were reviewed for inclusion from Medline search, bibliographies of relevant studies, review articles and books. Studies had to be prospective intervention trials, randomized or not, evaluating the effectiveness of an exercise program of any duration, frequency and intensity, with a control group. Studies had to measure bone parameters and involve healthy postmenopausal women over 50 years of age who were free of symptomatic osteoporosis at the time of study entry. Effect sizes (ES) were calculated for each bone parameter and site measured in every eligible study according to Hedges and Olkin. DerSimonian and Laird's model was used to estimate overall effect sizes when combining studies. All analyses were bone parameter and site specific. Of 217 papers extracted from the literature, 187 did not meet eligibility criteria and 12 others were rejected. The two main reasons for rejection were that both genders were combined in the analyses and no exercise group without drug interaction was present. Eighteen studies were included for meta-analysis. Taking into account the frequency, duration, compliance rate and average age of the subjects, the programs were judged of moderate intensity and focused on walking, running, physical conditioning and aerobics. A significant effect of physical activity was detected on the bone mineral density at the L2-4 level of the lumbar column in studies published after 1991 (ES = 0.8745, p < 0.05). No effect could be seen, however, on forearm and femoral bone mass. Although applied to a small number of studies, this meta-analysis suggests that exercise programs in a population of postmenopausal women over 50 years of age are effective for preventing spinal bone mineral density loss at the L2-4 level. However, such programs do not have any effect on the forearm or femoral bone mass.

Reliability of the Modified Mini-Mental State Examination in the context of a two-phase community prevalence study

Data collected through the Canadian Study of Health and Aging were analyzed to estimate the reliability of the Modified Mini-Mental State (3MS) Examination when used in the context of a two-phase community prevalence study. During the screening phase of the study, subjects were tested in their home by a lay interviewer, either in English or French. All subjects scoring 77 or under on the 3MS and a sub-sample of those scoring over 77 were reassessed by a nurse during a clinical examination, following which subjects were classified as normal, cognitively impaired but not demented, or demented. Results indicate substantial reproducibility of the 3MS, slightly higher than that of the Mini-Mental State Examination from which it is derived. The english versions of these tests appear slightly more reproducible than their French counterparts.

Isometric grip endurance of healthy elderly men and women

Grip endurance is one of the important prerequisites for good performance of the upper extremity and hence it is important to evaluate it correctly. However, we know little about normal grip endurance, especially for elderly people. The main objective of this study was to examine the age-related changes in grip isometric endurance of healthy community-dwelling elderly people. Two-hundred and eighty-six subjects aged between 60 and 90, were randomly selected from the electoral list of the city of Sherbrooke, Quebec, Canada. Grip relative isometric endurance was evaluated using the Jamar dynamometer. Isometric grip endurance was estimated by the number of seconds a subject could sustain 50% of his/her maximal voluntary grip strength. Contrary to other upper extremity sensorimotor parameters, no grip isometric endurance difference was found with age, in spite of a slight tendency towards a decrease. The women tended to have better scores than the men and endurance of dominant hand is better than the non-dominant. The stability with age could be explained by muscle fiber composition modifications.

Performance of the 'unaffected' upper extremity of elderly stroke patients

BACKGROUND AND PURPOSE

The main objective of this study was to compare the sensorimotor performance of the unaffected upper extremity (UE) of elderly stroke patients with that of healthy elderly people.

METHODS

The group of stroke patients was composed of 43 hemiplegic/paretic subjects who had had a cerebrovascular accident at least 6 months earlier. They were > or = 60 years old, were right-handed before the stroke, had visual perception within normal limits, and showed no major cognitive impairments. A group of 43 healthy subjects matched for dominance, age, and sex was used for comparison. The main parameters of the performance of the unaffected UE of the stroke subjects and of the same side of the healthy subjects were measured with valid, reliable instruments. Some variables potentially related to the unaffected UE were also measured: affected UE motor function, functional independence, length of time since the stroke, self-perceived health status, activity level, and hand anthropometry.

RESULTS

Statistical analyses showed significant deficits in the unaffected UE of hemiplegic/paretic subjects compared with normal subjects with regard to the following parameters: gross manual dexterity, fine manual dexterity, motor coordination, global performance, and kinesthesia (P < .01 to P < .0001). No significant clinical or statistical difference was found for grip strength (P < .81), static and moving two-point discrimination (P = .21 and P = .12), or touch/pressure threshold (P < .91).

CONCLUSIONS

Many factors (frequency of use of the unaffected hand, sensorimotor interaction tasks, severity of the deficits in corticifugal projections, and deficits in postural stabilization) could interact to provide the clinical picture obtained in the present study.

Hand sensibility of healthy older people

OBJECTIVE

To develop normative data for four hand sensibility modalities in older subjects.

DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

Three hundred and sixty community-dwelling subjects of both sexes, aged 60 to 94, randomly selected from the electoral list of the city of Sherbrooke, Quebec, Canada.

MEASUREMENTS

Touch/pressure threshold (Semmes-Weinstein monofilaments), static and moving two-point discrimination (Mackinnon-Dellon Disk-Criminator), tactile recognition (Modified Pick-up test), and thumb kinesthesia.

RESULTS

A reduction with age was found in the performance of the study subjects, with the exception of the kinesthesia test. The values obtained in this study are clearly lower than the norms proposed for adults, underlining the importance of using reference values developed for the target clientele.

CONCLUSION

The norms will help clinicians to differentiate better between normal and pathological changes in sensibility with age.

Impact of a 12-month exercise program on the physical and psychological health of osteopenic women

OBJECTIVE

To describe the effect of a supervised physical activity program on the physical and psychological health of osteopenic women.

DESIGN

A randomized controlled trial.

SETTING

Sherbrooke, Quebec, Canada.

PARTICIPANTS

A total of 124 community-living postmenopausal women, between 50 and 70 years of age, with low bone mass took part in the study.

INTERVENTION

Subjects allocated to the experimental group performed weight-bearing exercises (walking, stepping up and down from benches), aerobic dancing, and flexibility exercises for 60 minutes, three times a week, over a period of 12 months. All subjects were invited to attend bi-monthly educational seminars covering topics related to osteoporosis.

OUTCOME MEASURES

Spinal and femoral bone mineral density (BMD), functional fitness (flexibility, coordination, agility, strength/endurance, cardiorespiratory endurance), psychological well-being, back pain intensity, and self-perceived health.

RESULTS

Spinal BMD stabilized in the exercisers while decreasing significantly in the controls (P = .031). No change in femoral BMD was observed in either group (P = .597). Four of the five parameters chosen to evaluate functional fitness, namely flexibility, agility, strength, and endurance, were affected positively by the exercise program (all P < .01). Adjusting for prescores by means of an analysis of covariance revealed a significant difference between the groups in psychological well-being, which favored the exercisers (P = .012). After 12 months, back pain reported by exercisers was lower than that reported by controls (P = .008). Finally, self-perceived health increased in the exercise group, whereas no difference was observed in the control group (P = .790).

CONCLUSION

These results suggest that after 12 months, exercising can produce a significant increase above initial levels in the functional fitness, well-being, and self-perceived health of osteopenic women. Intensity of back pain can also be lowered by exercise. The exercise program succeeded in stabilizing spinal BMD but had no effect on femoral BMD.

Development and validation of an evaluation instrument for medical students in tutorials

PURPOSE

To develop and explore the validity of the Tutotest, the first standardized instrument designed to assess the skills and attitudes of medical students working in tutorials in a problem-based learning curriculum.

METHOD

The Tutotest, consisting of 44 items rated on a four-point Likert-type scale, was developed from well-defined theoretical frameworks after consultation with students and teachers at the Université de Sherbrooke Faculty of Medicine. In 1988-89, 40 tutors were asked to use the Tutotest to evaluate a total of 100 students at the end of each of the four units of the first-year curriculum. Data were analyzed to examine the homogeneity and reliability of the instrument, explore its factorial structure, and document its correlation with students' grades.

RESULTS

A total of 28 tutors (70%) conducted Tutotest evaluations; of a possible 400 evaluations, 270 (67.5%) were returned with complete data. Exploratory factor analysis revealed that the Tutotest was structured around four factors that accounted for 82% of the variance: effectiveness in the group (23 items), communication and leadership skills (13 items), scientific curiosity (four items), and respect for colleagues (four items). The Tutotest had a Cronbach's alpha coefficient of .98 and a split-half coefficient of .98. The intraclass correlation coefficient was estimated to be .46 and would reach up to .81 after averaging five Tutotest evaluations. Tutotest scores showed good correlation (r = .64) with the official tutor's global evaluation and a moderate correlation (r = .39) with students' written examination results.

CONCLUSION

The Tutotest was found to be a standardized reliable and valid instrument that can significantly improve the evaluation of students' skills and attitudes during tutorials. Although lengthier than the usual tutor evaluation form, the Tutotest is a good compromise between an unreliable short global scale and a more comprehensive but impractical instrument.

Predictive validity of a postal questionnaire for screening community-dwelling elderly individuals at risk of functional decline

Screening elderly individuals who are at risk of functional decline in the community is essential in order to implement effective programmes of assessment and surveillance in a context of secondary prevention. The postal questionnaire technique consists of sending a simple questionnaire to all elderly individuals living in a defined area in order to identify those who are at risk. The objective of this study was to develop a postal questionnaire and to test its capacity to predict functional decline in community-dwelling elderly people. A 21-item postal questionnaire was sent with a birthday card to a representative sample of community-dwelling individuals over the age of 75 years (n = 842). One month after sending the questionnaire, all subjects were contacted by a nurse for an in-home interview (n = 655) that included assessment of functional autonomy. One year later, the subjects (n = 607) were reassessed by the same nurse. Of the eligible subjects, 87.4% returned the postal questionnaire. During the year following the completion of the postal questionnaire, 43 subjects died, 13 were institutionalized and 109 had experienced a significant decrease on the autonomy scale, for a total annual occurrence of functional decline of 27.2%. Age and 14 of the 21 items of the questionnaire were associated with a significant relative risk of functional decline. The relative risk associated with not responding to the questionnaire was 2.1. A stepwise logistic regression analysis showed that six items were independent predictors of functional decline. This 6-item Sherbrooke Postal Questionnaire identifies as positive 56% of the population with 75% sensitivity and 52% specificity. We conclude that a postal questionnaire is a feasible and valid technique for screening elderly individuals at risk for functional decline.

Refusal and information bias associated with postal questionnaires and face-to-face interviews in very elderly subjects

Our objectives were (1) to analyze the refusal bias associated with postal questionnaires and face-to-face interviews and (2) to compare responses elicited from a postal questionnaire with those provided by a face-to-face interview in subjects over 75 years of age. Our methods included a postal questionnaire sent to a representative sample of community-dwelling elderly individuals (n = 842). All subjects were also invited to participate in an in-home interview conducted by a trained nurse. One hundred and six subjects (12.6%) were nonrespondents to the postal questionnaire. These nonrespondents were more cognitively impaired, more disabled, and showed a higher 1-year mortality rate (13.2 versus 5.2%) than respondents. Late respondents who needed a reminder letter were similar to nonrespondents. One hundred and eighty-seven subjects (22.2%) refused to participate in the home interview. These nonparticipants were similar to the participants on age, sex, 1-year mortality rate, and responses given to all but two postal questions. Comparison of postal questionnaire responses and face-to-face responses revealed that agreement was substantial to moderate for factual information (kappa = 0.41 to 0.80) but poor for clinical information (depression, cognitive impairment, disability). A short index including age, sex, and six questions on disability was useful in identifying disabled subjects by a postal questionnaire. Our conclusion is that nonresponse bias is evidenced when postal questionnaires are utilized in the very elderly population and caution should be used when interpreting health data obtained by this technique. Refusal bias from face-to-face interviewing is less important in this population.