Development and psychometric performance of the schizophrenia objective functioning instrument: an interviewer administered measure of function

Existing measures for functional assessment do not adequately address the relationship between cognitive impairment and function. The Schizophrenia Outcomes Functioning Interview (SOFI) was developed to measure community functioning related to cognitive impairment and psychopathology. Following review of existing measures and discussion with experts, caregivers, and patients, content was generated for four domains: 1) living situation; 2) IADLs; 3) productive activities; and 4) social functioning. The final SOFI was constructed with items informing domain scores, and an interviewer-completed global rating for each domain. Psychometric characteristics of the SOFI were evaluated in a sample of 104 community residing patients with schizophrenia and their informants. Test-retest reliability was evaluated in a sub-sample of patient-informant dyads using ICC; all values were >0.70 for both patient-interviews (SOFI-P) and informant-interviews (SOFI-I). Inter-rater reliability ICCs ranged from 0.50 to 0.79 on a different sub-sample. The SOFI demonstrated adequate construct validity based on correlations with the PSP (range 0.58 to 0.76; p<0.0001) and the QLS (p<0.001). Some correlations between SOFI and PETiT scores were low to moderate (p<0.05). Discriminant validity was supported based on SOFI score comparisons for patient groups based on PANSS and BACS scores (p<0.05); SOFI scores differed between borderline and moderately ill patients as measured by the CGI-S (p<0.05). The SOFI expands on existing measures and more comprehensively captures functioning of patients in the real world than other performance-based (proxy) measures. The SOFI has good evidence supporting reliability and construct validity, and may be a useful measure of functional outcomes in schizophrenia.

Development and validation of the Congestion Quantifier seven-item test (CQ7): a screening tool for nasal congestion

OBJECTIVE

This study aimed to develop and validate a short, simple, patient-completed instrument for identifying patients with congestion in a 15-day study. Allergic rhinitis (AR) is the most common allergic condition worldwide, with congestion as one of the most salient symptoms. Nevertheless, there is no short screening tool designed specifically to identify congestion that can help patients make decisions about seeking treatment.

METHODS

Patients (N = 354) received a clinical exam to confirm congestion and assess its possible causes including confirmation of AR. They completed the 13-item draft of the Congestion Quantifier (CQ) and five additional patient-reported outcome instruments.

RESULTS

The 13-item draft CQ was reduced to a seven-item version, the CQ7. Internal consistency reliability was 0.93; test-retest reliability = 0.85. Construct validity was demonstrated by significant correlations with the Medical Outcomes Study Sleep Scale, the Work Productivity and Activity Impairment Questionnaire-Allergy Specific, and the Positive Affect and Negative Affect Scale Fatigue subscale (r = 0.23-0.67). The CQ7 can discriminate between controls and patients (AUC > 0.9). Moreover, it can discriminate between different levels of severity of symptoms of AR. A score of 7 provided optimum balance of sensitivity (91%), specificity (86%), and correct classification (90%) for detecting congestion.

CONCLUSION

The CQ7 is reliable, valid, and responsive to differences in severity of nasal congestion. The CQ7 can identify patients with congestion that may need to be evaluated by a clinician.

The patient experience of depression and remission: focus group results

Few depression measures were developed with the patient perspective. To obtain patient views on depression and early symptom resolution, 4 focus groups (N=31) were conducted. Patients also completed the Quick Inventory of Depressive Symptomology (Self-Report), SF-36, and a rating of the bothersomeness and significance of 12 symptoms of depression. Transcripts were reviewed for major themes. Irritability was a key symptom and it remitted earlier than others. Important to participants were low mood, low energy, lack of motivation, lack of focus/concentration, feelings of guilt, self-critical thoughts, feeling overwhelmed, lack of enjoyment, hypersomnia, restlessness, anger, and irritability. Gender differences emerged; most men reported irritability as one of the first symptoms to remit; for women, motivation level and energy commonly remitted first. Results suggest that new measures of treatment outcome should encompass irritability, anger, and ability to cope with life stressors.

Relationship of nasal congestion with sleep, mood, and productivity

OBJECTIVE

To explore the impact of nasal congestion alone relative to a full set of allergic rhinitis (AR) symptoms on sleep, fatigue, daytime somnolence, and work and school productivity in a 15-day prospective, naturalistic study.

RESEARCH DESIGN AND METHODS

Patients (N = 404) received a clinical exam to confirm congestion and assess its possible causes, including confirmed allergic rhinitis. They completed a battery of patient-reported outcomes (PROs) that assess the impact of nasal congestion and morning AR symptoms on patients' reports of sleep, daytime sleepiness, fatigue, and work, school, and activity impairment. Data were analyzed using multiple regression. Each PRO was regressed separately on congestion and morning AR symptoms, controlling for patient demographics.

RESULTS

Nasal congestion has a significant (p < 0.05), negative impact on patients' lives. Nasal congestion alone had only a slightly smaller negative impact on sleep adequacy relative to AR symptoms more broadly (congestion: beta = 0.137-0.534; AR: beta = 0.123-0.642). Congestion increases the likelihood of sleep problems, fatigue, shortness of breath, headache, and daytime somnolence.

CONCLUSIONS

A single congestion item by itself is a statistically and substantively significant predictor of patient-relevant outcomes. Although the sample was not randomly drawn from clinics or physician offices, the consistency and strength of the findings suggest the salience of this single symptom for patients' experiences.

Bioluminescent signal system: bioluminescence immunoassay of pathogenic organisms

The Ca(2+)-regulated photoprotein obelin has been examined as a label for bioluminescence immunoassay of infective agents. The hepatitis B virus (HbsAg) and the bacteria Escherichia coli and Shigella sonnei lipopolysaccharide (LPS) were chosen as model antigens. Chemically synthesized obelin-corresponding antibody conjugates were used in a solid-phase microplate immunoassay. The sensitivities achieved by the assay were 0.25 ng/mL for S. sonnei LPS and 0.375 ng/mL for HbsAg. A novel, filter-based immunoassay to determine bacterial admixtures in the environment was proposed. The NanoCeram filters were effectively applied to 'trap' and pre-concentrate pathogens from samples under study for the purposes of further detection and measurement of the absorbed material by bioluminescence immunoassay.

Impact of PTSD comorbidity on one-year outcomes in a depression trial

Low-income African American, Latino, and White women were screened and recruited for a depression treatment trial in social service and family planning settings. Those meeting full criteria for major depression (MDD; N = 267) were randomized to cognitive-behavior therapy (CBT), antidepressant medication, or community mental health referral. All randomly assigned participants were evaluated by baseline telephone and clinical interview, and followed by telephone for one year. Posttraumatic stress disorder (PTSD) comorbidity was assessed at baseline and one-year follow-up in a clinical interview. At baseline, 33% of the depressed women had current comorbid PTSD. These participants had more exposure to assaultive violence, had higher levels of depression and anxiety, and were more functionally impaired than women with depression alone. Depression in both groups improved over the course of one year, but the PTSD subgroup remained more impaired throughout the one-year follow-up period. Thus, evidence-based treatments (antidepressant medication or structured psychotherapy) decrease depression regardless of PTSD comorbidity, but women with PTSD were more distressed and impaired throughout. Including direct treatment of PTSD associated with interpersonal violence may be more effective in alleviating depression in those with both diagnoses.

Corrections of magnification and focusing in a cathode lens-equipped scanning electron microscope

One of the well-proven and efficient methods of obtaining a very low-energy impact of primary electrons in the scanning electron microscope is to introduce a retarding field element below the pole piece of the objective lens (OL). It is advantageous to use the specimen alone as the negatively biased electrode (i.e., cathode of the cathode lens). The optical power of the cathode lens modifies some of the standard parameters of the image formation such as relation of working distance to OL excitation or magnification to the scanning coils current, the impact angle of primary electrons, and so forth. In computer-controlled electron microscopes these parameters, particularly with regard to focusing and magnification, can be corrected automatically. Derivation of algorithms for such corrections and their experimental verifications are presented in this paper. Furthermore, a more accurate analytical expression for the focal length of an aperture lens is derived.

Impact of cognitive impairment on mild dementia patients and mild cognitive impairment patients and their informants

BACKGROUND

The aim of this study was to identify key aspects of the impact of cognitive impairment on patients with mild cognitive impairment (MCI) and mild probable Alzheimer disease (AD) and their informants, and identify overlap and differences between the groups.

METHODS

Structured focus group discussions were conducted with MCI patients, AD patients, MCI informants, and AD informants. Participants were recruited from memory clinics in the U.K. and the U.S.A. A total of 20 AD and 20 MCI patients and 16 AD and 11 MCI informants participated. Sessions were content reviewed to identify key impacts of cognitive impairment; results were compared across diagnostic groups and for patients and informants.

RESULTS

Seven key themes emerged: uncertainty of diagnosis, skill loss, change in social and family roles, embarrassment and shame, emotionality, insight, and burden. Patients were able to discuss the impact of cognitive impairment on their lives and reported frustration with recognized memory problems, diminished self-confidence, fear of embarrassment, concerns about changing family roles due to cognitive impairment, and anxiety. Informants reported more symptoms and more impairment than did patients and indicated increased dependence on others among patients.

CONCLUSION

MCI and mild AD exert substantial burden on patients' lives and the lives of those close to them.

Validation of a new symptom impact questionnaire for mild to moderate cognitive impairment

BACKGROUND

Patient-reported outcomes assessment enhances the understanding of disease impact in a range of disorders. At mild levels of cognitive impairment the patient perspective on functioning, behavior and symptoms can be particularly valuable for syndrome characterization when clinical and neuropsychological findings are limited. We have evaluated the psychometric performance of the 55-item Patient-Reported Outcomes in Cognitive Impairment (PROCOG), a new patient-reported measure, to measure mild to moderate cognitive impairment symptoms and their impact from the perspective of patients with dementia of the Alzheimer's type (DAT) and mild cognitive impairment (MCI).

METHODS

The sample of 75 DAT patients, 78 MCI patients and 33 cognitively intact control subjects (> 64 years) was recruited through medical centers in the U.SA. Validity was assessed through correlation to the Quality of Life--Alzheimer's Disease (QOL-AD) and Centers for Epidemiologic Studies--Depression Scale (CES-D) and neuropsychological assessments (WAIS subscales and MMSE).

RESULTS

PROCOG scores for MCI patients were generally intermediate between DAT and control subjects. Internal consistency and test-retest reliability were acceptable. Correlations with the CES-D and QOL-AD were in the moderate to high range; correlations with the neuropsychological measures were low to moderate.

CONCLUSIONS

The PROCOG demonstrated good to excellent psychometric properties among a sample of older adults with MCI and DAT as well as cognitively intact older adult control subjects and provides a method for collecting unique information on the patient experience of cognitive impairment. Subscales permit focused evaluation of domains relevant to the patient's experience of cognitive impairment.

Cost-effectiveness of Evidence-Based Pharmacotherapy or Cognitive Behavior Therapy Compared With Community Referral for Major Depression in Predominantly Low-Income Minority Women

BACKGROUND

Few clinical trials have evaluated interventions for major depressive disorder in samples of low-income minority women, and little is known about the cost-effectiveness of depression interventions for this population.

OBJECTIVE

To evaluate the cost-effectiveness of pharmacotherapy or cognitive behavior therapy (CBT) compared with community referral for major depression in low-income minority women.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial was conducted in 267 women with current major depression.

INTERVENTIONS

Participants were randomly assigned to pharmacotherapy (paroxetine hydrochloride or bupropion hydrochloride) (n = 88), CBT (n = 90), or community referral (n = 89).

MAIN OUTCOME MEASURES

The main outcomes were intervention and health care costs, depression-free days, and quality-adjusted life years based on Hamilton Depression Rating Scale scores and Medical Outcomes Study 36-Item Short-Form Health Survey summary scores for 12 months. Cost-effectiveness ratios were estimated to compare incremental patient outcomes with incremental costs for pharmacotherapy relative to community referral and for CBT relative to community referral.

RESULTS

Compared with the community referral group, the pharmacotherapy group had significantly lower adjusted mean Hamilton Depression Rating Scale scores from the 3rd month through the 10th month (P = .04 to P<.001) of the study, and the CBT group had significantly lower adjusted mean scores from the 5th month through the 10th month (P = .03 to P = .049). There were significantly more depression-free days in the pharmacotherapy group (mean, 39.7; 95% confidence interval, 12.9-66.5) and the CBT group (mean, 25.80; 95% confidence interval, 0.04-51.50) than in the community referral group. The cost per additional depression-free day was USD 24.65 for pharmacotherapy and USD 27.04 for CBT compared with community referral.

CONCLUSIONS

Effective treatment for depression in low-income minority women reduces depressive symptoms but increases costs compared with community referral. The pharmacotherapy and CBT interventions were cost-effective relative to community referral for the health care system.

An observational study of health-related quality of life and pain outcomes in chronic low back pain patients treated with fentanyl transdermal system

BACKGROUND

The analgesic effect of long-acting opioids, such as transdermal fentanyl, has been demonstrated in patients with cancer, neuropathic pain and chronic low back pain (CLBP). However, the broader effect of long-acting opioids on the patient's health-related quality of life (HRQoL) is less well known.

OBJECTIVE

To evaluate HRQoL outcomes in CLBP patients treated with transdermal fentanyl.

RESEARCH DESIGN AND METHODS

An observational study was conducted at 17 clinical centers in the US. Eligible patients had CLBP diagnosis for at least 3 months and were taking short-acting opioids chronically, and then initiated transdermal fentanyl treatment. Patients completed the Treatment Outcomes in Pain Survey (TOPS), which includes the SF-36 Health Survey, at baseline and > or = 9 weeks of treatment. The HRQoL burden of CLBP was determined by comparing CLBP patients' SF-36 scores to the general US population and low back pain patient norms. HRQoL outcomes were determined by comparing baseline and follow-up TOPS and SF-36 scores. Additionally, HRQoL outcomes were evaluated across patient groups stratified by changes in pain intensity ratings as measured by an 11-point numerical rating scale.

RESULTS

At baseline CLBP patients (N = 131) scored one-to-two standard deviations (SD) below age and gender adjusted SF-36 general population norms (MANOVA F = 127.1, p < 0.0001) and significantly lower than low back pain norms (MANOVA F = 125.3, p < 0.0001). At follow-up, significant improvement (p < 0.05) was observed on six of the SF-36 scales and both SF-36 summary measures and five of the six TOPS pain-related scales. The magnitude of change in scores in effect size units among these scales ranged from 0.17 to 0.80, which are considered small to large effect size changes. HRQoL score improvement was greatest among patients experiencing the greatest pain relief.

CONCLUSION

CLBP patients who chronically used short-acting opioids showed tremendous HRQoL burden. Favorable HRQoL outcomes were observed among patients who reported pain relief.

Growth inhibition of MCF-7 tumor cell line by phenylacetate linked to functionalized dextran

We investigated the antiproliferative effect of phenylacetate covalently linked to dextran derivatives (DMCBPA conjugates) on human breast cancer MCF-7 cells. We show that free sodium phenylacetate (NaPA) inhibits the cell growth (IC50 = 14 mM), while an important inhibitory effect is observed for DMCBPA conjugates. The IC50 dose of these conjugates is as low as 1.0 mg/ml, corresponding to 1.3 mM of phenylacetate. The precursors, dextran substituted with methylcarboxylate and benzylamide groups, did not affect the growth of MCF-7 tumor cells. We have observed that MCF-7 cell growth inhibition depends on amount of phenylacetate linked to the conjugate. The data indicated that an optimum antiproliferative effect is more significant when the amount of phenylacetate groups present on the dextran backbone is high. Analysis of doubling time by growth kinetics study shows that conjugates have more time-sustained effect than free NaPA. It is noteworthy that the inhibitory effect is observed at non-toxic concentration. Theses conjugates could be considered as acceptable derivatives to prevent tumor progression.

Psychometric performance of an assessment scale for strain in nursing care: the M-NCAS

Background

Multiple instruments exist to measure dementia behaviors, but the nursing staff perspective on those behaviors and their level of burden has not been well measured. The goal of this study was to examine the psychometric performance of the Modified Nursing Care Assessment Scale (M-NCAS), a 28-item nurse rating of burden associated with care for institutionalized individuals with dementia. Nurses rate items in terms of extent to which the behavior or characteristic is present ("attitude" domain), and extent to which it is a burden ("strain" domain).

Methods

Data from 282 patients enrolled in a 12-week, double-blind, randomized clinical trial comparing risperidone treatment to placebo was used to evaluate M-NCAS item performance, internal consistency reliability, and construct validity. Empirical subscales were identified via exploratory factor analysis (EFA).

Results

Four poorly-performing items were deleted from further analyses. EFA identified 3 "attitude" subscales and 5 "strain" subscales. Cronbach's alphas were 0.65 and above. Correlation with the Cohen-Mansfield Agitation Inventory and the BEHAVE-AD, clinical ratings of dementia behaviors, were low to moderate.

Conclusion

The M-NCAS provides a valid and reliable means of obtaining care burden ratings from formal caregivers in long-term care, and provides a method for evaluating dementia interventions from the perspective of nursing staff.

The Effect of Risperidone on Nursing Burden Associated with Caring for Patients with Dementia

OBJECTIVES

To compare risperidone treatment with placebo for the burden to nursing staff of older nursing-home residents with dementia.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Long-term care institutions in Australia and New Zealand.

PARTICIPANTS

Two hundred seventy-nine residents had evaluable data for comparison of oral risperidone with placebo treatment at 4 weeks, 8 weeks, and endpoint across the 12-week trial.

MEASUREMENTS

The Modified Nursing Care Assessment Scale (M-NCAS) is a 28-item instrument that measures behavior occurrence in patients (patient outcome) and difficulty of those behaviors for nursing staff as rated by nurse carers (nurse outcome). Treatment groups were compared via analysis of covariance (ANCOVA). To aid score interpretation, M-NCAS effect sizes were examined by response category, with response defined as subjects with mean Cohen-Mansfield Agitation Inventory total aggression subscale score change of 4 points or greater, a clinical outcome for patients.

RESULTS

Between-group ANCOVAs showed statistically significant reductions in nurse-rated M-NCAS scores from baseline to endpoint for the patients randomized to risperidone relative to placebo (P<.05). Effects were evident at 4 weeks and maintained over time. Effect sizes were moderate to large for responders and near zero for nonresponders.

CONCLUSION

Risperidone treatment was associated with an early and sustained reduction in nursing staff burden as measured using the M-NCAS compared with placebo treatment for older nursing home residents with dementia.

Key Articles and Guidelines in Pharmacotherapeutic Management of Arrhythmias

Clinical studies are among the most important literature published in the area of cardiovascular pharmacotherapy and are the basis of many of the standards of practice today. We compiled a list of these clinical trials, as well as well-written, up-to-date review articles and important treatment guidelines, that focus on pharmacotherapeutic management of arrhythmias. This list should be useful not only to practitioners and trainees in cardiovascular pharmacotherapy, but also to other clinicians as an update.