The status of health assessment 1994

Patient-Reported Outcome Measure Development and Validation: A Primer for Clinicians

A comprehensive definition of health includes the assessment of patient experiences of a disease and its treatment. These patient experiences are best captured by standardized patient-reported outcome (PRO) instruments. A PRO is reported directly by the patient (or caregiver) and provides the patient's perspective into how a disease and its treatment impact their lives. PRO instruments are typically standardized, validated questionnaires with items that are scaled and can be combined to represent an underlying health-related construct such as physical, social, and role functioning, psychological well-being, symptoms, pain, and quality of life. Over the past few decades, PROs have become increasingly used in clinical trials as endpoints to better understand treatment benefits from the patient's perspective and in clinical practice to identify unmet needs of patients, health risk surveillance, and monitor outcomes of care. In this paper, we describe the process for developing standardized PRO instruments, from conceptual model development through instrument validation.

A critical narrative questioning the assessment of physical literacy: foster authentic human flourishing across the life course

The study provides a summary, reflection, and clarification on the existing literature amid the recent rise in physical literacy assessment through a critical narrative that will contribute to future developments. In this review, the author addressed the significance of acknowledging the ultimate goal of assessing physical literacy throughout the life course is to foster authentic human flourishing. The study questioned the assessment practice in detail by discussing whether it is to translate and validate or to establish locally and to quantify or to specify qualitatively. The current tendency of a comprehensive dimension but not an inclusive journey was found. Subject to limitation, the merits of this study still stand and, moreover, further point to valuable areas for further inquiry that may refine and foster physical literacy and authentic human flourishing across the life course. And based on the arguments, future direction and recommendations when conducting assessment were discussed.

Structural validity of the 5-item World Health Organization Well-being Index (WHO-5) in patients with schizophrenia spectrum disorders

BACKGROUND

When monitoring the severity and impact of schizophrenia spectrum disorders, a measure of subjective well-being should ideally accompany measures of symptom severity and medication side effects. The self-reported 5-item World Health Organization Well-being Index (WHO-5) is a brief, generic, and widely used measure of subjective well-being. However, the structural validity of the WHO-5, namely, whether the individual item scores can be combined to produce a meaningful total score, has not been examined among patients with schizophrenia spectrum disorders.

METHOD

Utilizing data from 399 Danish patients with schizophrenia spectrum disorders attending the Psychiatric Services of the Central Denmark Region, we employed Rasch analysis to examine the structural validity (i.e., unidimensionality, overall fit to the Rasch model, and differential item functioning) of the WHO-5.

RESULTS

The WHO-5 was found to be unidimensional with no differential item functioning for age, sex, or inpatient/outpatient status. However, in the initial analysis, some misfit to the Rasch model, partially caused by the disordering of response categories, was evident. In adjusted analyses in which the item response categories 2 (Less than half of the time) and 3 (More than half of the time) were merged, overall fit to the model was improved.

CONCLUSIONS

When two item response categories were merged, the Danish version of the WHO-5 was found to be structurally valid for patients with schizophrenia spectrum disorders. This suggests that the WHO-5 holds promise as a measure of subjective well-being in this patient population.

Influence of job satisfaction on SRH and happiness among Korean disabled workers: findings from the panel survey of employment for the disabled 2016-2018

Background

An understanding of the economic life activities of persons with disabilities (PWD) is important. Their ability to perform tasks and an increase in their income are more likely to yield an improvement in their Self-Rated Health (SRH) and happiness. However, there is still a lack of understanding of the specific associations among PWD in South Korea. Thus, this study conducted a longitudinal analysis of the association between job satisfaction and SRH, happiness among the Korean PWD.

Methods

After excluding missing values, data on 1,637 participants at baseline (1st wave) were analyzed using the chi-square test, t-test, Analysis of Variance (ANOVA) and generalized estimating equation (GEE) model for data from 1st to 3rd Panel Survey of Employment for the Disabled (PSED). All analyses were conducted using the SAS statistical software package, version 9.4.

Results

Compared to very high job satisfaction group, low job satisfaction group was more likely to experience negative SRH [odds ratio (OR): 3.497, value of p: <0.0001] and experience low happiness (B: -0.291, value of p: <0.0001). Furthermore, in terms of the overall satisfaction with current job among the PWD, compared to the 'very satisfied' group, 'very unsatisfied' group had higher negative SRH (OR: 5.158, value of p: 0.003) and lower happiness (B: -0.327, value of p: <0.0001).

Conclusion

This study suggests that increasing job satisfaction of PWD possibly leads to decreased negative SRH and to increased happiness, resulting in better SRH and happiness. Furthermore, it suggests the establishment of systemic, policy-oriented measures to enhance the employment opportunities for disabled individuals in Korea and create an inclusive working environment that aligns with their respective job responsibilities.

Single-Cell RNA sequencing investigation of female-male differences under PAD conditions

Peripheral arterial disease (PAD) is an age-related medical condition affecting mostly muscular arteries of the limb. It is the 3rd leading cause of atherosclerotic morbidity. The mechanical environment of endothelial cells (ECs) in PAD is characterized by disturbed blood flow (d-flow) and stiff extracellular matrices. In PAD, the stiffness of arteries is due to decreased elastin function and increased collagen content. These flow and stiffness parameters are largely missing from current models of PAD. It has been previously proven that ECs exposed to d-flow or stiff substrates lead to proatherogenic pathways, but the effect of both, d-flow and stiffness, on EC phenotype has not been fully investigated. In this study, we sought to explore the effect of sex on proatherogenic pathways that could result from exposing endothelial cells to a d-flow and stiff environment. We utilized the scRNA-seq tool to analyze the gene expression of ECs exposed to the different mechanical conditions both in vitro and in vivo. We found that male ECs exposed to different mechanical stimuli presented higher expression of genes related to fibrosis and d-flow in vitro. We validated our findings in vivo by exposing murine carotid arteries to d-flow via partial carotid artery ligation. Since women have delayed onset of arterial stiffening and subsequent PAD, this work may provide a framework for some of the pathways in which biological sex interacts with sex-based differences in PAD.

Translation and evaluation of the HeartQoL in patients with coronary heart disease in Iceland

BACKGROUND

Health-related quality of life (HRQoL) reflects an individual's own perception of their symptom burden, functional limitations, prognosis, overall health and changes associated with treatment. The HeartQoL is a validated heart disease-specific questionnaire with a physical and an emotional subscale that is used internationally to assess HRQoL in patients with coronary heart disease (CHD). The aim of this study was to translate and evaluate the psychometric properties of the HeartQoL in patients with CHD in Iceland.

METHODS

Patients ≥ 18 years (n = 396; mean age 64.4 ± 8.8 years; 79.6% male) admitted with CHD were recruited from two hospitals in Iceland and completed the Icelandic versions of the HeartQoL, Short-Form 12v2 Health Survey (SF-12v2), and Hospital Anxiety and Depression Scale (HADS). A subsample of 47 patients completed the HeartQoL 14 days later. Confirmatory factor analysis for ordinal data was used to evaluate the measurement model with a physical and an emotional subscale. Convergent and divergent validity, internal consistency, and test-retest reliability were evaluated.

RESULTS

Overall, the hypothesized two-factor structure of the Icelandic version of the HeartQoL was supported. However, problems with cross-loadings and correlated error variances were identified. Convergent and divergent validity were supported in correlational analyses between HeartQoL, SF-12v2, and HADS. Internal consistency reliability, measured by ordinal alpha, was good for the physical (α = 0.96) and emotional (α = 0.90) subscale. According to intraclass correlations (ICC), acceptable test-retest reliability was demonstrated (ICC = 0.79-0.86).

CONCLUSION

With the two-factor structure confirmed, the Icelandic HeartQoL demonstrated satisfactory psychometric properties in the sample of patients with CHD. Users of the instrument can use the original scoring.

Effect of the Juggling-Based Motor Learning Physical Activity on Well-Being in Elderly: A Pre-Post Study with a Special Training Protocol

Background: The importance of physical activity for the elderly is undeniable. Specific forms of exercise that are able to engage practitioners, both cognitively and physically, may provide more positive consequences for health and quality of life. Juggling is one of these activities that has both of these characteristics. Methods: Twenty elderly people (70.55 ± 4.91) were included in a juggling-based motor learning protocol for twelve training units during one month of exercising. An evaluation of the proposed exercises (five-point Likert scale) and a subjective assessment of well-being (WHO-5) were conducted during the protocol. Results: All participants learned to perform a three-ball flash cascade. Exercises were rated as very attractive (4.85 ± 0.31) by the practitioners, and a statistically significant improvement in well-being in participants was shown (p < 0.01; d = 0.76). Additionally, in the participating group, the number of people at risk of depression decreased significantly after the intervention with juggling classes (p < 0.01; g = 0.5). Conclusions: The proposed protocol could be an interesting physical activity for the elderly. It can be assumed that this activity, especially when performed in a group form, can improve the well-being of participants in a short period of time.

Walkable Neighborhoods and Cognition: Implications for the Design of Health Promoting Communities

Objective: This study seeks to examine neighborhood characteristics, physical activity, and health status and their roles in promoting healthy cognitive aging. Methods: Using data from the REasons for Geographic And Racial Difference in Stroke (REGARDS) study (N=10,289, mean age=73.4 years), we used multilevel linear regression to examine the relationships between walkable neighborhoods (both objectively measured and subjective perceptions), walking behavior, physical activity, health status, and cognitive function. Results: Engaging in any moderate physical activity (β=0.47, p < 0.001), having better health status (β=0.02, p < 0.001), living in neighborhoods with greater street connectivity (β=0.15, p < 0.05), and positive perceptions of neighborhood traffic (p < 0.01) and parks (p < 0.05), were associated with higher cognitive function. Residence in socioeconomically disadvantaged neighborhoods (β=-0.01, p < 0.01) was negatively associated with cognitive function. Discussion: Both perceived and objective features of walkable environments may have consequences for cognitive health, and can inform the development of health promoting communities.

Correlation between Glycation-Related Biomarkers and Quality of Life in the General Japanese Population: The Iwaki Cross-Sectional Research Study

The correlation between diabetes-related biomarkers and quality of life (QOL) remains unclear. In this cross-sectional study, we investigated the correlation between diabetes-related biomarkers and QOL in a general Japanese population who underwent health checkups as a part of the Iwaki Health Promotion Project. Male and female participants aged ≥ 20 years from Iwaki District, Hirosaki City, Aomori Prefecture who participated in the 2019 medical evaluation were recruited. QOL was evaluated using the Short Form Health Survey 36 (SF-36). Fasting blood glucose, homeostatic model assessment-estimated insulin resistance (HOMA-IR), hemoglobin A1c (HbA1c), glycoalbumin, and plasma pentosidine were also evaluated as diabetes-related markers. Of the 1065 recruited participants, 1053 completed the clinical and QOL evaluations. Multivariate regression analysis revealed that upregulated diabetes-related markers levels were correlated with decreased SF-36 scores. Blood glucose, HOMA-IR, HbA1c, glycoalbumin, and plasma pentosidine levels were correlated with general health. Moreover, plasma pentosidine levels were correlated with role physical, social functioning, and role emotional in addition to general health. These results indicated that the levels of diabetes-related biomarkers, particularly the levels of plasma pentosidine, a glycation marker, were associated with QOL in our cohort.

Development of the SF-6Dv2 health utility survey: comprehensibility and patient preference

Background

The SF-6Dv2 classification system assesses health states in six domains—physical functioning, role function, bodily pain, vitality, social functioning, and mental health. Scores have previously been derived from the SF-36v2® Health Survey. We aimed to develop a six-item stand-alone SF-6Dv2 Health Utility Survey (SF-6Dv2 HUS) and evaluate its comprehensibility.

Methods

Two forms of a stand-alone SF-6Dv2 HUS were developed for evaluation. Form A had 6 questions with 5–6 response choices, while Form B used 6 headings and 5–6 statements describing the health levels within each domain. The two forms were evaluated by 40 participants, recruited from the general population. Participants were randomized to debrief one form of the stand-alone SF-6Dv2 HUS during a 75-min interview, using think-aloud techniques followed by an interviewer-led detailed review. Participants then reviewed the other form of SF-6Dv2 and determined which they preferred. Any issues or confusion with items was recorded, as was as overall preference. Data were analyzed using Microsoft Excel and NVivo Software (v12).

Results

Participants were able to easily complete both forms. Participant feedback supported the comprehensibility of the SF-6Dv2 HUS. When comparing forms, 25/40 participants preferred Form A, finding it clearer and easier to answer when presented in question/response format. The numbered questions and underlining of key words in Form A fostered quick and easy comprehension and completion of the survey. However, despite an overall preference for Form A, almost half of participants (n = 19) preferred the physical functioning item in Form B, with more descriptive response choices.

Conclusion

The results support using Form A, with modifications to the physical functioning item, as the stand-alone SF-6Dv2 HUS. The stand-alone SF-6Dv2 HUS is brief, easy to administer, and comprehensible to the general population.

What is related to postoperative outcome of frail status in elective colorectal cancer surgery?

Background

The population affected by colorectal cancer is growing, and there is an increasing need for prevention of functional decline following treatment. We proposed that the Kihon Checklist published by the Japanese Ministry of Health, Labor, and Welfare would be an appropriate means of frailty assessment for prediction of postoperative complications in older patients with colorectal cancer. This prospective cohort study aims to identify the factors influencing postoperative frailty.

Methods

We prospectively enrolled consecutive patients with colorectal cancer and aged ≥ 65 year (N = 500) between May 2017 and December 2018. Eligible patients were assessed with the Kihon Checklist prior to surgery and 30 days after surgery. The main measures were variables related to postoperative change in view of frail status.

Results

According to the Kihon Checklist questionnaire, 164 patients were frail preoperatively and 172 patients were frail postoperatively, whereas 38 patients changed from "nonfrail" before surgery to postoperative "frail." Overall complications were counted in 97 patients (19.4%), and 5 patients died. Performance status ≥ 2, history of laparotomy, open surgery, complication, ostomy creation, and delirium were significantly associated with changing postoperative "frail" (P = .014, P = .023, P = .006, P < .001, P = .023, and P = .024, respectively). In multivariate analysis, independent related factors of changing postoperative "frail" were complication (odds ratio 2.69, 95% confidence interval 1.19–6.09, P = .018) and ostomy creation (odds ratio 2.32, 95% confidence interval 1.01–5.33, P = .047).

Conclusion

The Kihon Checklist questionnaire could identify the factors related to postoperative change of frailty status in older patients with colorectal cancer. This cohort concluded that whether postoperative complication occurred or not was closely associated with perioperative change of frailty status.

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Our prospective cohort study examined the factor influencing postoperative frailty in older patients with colorectal cancer by Kihon Checklist questionnaire.

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The importance of this study is that postoperative complication and ostomy creation were significantly associated with postoperative change of frailty status.

Longitudinal changes in physical and mental health of older adults with chronic hepatitis B infection: Trajectories and predictors

Despite the increasing health burden of chronic hepatitis B (CHB) in aging populations, little is known about the course of health-related quality of life (HRQoL) changes. We aimed to assess individual-level longitudinal HRQoL changes in elderly patients with CHB and to examine their correlates. A prospective 5.1 years-cohort study was conducted in community-dwelling adults aged 55 years with hepatitis B surface antigen-positive. Participants underwent serial measurement of HRQoL using the short-form (12) health survey version 2. Of 503 participants, 82.7% remained in good physical health throughout the study period, whereas 9.1% had declining physical health and 8.2% were in poor physical health. We likewise identified three trajectories of mental health changes ("good mental health" [86.9%], "declining mental health" [6.8%], and "poor mental health" [6.4%]). Three baseline characteristics were independently associated with a lower likelihood of remaining physically or mentally healthy: sarcopenic obesity (odds ratio [OR] with 95% confidence interval [95% CI] of 7.5 [2.8-20.5] for poor physical health, 3.1 [1.1-8.4] for declining physical health, 4.3 [1.4-13.0] for poor mental health), a higher number of metabolic abnormalities (OR [95% CI] of 3.6 [1.6-8.0] for poor physical health) and depressed mood (OR [95% CI] of 21.7 [5.8-81.0] for poor physical health, 5.3 [1.4-19.9] for declining physical health, 83.1 [19.7-350.2] for poor mental health, 13.6 [2.9-64.8] for declining mental health). In conclusion, in a cohort of elderly patients with CHB, we demonstrated the heterogeneity and nonlinearity of HRQoL changes and their associations with variations in specific extrahepatic organs/systems.

Metabolic Syndrome Trajectories and Objective Physical Performance in Mid-to-Early Late Life: The Study of Women's Health Across the Nation (SWAN)

BACKGROUND

Little is known about how adverse, midlife metabolic profiles affect future physical functioning. We hypothesized that a higher number of midlife metabolic syndrome (MetS) components are associated with poorer physical performance in early old age for multiethnic women.

METHODS

MetS status from 1996 to 2011 (8 visits) and objective physical performance in 2015/2016 (Short Physical Performance Battery [SPPB; 0-12], 40-foot walk [meter/second], 4-meter gait speed [meter/second], chair stands [seconds], stair climb [seconds]) were assessed in the Study of Women's Health Across the Nation (SWAN; n = 1722; age 65.4 ± 2.7 years; 26.9% African American, 10.1% Chinese, 9.8% Japanese, 5.5% Hispanic). Poisson latent class growth modeling identified MetS component trajectory groups: none (23.9%), 1 = low-MetS (28.7%), 2 = mid-MetS (30.9%), and ≥3 = high-MetS (16.5%). Adjusted linear regression related MetS groups to physical performance outcomes.

RESULTS

High-MetS versus none had higher body mass index, pain, financial strain, and lower physical activity and self-reported health (p < .0001). Compared with White, African American and Hispanic women were more likely to be in the high-MetS groups and had worse physical functioning along with Chinese women (SPPB, chair stand, stair climb, and gait speed-not Hispanic). After adjustments, high-MetS versus none demonstrated significantly worse 40-ft walk (β: -0.08; 95% CI: -0.13, -0.03), gait speed (β: -0.09; 95% CI: -0.15, -0.02), SPPB (β: -0.79; 95% CI: -1.15, -0.44), and chair stands (β: 0.69; 95% CI: 0.09, 1.28), but no difference in stair climb.

CONCLUSIONS

Midlife MetS groups were related to poor physical performance in early old age multiethnic women. Midlife management of metabolic function may improve physical performance later in life.

GDS score as screening tool to assess the risk of impact of chronic conditions and depression on quality of life in hospitalized elderly patients in internal medicine wards

Aging of population is characterized by multiple chronic conditions in the same individual. Health-related quality of life (HR-QOL) reflects the multidimensional impact of chronic disease on population and it is increasingly analysed as outcomes.The aim of this study was the evaluation of the predictors of quality of life among elderly patients hospitalized in internal medicine ward, investigating the effect of comorbidities on health-related quality of life.Data collected in this cross-sectional study were analysed. Socio-demographic, clinical characteristics, disease distribution and quality of life by the 12-Item Short Form Health Survey (SF-12) were evaluated.Of 240 inpatients, subjects with Barthel Index (BI)≤40 were 23.7%, 55% had a Geriatric Depression Scale (GDS)≥2. After categorizing mental component score (MCS) and physical component score (PCS) in five classes, we found that diabetics and patients with cancer were more frequent in the first class of MCS while patients with NYHA III-IV are significantly more frequent in the first class of PCS. When we classified patients according to GDS≥2 or < 2, subjects with GDS≥2 had BI and MCS significantly lower. In the multivariate analysis GDS score ≥2 was independently associated with first MCS class [16.32 (3.77-70.68)] while NYHA III-IV class and claudicatio intermittents were strong predictors of the worst PCS class [9.54 (1.97-47.40), 2.53 (1.16-5.49), respectively]. Liver disease was independently associated with GDS≥2 [5.26 (1.13-24.39)].Our study highlighted the impact of chronic diseases on health-related quality of life in elderly subjects hospitalized in an internal medicine ward pointing out the importance of taking into account patient's needs and perception and the setting up of a personalised health-care. Patients with diabetes and liver disease along with persons affected by cancer need psychological support to improve their quality of life. A GDS score ≥ 2 is a strong predictor of poor quality of life and should trigger an in-depth assessment of mental health in this kind of patients.

The PROMISⓇ-Plus-Osteoarthritis of the Knee (OAK) profile measure integrates generic and condition-specific content to enhance relevance and efficiency

OBJECTIVE

The Patient-Reported Outcomes Measurement Information System (PROMIS)-Plus-Osteoarthritis of the Knee (OAK) profile integrates universal PROMIS items with knee-specific items across 13 domains. We evaluated the psychometric properties of a subset of six domains associated with quality of life in people with OAK.

STUDY DESIGN AND SETTING

In a cross-sectional study of OAK patients (n=600), we estimated reliability using Pearson and Spearman correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and known-groups validity with PROMIS Global Health. Measure responsiveness was tested via paired t-tests in a longitudinal study (n=238), pre/post total knee replacement.

RESULTS

Across the six domains, internal consistency reliability (Cronbach's alpha) was 0.77-0.95 and test-retest reliability (intraclass correlation coefficients) was ≥0.90. Correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and PROMIS Global supported convergent and divergent validity. Known-groups validity testing revealed better scores in all domains for high vs. low global status groups, and knee-specific items added value in physical function and pain. All domains reflected (p<0.001) better health status scores at follow up.

CONCLUSION

The six PROMIS-Plus-OAK profile domains demonstrated good psychometric characteristics. The measure integrates universal and knee-specific content to provide enhanced relevance, measurement precision and efficient administration for patient care and clinical research.

Quality of life and mortality in the general population: a systematic review and meta-analysis

BACKGROUND

Quality of life (QoL) is multi-dimensional concept of an individual' general well-being status in relation to their value, environment, cultural and social context in which they live. This study aimed to quantitatively synthesise available evidence on the association between QoL and mortality in the general population.

METHODS

An electronic search was conducted using three bibliographic databases, MEDLINE, EMBASE and PsycINFO. Inclusion criteria were studies that assessed QoL using standardized tools and examined mortality risk in a non-patient population. Qualitative data synthesis and meta-analyses using a random-effects model were performed.

RESULTS

Of 4184 articles identified, 47 were eligible for inclusion, involving approximately 1,200,000 participants. Studies were highly heterogeneous in terms of QoL measures, population characteristics and data analysis. In total, 43 studies (91.5%) reported that better QoL was associated with lower mortality risk. The results of four meta-analyses indicated that higher health-related QoL (HRQoL) is associated with lower mortality risk, which was consistent for overall HRQoL (HR 0.633, 95% CI: 0.514 to 0.780), physical function (HR 0.987, 95% CI: 0.982 to 0.992), physical component score (OR 0.950, 95% CI: 0.935 to 0.965), and mental component score (OR 0.980, 95% CI: 0.969 to 0.992).

CONCLUSION

These findings provide evidence that better QoL/HRQoL was associated with lower mortality risk. The utility of these measures in predicting mortality risk indicates that they should be considered further as potential screening tools in general clinical practice, beyond the traditional objective measures such as body mass index and the results of laboratory tests.

Health-related quality of life in burning mouth syndrome - a case-control study

Objectives The cardinal symptom of burning mouth syndrome (BMS) is long-lasting pain and comprehensive health-related quality of life (HRQL) assessments may estimate how well patients with BMS live in relation to their health issues. The aims of the study were to explore general and BMS-specific HRQL based on an HRQL model and to compare HRQL in patients with BMS and age-matched controls. Methods For this case-control study 56 female patients with BMS and 56 female controls completed the following: A general questionnaire with Global items for life satisfaction, general health and oral health; General Population-Clinical Outcomes in Routine Evaluation (GP-CORE); Hospital Anxiety and Depression Scale (HADS); and Oral Health Impact Profile-14 (OHIP-14). Patients with BMS completed additional questionnaires which included BMS-problem severity, a global item for ratings of overall severity perceptions measured by visual analog scale (VAS); and BMS-modified Multidimensional Pain Inventory-Swedish version (MPI-S). BMS-modified MPI-S includes the three subscales Pain severity, Interference and Social support. Results Patients with BMS scored worse on all global items, GP-CORE, HADS and OHIP-14 compared to controls and the differences were large. Patients with severe BMS problems, as defined by a median split on BMS-problem severity, scored worse on the BMS-modified MPI-S subscale Pain severity and the difference was large. Conclusions We found clearly impaired general HRQL in patients with BMS compared to controls. For specific HRQL, the severity of pain was worse among patients with higher overall BMS-problem severity. The HRQL model with global ratings together with physical, psychological and social concepts has capacity to increase comparability and validity of studies, however further evaluations of the measures are needed. The HRQL model may be used over time to increase the understanding of different HRQL aspects and their internal relationships. In clinical settings, with an increased knowledge of one´s own distinctive quality of life abilities and restrictions, the patients with BMS can be guided and supported to manage their long-lasting pain. The HRQL model may be an aid toward bridging distinctions between general and oral health to further encourage collaboration between medicine and odontology.

Patients With Peripheral Arterial Disease With Exaggerated Pressor Response Have Greater Ambulatory Dysfunction Than Patients With Lower Pressor Response

We determined whether patients with peripheral arterial disease (PAD) who have either an exaggerated or a negative pressor response during treadmill walking have shorter peak walking time (PWT) and claudication onset time (COT) than patients with a normal pressor response, independent of comorbid conditions. A total of 249 patients were categorized to 1 of 3 groups based on systolic blood pressure (SBP) responses at 2 minutes of treadmill walking (speed = 2 mph, grade = 0%): group 1 (negative pressor response, SBP < 0 mm Hg), group 2 (normal pressor response, SBP 18 mm Hg), and group 3 (exaggerated pressor response, SBP > 18 mm Hg). After adjusting for comorbid conditions, group 3 (exaggerated) had significantly reduced COT (P = .011) and PWT (P = .002) compared to group 2 (normal), while group 1 (negative) and group 2 (normal) were not different. Patients with symptomatic PAD with an increase in SBP > 18 mm Hg after 2 minutes of treadmill walking experience claudication earlier and thus have greater ambulatory dysfunction, compared to patients with PAD with a normal pressor response, whereas patients with PAD with negative pressor response had a similar walking performance. The implication is that the magnitude of pressor response to only 2 minutes of treadmill walking can partially explain the degree of ambulatory dysfunction in patients with PAD.

Statistical validity and reliability of the Persian version of the Western Ontario Meniscal Evaluation Tool (WOMET) according to the COSMIN checklist

BACKGROUND

The Western Ontario Meniscal Evaluation Tool (WOMET) is the only questionnaire available to assess quality of life in patients with isolated meniscal injuries. The aims of this study were to prepare the Persian version of the WOMET (PWOMET) and validate it in Iranian patients with isolated meniscal tears.

METHODS

In the first stage, the English version of WOMET was translated into Persian. Content validity, and qualitative and quantitative (impact score) face validity were tested by specialists and in a sample of 30 patients. In the second stage, PWOMET was assessed for the evaluation of psychometric properties in 100 patients with isolated meniscal injury and 50 healthy people based on the COSMIN checklist. Construct validity was tested based on structural validity (factor analysis) and hypothesis testing. Correlation with the total scores on the SF-36, IKDC and KOOS were used for concurrent criterion validity. Test-retest reliability and internal consistency were calculated using intraclass correlation coefficient (ICC) and Cronbach's alpha, respectively. In addition the standard error of measurement (SEM) and smallest detectable change were calculated. Interpretability was investigated as the ceiling and floor effects and minimal important difference.

RESULTS

The PWOMET had acceptable qualitative face validity and content validity. The impact score (quantitative face validity) was more than 1.5 for all items. For construct validity, structural validity (factor analysis) and hypothesis testing ability were confirmed. Correlations between the PWOMET total score and IKDC, SF-36, KOOS scores were 0.61, 0.54 and 0.63, respectively (p < 0.001), thus confirming concurrent criterion validity. The intraclass correlation coefficient, Cronbach's alpha, SEM and smallest detectable change for the PWOMET were 0.73, 0.89, 9.43 and 26.13, respectively. The PWOMET had no ceiling or floor effects, and minimal important difference was 9.07.

CONCLUSION

The PWOMET provides valid and reliable scores for assessment of the quality of life in patients with isolated meniscal injury.

Physical activity and exercise for older people living with HIV: a protocol for a scoping review

BACKGROUND

Older people living with HIV (OPLWH) are expected to live longer in the era of antiretroviral treatment, but at the same time, they are at risk for developing various health complications as a consequence of a life with the infection, exposure to medications that carry their own toxicity and side effects, and the natural effects of aging on the immune system. Because senescence is an inherent process that can be accelerated by HIV, it is important to identify strategies that can modify this phenomenon. Emerging data suggests that while physical activity and exercise may not have a positive impact on viral replication and on the immune system of people living with HIV, it can elicit improvements in cardiorespiratory fitness, strength, body composition, and overall quality of life. The purpose of this study is to map out empirical evidence on the effects of physical activity and exercise in OPLWH.

METHODS

The scoping review methods will be guided by the framework proposed by the Joanna Briggs Institute guidelines. Literature searches will be conducted in the following electronic databases (from inception onwards): PubMed/MEDLINE, Cochrane Library, and Google Scholar. Peer-reviewed journal papers will be included if they are written in English, involved human participants aged 50 years, and older with HIV and described a measure for physical, mental, or functional status of physical activity/exercise and/or the recommendations in OPLWH. Quantitative, qualitative, and mixed-method studies will be included in order to consider different aspects of measuring the effects of physical activity and exercise (e.g., quality of life, functional status, activities of daily living). Two reviewers will screen all citations and full-text articles. We will abstract data, organize them into themes and sub-themes, summarize them, and report the results using a narrative synthesis. The study methodological quality (or bias) will be appraised using a Mixed Methods Appraisal Tool.

DISCUSSION

The evidence gathered from the selected studies will be discussed in relation to the research questions using a narrative to identify and explore emergent themes. The review will provide a baseline of evidence on exercise and physical activity interventions for OPLWH. It will highlight gaps regarding the use of exercise and physical activity and contribute to the design of an effective intervention approach to the rehabilitation of OPLWH.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (https://osf.io/728kp/).

Microvascular Disease Increases Amputation in Patients With Peripheral Artery Disease

It is estimated that >2 million patients are living with an amputation in the United States. Peripheral artery disease (PAD) and diabetes mellitus account for the majority of nontraumatic amputations. The standard measurement to diagnose PAD is the ankle-brachial index, which integrates all occlusive disease in the limb to create a summary value of limb artery occlusive disease. Despite its accuracy, ankle-brachial index fails to well predict limb outcomes. There is an emerging body of literature that implicates microvascular disease (MVD; ie, retinopathy, nephropathy, neuropathy) as a systemic phenomenon where diagnosis of MVD in one capillary bed implicates microvascular dysfunction systemically. MVD independently associates with lower limb outcomes, regardless of diabetic or PAD status. The presence of PAD and concomitant MVD phenotype reveal a synergistic, rather than simply additive, effect. The higher risk of amputation in patients with MVD, PAD, and concomitant MVD and PAD should prompt aggressive foot surveillance and diagnosis of both conditions to maintain ambulation and prevent amputation in older patients.

Chronic kidney disease attenuates the impact of obesity on quality of life

The impact of obesity on health-related quality of life (HRQoL) in chronic kidney disease (CKD) population has not been elucidated, despite the impairment of HRQoL in the obese among general population. We hypothesized that the impact of obesity on HRQoL might be confounded by impaired renal function in CKD population, and that CKD would attenuate the impact of obesity on HRQoL. To compare the impact of obesity on HRQoL according to kidney function, 17,001 subjects from Korea National Health and Nutrition Examination Survey (2008–2011) were categorized by estimated glomerular filtration rate (eGFR), as follows: group 1, eGFR ≥ 90 mL/min/1.73 m²; group 2, eGFR of 60–89 mL/min/1.73 m²; group 3, eGFR < 60 mL/min/1.73 m². The association between obesity parameters (body mass index, waist circumference and, truncal fat mass) and HRQoL parameters (EQ-5D index and EQ-VAS) were cross-sectionally analyzed. Despite robust correlations between obesity parameters and low EQ-5D index or EQ-VAS in general population, no significant association was observed in group 3 population. Impact of obesity on HRQoL in CKD population was only limitedly observed in the mobility domain of EQ-5D, as mobility limitation was associated with increased body mass index or waist circumference regardless of kidney function. Therefore, the impact of obesity on HRQoL seems significantly attenuated in CKD population, suggesting that the risk of obesity should not be over-estimated in patients with CKD, especially with respect to HRQoL.

Effects of heated water-based versus land-based exercise training on vascular function in individuals with peripheral artery disease

Peripheral artery disease (PAD) is an atherosclerotic disease that is associated with poor vascular function, walking impairment, and reduced quality of life. Land-based exercise therapy (LBET) is frequently recommended to improve walking and reduce symptoms. Recently, evidence has suggested that heated-water exercise therapy (HWET) is an effective intervention for PAD. However, the efficacy of LBET versus HWET in PAD patients had not been elucidated. Therefore, we sought to compare effects of LBET with HWET on cardiovascular function, exercise tolerance, physical function, and body composition in PAD patients. PAD patients (n = 53) were recruited and randomly assigned to a LBET group (n = 25) or HWET group (n = 28). The LBET group performed treadmill walking, whereas the HWET group performed walking in heated water for 12 wk. Leg (legPWV) and brachial-to-ankle arterial stiffness (baPWV), blood pressure (BP), ankle-brachial index (ABI), 6-min walking distance (6MWD), claudication onset time (COT), physical function, and body composition were assessed before and after 12 wk. There were significant group-by-time interactions (P < 0.05) for legPWV, BP, 6MWD, COT, body composition, and resting metabolic rate (RMR). Both groups significantly reduced (P < 0.05) legPWV, BP, and body fat percentage, and HWET measures were significantly lower than LBET measures. Both groups significantly increased 6MWD, COT, and RMR, and HWET group measures were significantly greater than LBET measures. A time effect was noted for baPWV reduction in both groups (P < 0.05). These results suggest that both LBET and HWET improve cardiovascular function, exercise tolerance, and body composition, and HWET showed considerably greater improvements compared with LBET in patients with PAD.NEW & NOTEWORTHY The results of this study reveal for the first time that although land-based exercise therapy is effective for reducing arterial stiffness and blood pressure in patients with peripheral artery disease (PAD), heated-water exercise therapy demonstrates greater benefits on vascular function. The greater improvements in muscular strength, time to onset of claudication, and exercise tolerance after heated-water exercise therapy may have clinical implications for improving quality of life in patients with PAD. The heated-water exercise therapy intervention demonstrated relatively higher exercise training adherence (∼88%) compared with the land-based exercise intervention (∼81%).

Development of a conceptual framework to underpin a health-related quality of life outcome measure in paediatric chronic fatigue syndrome/myalgic encephalopathy (CFS/ME): prioritisation through card ranking

Purpose

Chronic fatigue syndrome (CFS)/myalgic encephalopathy (ME) is relatively common in children and is disabling at an important time in their development. This study aimed to develop a conceptual framework of paediatric CFS/ME using the patient-perspective to ensure that the content of a new outcome measure includes the outcomes most important to young people.

Methods

We developed a child-centred interactive card ranking exercise that included health-related quality of life (HRQoL) outcomes identified from a previous review of the literature as well as qualitative work. Adolescents and their parents selected and ranked the outcomes most important to them and discussed each outcome in further detail. Adolescents were purposively sampled from a single specialist paediatric CFS/ME service in England. Interviews were audio recorded and transcribed verbatim, and thematic framework analysis was used to develop the final conceptual framework.

Results

We interviewed 43 participants in which there are 21 adolescents, 12–17 years of age with mild–moderate CFS/ME and their parents (20 mothers and 2 fathers). ‘Symptoms’, ‘tiredness’, ‘payback and crashing’ and ‘activities and hobbies’ were ranked most important to improve by both children and parents. Children ranked ‘school’ higher than parents and parents ranked ‘mood’ higher than children. A youth- specific CFS/ME conceptual framework of HRQoL was produced that included 4 outcome domains and 11 subdomains: sleep, tiredness, problems concentrating, individual symptoms, fluctuation and payback, daily and general activities, participation in school, leisure and social life, mood, anxiety and self-esteem.

Conclusions

An interactive card ranking exercise worked well for adolescents aged 12–17 to elicit the most important outcomes to them and explore each domain in further detail. We developed a final conceptual framework of HRQoL that forms the basis of a new paediatric patient-reported outcome measure (PROM) in CFS/ME.

Low health-related quality of life is strongly linked to upper extremity impairments in type 1 diabetes with a long duration

PURPOSE

To compare health-related quality of life (HRQOL) in type 1 diabetes and non-diabetic controls and possible links to upper extremity impairments (UEIs). Prevalence of sick-leave and causes were investigated.

MATERIALS AND METHODS

This Swedish population-based case-control study included type 1 diabetes patients <67 years old and with a diabetes duration ≥20 years. Participants completed a postal questionnaire including Short Form 36, and questions regarding UEIs, and sick-leave.

RESULTS

In total, 773 patients, aged 50 ± 10 years (diabetes duration 35 ± 10 years), and 708 non-diabetic controls, aged 54 ± 9 years, completed the study. Patients reported significantly lower HRQOL compared with controls. The difference was greatest for general health, vitality, and bodily pain. Patients with shoulder or hand but not finger impairments scored significantly lower than asymptomatic patients. The prevalence of sick leave was higher in patients vs. controls (23% vs. 9%, p < 0.001), and nearly half cited impairments from back, muscles, or joints as the main reason.

CONCLUSIONS

Health-related quality of life is lower in type 1 diabetes than controls and in patients with shoulder and hand impairments than in asymptomatic. Musculoskeletal impairments (back/muscle/joints) have impact on work ability. Identification of UEIs is important for initiating preventative-, therapeutic-, and rehabilitative interventions.Implications for rehabilitationUpper extremity impairments (UEIs) that are common in type 1 diabetes, and associated with reduced health-related quality of life, should preferably be screened for on a regular basis along with other known diabetes complications.Early identification of UEIs is important to improve health by initiating preventive as well as therapeutic multi-professional rehabilitative interventions.Sick leave is higher in type 1 diabetes than in controls. Musculoskeletal impairments, including the back, muscles, and joints, are a common cause for sick leave warranting further studies.

Impacts of aquatic walking on arterial stiffness, exercise tolerance, and physical function in patients with peripheral artery disease: a randomized clinical trial

Peripheral artery disease (PAD) is an atherosclerotic disease that is associated with attenuated vascular function, cardiorespiratory capacity, physical function, and muscular strength. It is essential to combat these negative effects on health by incorporating lifestyle interventions to slow disease progression, such as exercise. We sought to examine the effects of aquatic walking exercise on cardiovascular function, cardiorespiratory capacity [maximal volume of oxygen consumption (V̇o_2max)], exercise tolerance [6-min walking distance (6MWD)], physical function, muscular strength, and body composition in patients with PAD. Patients with PAD (n = 72) were recruited and randomly assigned to a 12-wk aquatic walking training group (AQ, n = 35) or a control group (CON, n = 37). The AQ group performed walking and leg exercises in waist-to-chest-deep water. Leg arterial stiffness [femoral-to-ankle pulse wave velocity (legPWV)], heart rate (HR), blood pressure (BP), ankle-to-brachial index (ABI), V̇o_2max, 6MWD, physical function, muscular strength, body composition, resting metabolic rate (RMR), and flexibility were measured before and after 12 wk. There were significant group × time interactions (P < 0.05) after 12 wk for legPWV and HR, which significantly decreased (P < 0.05) in AQ, and V̇o_2max, 6MWD, physical function, and muscular strength, which significantly increased (P < 0.05) in AQ, compared with no changes in CON. There were no significant differences (P > 0.05) for BP, ABI, RMR, or flexibility after 12 wk. Interestingly, there was relatively high adherence (84%) to the aquatic walking exercise program in this population. These results suggest that aquatic walking exercise is an effective therapy to reduce arterial stiffness and resting HR and improve cardiorespiratory capacity, exercise tolerance, physical function, and muscular strength in patients with PAD.NEW & NOTEWORTHY The results of this study reveal for the first time that aquatic walking exercise can decrease arterial stiffness and improve exercise tolerance, cardiorespiratory capacity, and muscular strength in patients with peripheral artery disease (PAD). Aquatic walking exercise training demonstrates relatively high exercise adherence in this population. Aquatic walking exercise training may be a useful therapeutic intervention for improving physical function in patients with PAD.

Factor Analysis of the Persian Version of the Voice Disability Coping Questionnaire

INTRODUCTION

Voice disorders can affect the quality of life and coping mechanisms and also coping mechanisms can affect the way in which patients deal with their voice problems. People with voice disorders need to use coping strategies to deal with the problems caused by their voice disorder. The purpose of this study was to examine the psychometric properties and cultural adaptation of the Voice Disability Coping Questionnaire in the Iranian population.

METHODS

The translation and cross-cultural adaptation procedures were performed according to the basic rules and instructions set by the International Quality of Life Assessment Project. Two hundred and forty-eight adults (218 patients with voice disorder and 30 healthy controls) were participated in the study. Face and content validity, clinical validity, and construct validity of the questionnaire were investigated by modern psychometric methods.

RESULTS

Quantitative methods were used to measure content validity and all items were detected applicable. This means that the final version was clear and easy to answer. Clinical validity shows that the Persian version of VDCQ can distinguish between patients and healthy controls (P < 0.001). The construct validity of the VDCQ was tested in a cross-sectional study. The questionnaire was analyzed by exploratory and confirmatory factor analyses. Investigation of initial communality and after extraction of factors by Varimax rotation method showed that the share of items for all items in the questionnaire except item 12, is higher than 0.5. Therefore, item 12 should be removed from the questionnaire (Table 3). Based on the confirmatory factor analysis model, items 2 and 10, whose factor load were less than 0.4, were excluded from the questionnaire (Fig. 1). For reliability the Cronbach's alpha coefficient and ICC were obtained as 0.82 and 0.99, respectively. The results of studying the role of items in the reliability of the VDCQ showed that all items increase internal consistency.

CONCLUSION

Based on modern statistical analysis conducted in this study, the original 15 item questionnaire was reduced to 12 item. The 12 item questionnaire is a valid and reliable tool for quantifying coping strategies in people with voice disorder.

Paclitaxel-Coated Balloons and Eluting Stents: Is There a Mortality Risk in Patients With Peripheral Artery Disease?

Paclitaxel drug-coated balloons and drug-eluting stents became commercially available for the treatment of intermittent claudication in 2015 and 2012, respectively. Both devices demonstrated superiority in limb revascularization compared with non-paclitaxel-coated devices and were rapidly accepted into clinical practice. In a recent systematic review and study-level meta-analysis, Katsanos et al reported a late all-cause mortality signal for patients in the drug-coated balloon and drug-eluting stent arms of randomized clinical trials for both devices. As a result of this safety signal, Vascular InterVentional Advances Physicians (VIVA), a not-for-profit 501c(3) organization, convened the Vascular Leaders Forum on March 1 and 2, 2019, in Washington, DC, to initiate an open and collaborative process of investigation into this finding. The Vascular Leaders Forum brought together 100 stakeholders, including an international group of representatives of cardiovascular medicine, interventional radiology, vascular medicine, and vascular surgery; oncologists; basic scientists; the Food and Drug Administration; the Centers for Medicare and Medicaid Services; and commercial manufacturers of these products. The Vascular Leaders Forum reviewed the natural history of peripheral arterial disease, the use of paclitaxel in peripheral arterial disease and other conditions, the harm signal noted by Katsanos et al, the impact of the methods chosen by Katsanos et al, possible mechanisms of harm, the role of the Food and Drug Administration in a setting like this one, and guidance for clinicians taking care of patients with symptomatic peripheral arterial disease. This document integrates the most current data to help establish an appropriate path forward to understand the risks and benefits associated with these technologies while ensuring the best treatment paradigm for patients.

Construct validity, test-retest reliability, and the ability to detect change of the Canadian Occupational Performance Measure in a spinal cord injury population

Study design

Cross-sectional study.

Objectives

To examine the construct validity and the ability to detect change, of the Italian version of the Canadian Occupational Performance Measure (COPM) in a spinal cord injury (SCI) population.

Settings

Rehabilitation service of the Paraplegic Center of Ostia, Italy.

Methods

Thirty-nine spinal cord injury participants were recruited. The clinimetric properties of the measure were assessed following international guidelines. Cronbach's alpha and the intraclass correlation coefficient were assessed for internal consistency and test-retest reliability, respectively. Construct validity was evaluated, by calculating correlation between COPM and the Spinal Cord Independence Measure (SCIM) through Pearson's correlation coefficient and Spearman's Rho. The ability to detect change was evaluated on the overall sample.

Results

The COPM was shown to be reliable in a spinal cord injury sample with positive and statistically significant results for Cronbach's alpha (0.89) and ICC (0.99 for the performance subtest and 0.98 for the satisfaction subtest). Correlation coefficients did not show a correlation between the COPM total score and the SCIM. The COPM scores improved significantly during in-patient rehabilitation, moreover the mean change between the start of treatment and the end of the therapy as evaluated with the Wilcoxon signed-rank test was -4.25 points for the performance score and -2.96 points for the satisfaction score.

Conclusions

This study showed that the COPM is a reliable tool for assessing SCI clients' perceived performance of daily activities and their satisfaction with their performance.

Vascular Inflammation, Calf Muscle Oxygen Saturation, and Blood Glucose are Associated With Exercise Pressor Response in Symptomatic Peripheral Artery Disease

We determined whether calf muscle oxygen saturation (StO2) and vascular biomarkers of inflammation and oxidative stress were associated with an exercise pressor response during treadmill walking in 179 patients with symptomatic peripheral artery disease (PAD). The exercise pressor response was measured as the change in blood pressure from rest to the end of the first 2-minute treadmill stage (2 mph, 0% grade). There was a wide range in the change in systolic blood pressure (−46 to 50 mm Hg) and in diastolic blood pressure (−23 to 38 mm Hg), with mean increases of 4.3 and 1.4 mm Hg, respectively. In multiple regression analyses, significant predictors of systolic pressure included glucose ( P < .001) and insulin ( P = .039). Significant predictors of diastolic pressure included cultured endothelial cell apoptosis ( P = .019), the percentage drop in exercise calf muscle (StO2; P = .023), high-sensitivity C-reactive protein ( P = .032), and glucose ( P = .033). Higher levels in pro-inflammatory vascular biomarkers, impaired calf muscle StO2 during exercise, and elevated blood glucose were independently associated with greater exercise pressor response in patients with symptomatic PAD. The clinical implication is that exercise and nutritional interventions designed to improve inflammation, microcirculation, and glucose metabolism may also lower blood pressure during exercise in patients with symptomatic PAD.

Disability-based disparity in outpatient health system responsiveness among the older adults in low- to upper-middle-income countries

Health system responsiveness (HSR) has been identified as one of the intrinsic goals of health systems for improvement in health and well-being of population. The HSR deals with the non-medical, legitimate expectations of a population in its interaction with the health system. It becomes essential in case of vulnerable groups like older adults with disability, who are more sensitive and risk-prone to the adversities of healthcare challenges. This paper uses data from the Study on Global Ageing and Adult Health conducted in China, Ghana, India, Mexico, Russia and South Africa during 2007-10 and examines the disability-based disparity in outpatient HSR among the older adults in the above-mentioned countries. Disability and HSR scores have been constructed using Item Response Theory Partial Credit Model. Also, the paper uses bivariate and multivariate analysis and finds that the HSR is significantly and substantially lower among the disabled and severely disabled older adults in all the study countries (except Ghana) as compared with those older adults who are not (or mildly) suffering from any form of disability. The policy efforts in the studied countries should focus on monitoring and reducing these disparities for improving HSR in order to make it inclusive.

Confirmatory Factor Analysis of the Disablement in the Physically Active Scale and Preliminary Testing of Short-Form Versions: A Calibration and Validation Study

CONTEXT

The Disablement in the Physically Active (DPA) scale is a patient-reported outcome instrument recommended for use in clinical practice and research. Analysis of the scale has indicated a need for further psychometric testing.

OBJECTIVE

To assess the model fit of the original DPA scale using a larger and more diverse sample and explore the potential for a short-form (SF) version.

DESIGN

Observational study.

SETTING

Twenty-four clinical settings.

PATIENTS OR OTHER PARTICIPANTS

Responses were randomly split into 2 samples: sample 1 (n = 690: 353 males, 330 females, and 7 not reported; mean age = 23.1 ± 9.3 years, age range = 11-75 years) and sample 2 (n = 690: 351 males, 337 females, and 2 not reported; mean age = 22.9 ± 9.3 years, age range = 8-74 years). Participants were physically active individuals who were healthy or experiencing acute, subacute, or persistent musculoskeletal injury.

MAIN OUTCOME MEASURE(S)

Confirmatory factor analysis was conducted to assess the factor structure of the original DPA scale. Exploratory factor, internal consistency, covariance modeling, correlational, and confirmatory factor analyses were conducted to assess potential DPA scale SFs.

RESULTS

The subdimensions of the disablement construct were highly correlated (≥0.89). The fit indices for the DPA scale approached recommended levels, but the first-order correlational values and second-order path coefficients provided evidence for multicollinearity, suggesting that clear distinctions between the disablement subdimensions cannot be made. An 8-item, 2-dimensional solution and a 10-item, 3-dimensional solution were extracted to produce SF versions. The DPA SF-8 was highly correlated (r = 0.94, P ≤ .001, R² = 0.88) with the DPA scale, and the fit indices exceeded all of the strictest recommendations. The DPA SF-10 was highly correlated (r = 0.97, P ≤ .001, R² = 0.94) with the DPA scale, and its fit indices values also exceeded the strictest recommendations.

CONCLUSIONS

The DPA SF-8 and SF-10 are psychometrically sound alternatives to the DPA scale.

Home-based aerobic exercise in patients with lacunar stroke: Design of the HITPALS randomized controlled trial

Background

The effects of physical exercise in patients with lacunar stroke, seem promising in secondary prevention and only few studies have investigated the effect of high-intensity interval training in patients with lacunar stroke. This study will be investigating whether high-intensity interval training improves cardiovascular fitness as well as cognitive- and endothelial function and potentially attenuating the risk of recurrent stroke.

Methods

A randomized controlled trial evaluating 12 weeks of home-based, high-intensity interval training compared with usual care. The intervention group will be exercising 15 min a day, 5 days a week, for 12 weeks. Outcomes will be evaluated at baseline, three, six and twelve months post-stroke with ‘The Graded Cycling Test with Talk Test’ as the primary outcome registered as power output in Watts. Additionally, an annually register-based follow-up will be performed for 5 years from date of inclusion with a composite endpoint of cardiovascular disease or death. Secondary outcomes will be: physical activity, endothelial response, mental well-being, cognition, mood, fatigue, stress, and MRI scan.

Discussion

This study is going to show if early initiated home-based high-intensity interval training is feasible and effective in patients with lacunar stroke. A self-chosen aerobic exercise modality allows a realistic implementation of practice, together with greater chance of long-term adherence. A limitation of the study is that recruitment bias cannot be ruled out, as there may be a preferential enrolment of patients who are self-motivated to engage in exercise.

Psychometric testing of the Norwegian Diabetes Health Profile (DHP-18) in patients with type 1 diabetes

OBJECTIVE

The Diabetes Health Profile-18 (DHP-18) was developed to measure disease-specific health-related quality of life. It has been translated into Norwegian but remains invalidated. The purpose of this paper was to examine the psychometric properties of the Norwegian DHP-18.

RESEARCH DESIGN AND METHODS

Participants with type 1 diabetes were recruited from three outpatient clinics in Norway. Clinical and sociodemographic data were collected, and participants completed the DHP-18 and the Short-Form 36 (SF-36). Descriptive analysis, frequencies, t-tests and the chi-squared tests were used. Principal axis factoring (PAF) and confirmatory factor analysis (CFA) were used. Convergent validity was tested using Spearman's correlation between the DHP-18 and SF-36. Reliability was tested using Cronbach's alpha and intraclass correlation coefficient.

RESULTS

In total, 288 patients were included. No floor and ceiling effects were found. A forced PAF analysis revealed that three questions had an eigenvalue below 0.40. In the unforced PAF analysis, one question loaded below 0.40, while three questions loaded into a fourth factor. The correlation between the DHP-18 and SF-36 dimensions was low to moderate. Problematic internal consistency was observed for the disinhibited eating dimension in the forced PAF and in the suggested fourth dimension in the unforced PAF. CFA revealed poor fit. The test-retest reliability displayed good to excellent values, but responsiveness was limited.

CONCLUSIONS

Problematic issues were identified regarding factor structure, item loadings, internal consistency and responsiveness. Further evaluation of responsiveness is particularly recommended, and using a revised 14-item DHP version is suggested.

Predictors of health-related quality of life in patients with symptomatic peripheral artery disease

OBJECTIVE

The aim of this study was to identify predictors of baseline measures of health-related quality of life (HRQoL) in symptomatic patients with peripheral artery disease (PAD) from objective markers of severity of PAD, clinical and demographic characteristics, comorbid conditions, cardiovascular risk factors, objectively measured physical activity, and patient-based measures of physical function.

METHODS

HRQoL measurements of 216 symptomatic men and women with PAD were assessed with the Medical Outcomes Study 36-Item Short Form Health Survey. Patients were further characterized on demographic variables, comorbid conditions, cardiovascular risk factors, ankle-brachial index, peak walking time during a maximal treadmill test, 6-minute walk distance, gait speed, ambulatory activity monitored during 1 week, activities of daily living (ADLs), Mini-Mental State Examination questionnaire, and Walking Impairment Questionnaire (WIQ).

RESULTS

For the physical function HRQoL subscale, the significant predictors included WIQ speed score (P < .001), history of stumbling (P < .001), WIQ stair climbing score (P < .001), ADL associated with bathing (P = .001), 6-minute walk distance (P = .004), and daily walking cadence (P = .043). For the role emotional function HRQoL subscale, the significant predictors included a history of stumbling (P < .001), the ADL associated with transferring from a bed to a chair (P < .001), and the WIQ distance score (P = .022).

CONCLUSIONS

Physical and mental subscales of HRQoL in symptomatic patients with PAD are primarily predicted by patient-based physical function rather than by more specific markers of PAD severity and comorbid conditions. The clinical significance is that interventions designed to improve HRQoL should focus on improving the quality of executing functional tasks, such as walking more steadily without stumbling; completing ADLs that are not specific to walking, such as bathing and transferring; and improving patient-based ability to walk various distances and speeds and to climb stairs.

Greater Exercise Pressor Response Is Associated With Impaired Claudication Outcomes in Symptomatic Peripheral Artery Disease

We determined whether a greater exercise pressor response during a constant-load treadmill test was associated with lower peak walking time (PWT) and claudication onset time (COT) measured during a graded maximal treadmill test in 304 patients with symptomatic peripheral artery disease (PAD). The exercise pressor response was assessed by measuring heart rate and blood pressure (BP) at rest and during a constant-load treadmill test (speed = 2 mph, grade = 0%). After only 2 minutes of walking, mean heart rate increased by 26 beats/min from rest and mean systolic BP increased by 16 mm Hg. In adjusted analyses, increases in systolic BP (P = .021), heart rate (P = .002), mean arterial pressure (P = .034), and rate-pressure product (P < .001) from rest to 2 minutes of constant-load exercise were negatively associated with COT. Similarly, increases in heart rate (P = .012) and rate-pressure product (P = .018) from rest to 2 minutes of constant-load exercise were negatively associated with PWT. A greater exercise pressor response observed after only 2 minutes of walking at no incline was independently associated with impaired claudication outcomes in patients with symptomatic PAD. The implication is that the exercise pressor response is an important and easily obtained clinical measurement that partially explains differences in PWT and COT.

Physical Activity Intensity Among Adolescents and Association With Parent-Adolescent Relationship and Well-Being

Participation in physical activity (PA) provides young people significant health benefits, including improved well-being. However, large percentages of children and adolescents do not meet the recommendations for PA. Given that PA patterns are established during childhood and adolescence, and evolve within the context of the family, the current study explores the relationship between perceived parent–adolescent relationships and adolescents’ PA levels, body mass index (BMI), and subjective well-being. The study was conducted in Israel, and the sample included 233 participants (126 girls, 107 boys) aged 13 to 18 years.

Participants self-reported the following measures: demographic information, BMI, the Godin-Shephard Leisure-Time Physical Activity Questionnaire, the Personal Well-Being Index, and parent–adolescent relationship. The data were analyzed using Pearson analyses, t tests, and regressions. A clear difference emerged in strenuous PA activity by sex [t(₂₂₃) = 2.1, p < .01]; the average strenuous PA was greater for boys (M = 3.9, SD = 2.4) than for girls (M = 1.8, SD = .2.4). Furthermore, different predictors of strenuous PA by sex were found: for boys, parent–adolescent relationship was a significant predictor; for girls, subjective well-being was a predictor. The findings can shed light on the need for different intervention programs for adolescent boys and girls to increase their involvement in PA.

Minimal clinically important differences in treadmill, 6-minute walk, and patient-based outcomes following supervised and home-based exercise in peripheral artery disease

We estimated minimal clinically important differences (MCIDs) for small, moderate, and large changes in measures obtained from a standardized treadmill test, a 6-minute walk test, and patient-based outcomes following supervised and home-based exercise programs in symptomatic patients with peripheral artery disease (PAD). Patients were randomized to either 12 weeks of a supervised exercise program ( n=60), a home-based exercise program ( n=60), or an attention-control group ( n=60). Using the distribution-based method to determine MCIDs, the MCIDs for small, moderate, and large changes in peak walking time (PWT) in the supervised exercise group were 38, 95, and 152 seconds, respectively, and the changes in claudication onset time (COT) were 35, 87, and 138 seconds. Similar MCID scores were noted for the home-based exercise group. An anchor-based method to determine MCIDs yielded similar patterns of small, moderate, and large change scores in PWT and COT, but values were 1-2 minutes longer than the distribution approach. In conclusion, 3 months of supervised and home-based exercise programs for symptomatic patients with PAD results in distribution-based MCID small, moderate, and large changes ranging from 0.5 and 2.5 minutes for PWT and COT. An anchor-based approach yields higher MCID values, ranging from a minimum of 73 seconds for COT to a maximum of 4 minutes for PWT. The clinical implication is that a goal for eliciting MCIDs in symptomatic PAD patients through a walking exercise intervention is to increase PWT and COT by up to 4 minutes, which corresponds to two work stages during the standardized progressive treadmill test.

Association between health status and sociodemographic, clinical and treatment disparities in the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry

Patients with peripheral artery disease (PAD) and intermittent claudication (IC) have impaired functional status and quality of life. However, little is known about which factors are associated with poorer health status at the time of initial presentation for PAD specialty care. Characterization of such features might provide insight into disparities that impact health status in this population. A total of 1258 patients from the United States, the Netherlands and Australia with new or worsened IC were enrolled at their first PAD specialty care visit between June 2011 and December 2015. The mean Peripheral Artery Questionnaire (PAQ) Summary Score (range 0–100), a disease-specific health status measure, was 49.2 ± 21.9. Hierarchical, multivariable linear regression was used to relate patient characteristics to baseline PAQ. Patient characteristics independently associated with poorer health status were age ( p < 0.001), female sex ( p < 0.001), not being married ( p = 0.02), economic burden (moderate/severe vs none, moderate/severe vs some; p = 0.03), difficulty getting care (moderate/severe vs none, moderate/severe vs some; p < 0.001), chronic lung disease ( p = 0.02), back pain ( p < 0.001), bilateral vs unilateral PAD ( p = 0.02), intermittent claudication severity (moderate vs mild, severe vs mild, p < 0.001), and lack of prior participation in an exercise program ( p = 0.005). Disparities in both vascular and non-vascular factors were associated with patients’ health status at the time of presentation and should be addressed by all who care for patients with vascular disease.

Preventive therapy with citalopram added to a beta blocker does not result in quality-of-life improvement in patients with episodic migraine

Background:

The quality of life of migraine patients, particularly mental domains, is severely diminished despite the preventive therapies available. We aimed to evaluate whether citalopram plus nadolol is superior to nadolol alone in terms of quality of life (QOL) in migraine patients.

Methods:

Adult patients with episodic migraine (≥ 3 headache days per month) were allocated by simple randomization to nadolol 40 mg daily plus citalopram 10 mg daily or to nadolol alone. Baseline visit confirmed the entry criteria and patients filled out a generic QOL (SF-36) as well a migraine-specific questionnaire (MSQoL), a measure of migraine-related disability (MIDAS), a headache calendar and Beck inventory for depression and anxiety. This battery was again completed after 16 weeks of therapy.

Results:

A total of 92 patients from a general neurology clinic completed the study, 85% females with migraine without aura. Fourty-four (47.83%) patients were allocated to nadolol therapy, and 48 (52.17%) to the combination of nadolol plus citalopram. After therapy, both groups had a similar gain in quality of life (SF-36 and MSQOL), but combination therapy was not superior to nadolol. Despite this improvement, all SF-36 domains remained below the population norms in both groups.

Conclusion:

Adding systematically citalopram 10 mg daily to a conventional migraine preventive drug (nadolol) does not result in an additional improvement in the QOL of migraine patients.

A systematic review of the application of Wilson and Cleary health-related quality of life model in chronic diseases

Background

A conceptual model approach to clarify the elements of health-related quality of life (HRQL), their determinants and causal pathways is needed to aid researchers, health practitioners and policy makers in their bid to improve HRQL outcomes in patients. The aim of this systematic review was to appraise empirical evidence on the performance of the Wilson and Cleary Model of HRQL.

Methods

We conducted a search of MEDLINE, Science Direct, PsyARTICLES and CINAHL databases to identify articles that used Wilson and Cleary model to examine HRQL in chronic diseases. A narrative synthesis was employed in the review of the articles.

Results

Evidence supports linkages between adjacent concepts and between non-adjacent concepts of the Wilson and Cleary model indicating that in practice there is a need to examine relationships among constructs - or to consider interventions in terms of - both with and without mediators. Symptoms status has the highest magnitude of relative impact on health-related quality of life.

Conclusion

The Wilson and Cleary model demonstrated good features suitable for evaluating health-related quality of life in chronic diseases.

Methods to Develop the Eye-tem Bank to Measure Ophthalmic Quality of Life

PURPOSE

There is an increasing demand for high-standard, comprehensive, and reliable patient-reported outcome (PRO) instruments in all the disciplines of health care including in ophthalmology and optometry. Over the past two decades, a plethora of PRO instruments have been developed to assess the impact of eye diseases and their treatments. Despite this large number of instruments, significant shortcomings exist for the measurement of ophthalmic quality of life (QoL). Most PRO instruments are short-form instruments designed for clinical use, but this limits their content coverage often poorly targeting any study population other than that which they were developed for. Also, existing instruments are static paper and pencil based and unable to be updated easily leading to outdated and irrelevant item content. Scores obtained from different PRO instruments may not be directly comparable. These shortcomings can be addressed using item banking implemented with computer-adaptive testing (CAT). Therefore, we designed a multicenter project (The Eye-tem Bank project) to develop and validate such PROs to enable comprehensive measurement of ophthalmic QoL in eye diseases.

METHODS

Development of the Eye-tem Bank follows four phases: Phase I, Content Development; Phase II, Pilot Testing and Item Calibration; Phase III, Validation; and Phase IV, Evaluation.

CONCLUSIONS/DISCUSSION

This project will deliver technologically advanced comprehensive QoL PROs in the form of item banking implemented via a CAT system in eye diseases. Here, we present a detailed methodological framework of this project.

Quality of Life and Awareness of Cardiac Rehabilitation Program in People With Cardiovascular Diseases

Objective

To evaluate the level of health-related quality of life (HRQoL), life satisfaction, and their present awareness of cardiac rehabilitation (CR) program in people with cardiovascular diseases.

Methods

A questionnaire survey was completed by 53 patients (mean age, 65.7±11.6 years; 33 men and 20 women) with unstable angina, myocardial infarction, or heart failure. The questionnaire included the Medical Outcome Study 36-item Short-Form Health Survey (MOS SF-36), life domain satisfaction measure (LDSM), and the awareness and degree of using CR program.

Results

The average scores of physical component summary (PCS) and mental component summary (MCS) were 47.7±18.5 and 56.5±19.5, respectively. There were significant differences in physical role (F=4.2, p=0.02), vitality (F=10.7, p<0.001), mental health (F=15.9, p<0.001), PCS (F=3.6, p=0.034), and MCS (F=11.9, p<0.001) between disease types. The average LDSM score was 4.7±1.5. Age and disease duration were negatively correlated with multiple HRQoL areas (p<0.05). Monthly income, ejection fraction, and LDSM were positively correlated with several MOS SF-36 factors (p<0.05). However, the number of modifiable risk factors had no significant correlation with medication. Thirty-seven subjects (69.8%) answered that they had not previously heard about CR program. Seventeen patients (32.1%) reported that they were actively participating in CR program. Most people said that a reasonable cost of CR was less than 100,000 Korean won per month.

Conclusion

CR should focus on improving the physical components of quality of life. In addition, physicians should actively promote CR to cardiovascular disease patients to expand the reach of CR program.

Montreal Accord on Patient-Reported Outcomes (PROs) use series - Paper 5: patient-reported outcomes can be linked to epidemiologic measures to monitor populations and inform public health decisions

BACKGROUND

A comprehensive picture of population health status can be captured by the incorporation of patient-reported outcome measures into population health monitoring.

OBJECTIVE

The aim of the study was to identify the current state, opportunities, and future research related to the utilization of patient-reported outcome measures for population health monitoring in Canada.

DISCUSSIONS

Patient-reported outcome measures can help to identify community health needs in public health topics including injury, chronic disease, and communicable disease. They are currently collected in major national surveys in Canada, while electronic medical records, personal health records, and online patient communities could facilitate rapid and cost-effective collection of population-based data. Their effective use requires well-validated measurements and consideration to the factors affecting validity and reproducibility and the modes of administering questionnaires. Methodologically, relevant public health application of patient-reported outcome measures includes analysis assessing measurement comparability across sociodemographically and clinically diverse population and the influence of physical and social environment. Research is needed to develop and apply analytical methods, harmonize patient-reported outcome measures across data sources and health jurisdictions, and link these measures to traditional epidemiologic indicators. Achieving these goals will benefit from collaboration among governmental agencies and expert groups.