Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Incidence of herpes zoster, 1997-2002

We estimated age-specific herpes zoster (HZ) incidence rates in the Kaiser Permanente Northwest Health Plan (KPNW) during 1997-2002 and tested for secular trends and differences between residents of two states with different varicella vaccine coverage rates. The cumulative proportions of 2-year-olds vaccinated increased from 35% in 1997 to 85% in 2002 in Oregon, and from 25% in 1997 to 82% in 2002 in Washington. Age-specific HZ incidence rates in KPNW during 1997-2002 were compared with published rates in the Harvard Community Health Plan (HCHP) during 1990-1992. The overall HZ incidence rate in KPNW during 1997-2002 (369/100,000 person-years) was slightly higher than HCHP's 1990-1992 rate when adjusted for age differences. For children 6-14 years old, KPNW's rates (182 for females, 123 for males) were more than three times HCHP's rates (54 for females, 39 for males). This increase appears to be associated with increased exposure of children to oral corticosteroids. The percentage of KPNW children exposed to oral corticosteroids increased from 2.2% in 1991 to 3.6% in 2002. Oregon residents had slightly higher steroid exposure rates during 1997-2002 than Washington residents. There were significant increases in HZ incidence rates in Oregon and Washington during 1997-2002 among children aged 10-17 years, associated with increased exposure to oral steroids.

Patient-based outcome results from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice

BACKGROUND

Shared decision-making (SDM) between professionals and patients is increasingly advocated from ethical principles. Some data are accruing about the effects of such approaches on health or other patient-based outcomes. These effects often vary substantially between studies.

OBJECTIVE

Our aim was to evaluate the effects of training GPs in SDM, and the use of simple risk communication aids in general practice, on patient-based outcomes.

METHODS

A cluster randomized trial with crossover was carried out with the participation of 20 recently qualified GPs in urban and rural general practices in Gwent, South Wales. A total of 747 patients with known atrial fibrillation, prostatism, menorrhagia or menopausal symptoms were invited to a consultation to review their condition or treatments. After baseline, participating doctors were randomized to receive training in (i) SDM skills; or (ii) the use of simple risk communication aids, using simulated patients. The alternative training was then provided for the final study phase. Patients were randomly allocated to a consultation during baseline or intervention 1 (SDM or risk communication aids) or intervention 2 phases. A randomly selected half of the consultations took place in 'research clinics' to evaluate the effects of more time for consultations, compared with usual surgery time. Patient-based outcomes were assessed at exit from consultation and 1 month follow-up. These were: COMRADE instrument (principal measures; subscales of risk communication and confidence in decision), and a range of secondary measures (anxiety, patient enablement, intention to adhere to chosen treatment, satisfaction with decision, support in decision making and SF-12 health status measure). Multilevel modelling was carried out with outcome score as the dependent variable, and follow-up point (i.e. exit or 1 month later for each patient), patient and doctor levels of explanatory variables.

RESULTS

No statistically significant changes in patient-based outcomes due to the training interventions were found: COMRADE risk communication score increased 0.7 [95% confidence interval (CI) -0.92 to 2.32] after risk communication training and 0.9 (95% CI -0.89 to 2.35) after SDM training; and COMRADE satisfaction with communication score increased by 1.0 (95% CI -1.1 to 3.1) after risk communication, and decreased by 0.6 (95% CI 2.7 to -1.5) after SDM training. Patients' confidence in the decision (2.1 increase, 95% CI 0.7-3.5, P < 0.01) and expectation to adhere to chosen treatments (0.7 increase, 95% CI 0.04-1.36, P < 0.05) were significantly greater among patients seen in the research clinics (when more time was available) compared with usual surgery time. Most outcomes deteriorated between exit and 1 month later. There was no interaction between intervention effects.

CONCLUSION

Patients can be more involved in treatment decisions, and risks and benefits of treatment options can be explained in more detail, without adversely affecting patient-based outcomes. SDM and risk communication may be advocated from values and ethical principles even without evidence of health gain or improvement in patient-based outcomes, but the resources required to enhance these professional skills must also be taken into consideration. These data also indicate the benefits of extra consultation time.

Public attitudes towards the use of primary care patient record data in medical research without consent: a qualitative study

OBJECTIVES

Recent legislative changes within the United Kingdom have stimulated professional debate about access to patient data within research. However, there is currently little awareness of public views about such research. The authors sought to explore attitudes of the public, and their lay representatives, towards the use of primary care medical record data for research when patient consent was not being sought.

METHODS

49 members of the public and four non-medical members of local community health councils in South Wales, UK gave their views on the value and acceptability of three current research scenarios, each describing access to data without patient consent.

RESULTS

Among focus group participants, awareness of research in primary care was low, and the appropriateness of general practitioners as researchers was questioned. There was general support for research but also concerns expressed about data collection without consent. These included lack of respect and patient control over the process. Unauthorised access to data by external agencies was a common fear. Current data collection practices, including population based disease registers elicited much anxiety. The key informants were equally critical of the scenarios and generally less accepting.

CONCLUSIONS

This exploratory study has highlighted a number of areas of public concern when medical records are accessed for research without patient consent. Public acceptability regarding the use of medical records in research cannot simply be assumed. Further work is required to determine how widespread such views are and to inform those advising on confidentiality issues.

Comparison of patient satisfaction after redo and primary fundoplications

BACKGROUND

Although much has been written about the results and patient satisfaction with fundoplication for the treatment of gastroesophageal reflux disease, the reports have focused primarily on surgical successes. With the growing number of fundoplications being performed, more patients are requiring reoperation because of recurrent symptoms or side effects. Reports of success rates for reoperation are available, but information regarding patient satisfaction is limited.

METHODS

All the patients undergoing fundoplication at our institution were sent short-form health surveys (SF-12), Gastroesophageal reflux disease-specific quality-of-life questionnaires (QOLRAD), and queries regarding long-term satisfaction.

RESULTS

Between November 1992 and July 2000, 221 patients (198 primary and 23 redo) underwent fundoplication. There were 19 open cases (3 primary and 16 redo). In the primary group, 173 patients underwent Nissen, 23 underwent Toupet, and 2 underwent Collis fundoplications. In the redo group, 12 patients underwent Nissen, 9 underwent Toupet, 1 underwent Collis, and l underwent Belsey fundoplications. Follow-up surveys were completed for 130 patients (112 primary and 18 redo) at a mean of 32.6 months (range, 0.8-98 months). In the primary group, 87% of the patients were satisfied with their operation, as compared with 75% in the redo group. There was a trend toward higher SF-12 mental scores (46 +/- 12 vs 40 +/- 14; p = 0.07) and QOLRAD scores (6.2 +/- 1.3 vs 5.2 +/- 2.0; p = 0.07) in the primary fundoplication group. There was a significant difference in the SF-12 physical scores between the groups (32 +/- 13 for the primary group vs 18.5 +/- 11 for the redo group; p = 0.0002). Additionally, 61% of the patients in the redo group were again using antireflux medications, whereas only 24% of the patients in the primary group were using medications again.

CONCLUSION

Gastroesophageal reflux disease symptom scores and quality-of-life scores for patients undergoing redo fundoplication are lower than the scores of patients having primary fundoplication. Quality of life is similar between primary and redo fundoplication patients in the mental component. However, redo patients do not do as well physically more than 2 years after surgery.

First year experience of patients undergoing the Stretta procedure

BACKGROUND

The Stretta procedure is a new, totally endoscopic treatment for GERD, where radiofrequency energy is delivered to the smooth muscle of the gastroesophageal junction.

METHODS

Forty-one patients undergoing the Stretta procedure between August 2000 and August 2001 were prospectively evaluated. Under an IRB-approved protocol, patients were studied preoperatively and postoperatively with esophageal manometry, 24-h pH testing, SF12 surveys, and GERD-specific questionnaires (QOLRAD).

RESULTS

Results are reported as mean +/- SEM. All procedures were performed on an outpatient basis; 33 were under conscious sedation and 8 were under general anesthesia. Prior to treatment, patients had a mean LES pressure of 25 +/- 2.4 mmHg, Johnson-Demeester score of 32.8 +/- 4.6 mmHg, and % time reflux 8.4 +/- 0.9%. The quality-of-life scores were significantly improved at 6 months: QOLRAD score increased from 3.7 +/- 0.2 to 5.1 +/- 0.2 (p = 0.002), SF12 mental score increased from 44.3 +/- 2.0 to 51.8 +/- 1.7 (p = 0.001), and SF12 physical score increased from 26.2 +/- 2.4 to 33.1 +/- 3.8 (p = 0.001). Eighteen patients returned for esophageal manometry and 24-h pH testing at a mean of 6.8 +/- 0.5 months. There was a significant decrease in esophageal acid exposure time (8.4 +/- 0.9% to 4.4 +/- 1.3%, p = 0.03) and Johnson-Demeester score (32.8 +/- 4.6 to 22.9 +/- 5.3, p = 0.04). There was no significant change in mean LES pressure (25.3 +/- 2.4 mmHg to 26.8 +/- 2.6 mmHg, p = 0.63). Twenty of 31 patients (65%) available for 6 months follow-up were completely off proton pump inhibitors. The only complication related to Stretta was a case of gastroparesis 10 days post-operatively that resolved completely.

CONCLUSIONS

The Stretta procedure is a promising new endoscopic treatment for GERD. It significantly improves GERD symptoms and quality of life while eliminating the need for proton pump inhibitors in the majority of patients.

It doesn't cost anything just to ask, does it? The ethics of questionnaire-based research

Patient-based outcome measures are increasingly important in health care evaluations, often through the use of paper-based questionnaires. The likely impact of questionnaires upon patients is not often considered and therefore, the balance of benefit and harm not fully explored. Harms that might accrue for research staff are even less frequently considered. This paper describes the use of postal questionnaires within a study of breast disease management in primary care. Questionnaire responses are used to describe the nature of discomfort or harms that may occur in such studies. Ethical issues raised by the harms are discussed in relation to the benefits of the study. Practical suggestions for reducing harm to patients are proposed. A secondary consideration, discomfort to the researcher, is also identified and suggestions made to reduce its effect. Finally, the role of research questionnaires as a study intervention is discussed.

Multi-disciplinary research can be more than parallel-disciplinary research: the case of GPs' use of magnetic resonance imaging

OBJECTIVES

We aimed to show how in multi-disciplinary research data collected to meet the needs of one discipline can provide information of value to another.

METHODS

Using the critical incident technique, 25 GPs were interviewed about recent scans requested for patients with knee and lumbar spine complaints. Transcripts of the interviews were scrutinized from both a medical and an economic perspective.

RESULTS

Five key economic issues where further research is needed were identified.

CONCLUSIONS

The total value of the information provided by multi-disciplinary research may exceed the sum of the information collected to meet the requirements of the individual disciplines.

An exploration of GPs' use of MRI: a critical incident study

BACKGROUND

Direct access to Magnetic Resonance Imaging (MRI) is becoming available to GPs in the UK, offering major benefits for the improved diagnosis and management of certain clinical conditions. Variations in usage of this service may be large, and effective locally produced guidelines are not currently available. The Department of General Practice is conducting a research programme to develop and evaluate methods to optimize MRI use by GPs.

OBJECTIVES

We aimed to describe the current use of MRI by GPs in South Glamorgan; to summarize their reasons for requesting MRI; and to produce criteria to assess the appropriateness of magnetic resonance (MR) scan requests.

METHODS

Using the critical incident technique, 25 GPs were interviewed about recent scans requested for patients with knee and lumbar spine complaints. A local panel of primary and secondary care doctors was convened to develop criteria for assessing MR scan requests.

RESULTS

Sixty-two scan requests were discussed. Doctors' reasons for requesting MR scans were identified and classified. Reasons for requests included personal, contextual and biomedical variables. Fifteen patients (24%) were managed in primary care following MRI when otherwise they would have been referred. When referrals were made, GPs felt able to reinforce the request and occasionally to direct the patient somewhere more appropriate. The panel reviewed the interview data to produce objective criteria to assess scan requests. The criteria reflect the relative importance of non-biomedical variables in the decision to request MRI.

CONCLUSION

The study identified those reasons which are important to GPs when requesting MR scans and the impact of this new technology upon patient management. Interview data have been used to inform locally developed consensus criteria, which will be made available as practice guidelines as the research programme progresses.

Problems in the diagnosis of foodborne infection in general practice

The incidence of acute gastroenteritis and self suspected food poisoning in general practice populations was compared with consultation rates in four group practices during a 3-month winter period and a 2-month autumn period. The average monthly consultation rate for acute gastroenteritis and self suspected food poisoning was 0.3% and 0.06% respectively. However, over the same period, on average, an estimated 7% of the practice population per month reported an acute gastroenteritis illness, and 0.7% suspected a food poisoning illness. Only about one in 26 people who suffer an acute episode of gastroenteritis consult their general practitioner (GP). In two practices, faecal samples were sought from all patient cases; the isolation rate for salmonellas was 2% (3/191) and for campylobacters it was 12% (23/191). In the other two practices following routine management, the isolation rate for salmonellas was 9% (6/64) and for campylobacters it was 2% (1/64). Isolation of faecal pathogens was not associated with patients' suspicion of food poisoning. A history of eating out in the week before onset was associated with a significantly increased yield of salmonellas and campylobacters.

Overdose and termination of pregnancy: an important association?

Are taking an overdose and undergoing termination of pregnancy linked? In one practice this study has identified a significant association between the two events. If this finding is supported more widely, could one event act as a risk marker for the second?

Screening for fever in an adult emergency department: oral vs tympanic thermometry

The accuracy of tympanic thermometers in clinical practice continues to be questioned. We evaluated the Genius tympanic thermometer in our adult emergency department. All patients had both tympanic and oral temperature measurements. Patients with an oral or tympanic temperature > or = 100.0 degrees F had a rectal temperature taken. Oral and rectal measurements were taken with the IVAC 2080A electronic thermometer, and the Genius thermometer was used in the oral equivalent mode. All instruments were calibrated. Of the 332 patients entered into the study, 51 had oral or tympanic temperatures > or = 100.0 degrees F. Forty-one of these patients consented to a rectal temperature measurement. The correlation (r) between tympanic and oral, tympanic and rectal, and oral and rectal temperature was .845, .853, and .940, respectively. The oral thermometer identified all 28 febrile patients (rectal temperature > or = 100.4 degrees F). However, the tympanic thermometer detected fever in only 19 of these cases. Two patients in whom the tympanic thermometer failed to detect fever had AIDS, and their workup was altered by the detection of the fever. We conclude that the tympanic thermometer is not as sensitive as the oral thermometer in the detection of fever. The use of tympanic thermometers in the adult emergency department should be questioned.

The Temporal Distribution of Seismic Radiation During Deep Earthquake Rupture

The time history of energy release during earthquakes illuminates the process of failure, which remains enigmatic for events deeper than about 100 kilometers. Stacks of teleseismic records from regional arrays for 122 intermediate (depths of 100 to 350 kilometers) and deep (depths of 350 to 700 kilometers) earthquakes show that the temporal pattern of short-period seismic radiation has a systematic variation with depth. On average, for intermediate depth events more radiation is released toward the beginning of the rupture than near the end, whereas for deep events radiation is released symmetrically over the duration of the event, with an abrupt beginning and end of rupture. These findings suggest a variation in the style of rupture related to decreasing fault heterogeneity with depth.

The hematopoietically expressed vav proto-oncogene shares homology with the dbl GDP-GTP exchange factor, the bcr gene and a yeast gene (CDC24) involved in cytoskeletal organization

The vav proto-oncogene encodes a protein of unknown function that is rendered oncogenic by loss of a short N-terminal domain. A correction reported here to the vav sequence reveals that a central domain of some 230 amino acids is similar to the products of three genes: the human dbl oncogene, now known to encode a GDP-GTP exchange factor for the Ras-like polypeptide CDC42Hs; the CDC24 gene of Saccharomyces cerevisiae, which participates with CDC42Sc in organization of the cytoskeleton for budding; and the human bcr gene, which recombines with the abl oncogene in certain forms of leukemia. Furthermore, the N-terminal portion of Vav (and of CDC24) is similar to that of certain proteins that associate with filamentous structures. These similarities suggest that Vav, and perhaps also Bcr, may function as a GDP-GTP exchange factor for a Ras-like molecule such as CDC42Hs, and that its action may coordinate cytoplasmic architecture with the cell cycle. Reported evidence that the vav proto-oncogene is widely expressed in hematopoietic cells but not other cell types is extended here by detection of vav mRNA in 49 of 50 murine hematopoietic cell lines representing diverse hematopoietic lineages, and by in situ hybridization in embryos showing expression confined to the only hematopoietic tissue, fetal liver. Thus, like Dbl in other cell types, Vav may function throughout the hematopoietic compartment to govern a Ras-like signal transduction pathway.

Expression of the X gene of hepatitis B virus

The hepatitis B virus (HBV) genome carries an open reading frame of 462 bases, the X region, but the corresponding protein has yet to be identified as a natural product. In rodent cells cotransformed with the thymidine kinase gene of herpes simplex virus and HBV DNA, however, Gough [1983] identified a mRNA that hybridises uniquely with the X region of the HBV genome. A large fragment of the X region was inserted into plasmid pCL19 delta Y-T in order to produce, in Escherichia coli, the X gene product, HBxAg, as a polypeptide fused to the N-terminal part of the phage lambda cro gene product. Antisera raised against this fused polypeptide gave positive immunofluorescence reactions with the transformed rodent cells. This provides direct evidence for the expression of the HBxAg gene in eukaryotic cells transformed with HBV DNA. The approach used here should be generally applicable.

The digestion of pectin in the human gut and its effect on calcium absorption and large bowel function

1. The effect of dietary fibre digestion in the human gut on its ability to alter bowel habit and impair mineral absorption has been investigated using the technique of metablic balance. 2. Five healthy male students were studied for 9 weeks under controlled dietary conditions and during the last 6 weeks they took 36 g pectin/d. Bowel habit, transit through the gut, faecal fibre excretion, calcium balance and faecal composition were measured. 3. During the control period only 15% of the dietary fibre ingested was excreted in the stools and when pectin was added to the diet there was no increase in fibre excretion. Stool frequency and mean transit time were unchanged by pectin but stool wet weight increased by 33% and faecal excretion increased (%) for fatty acids 80, nitrogen 47, total dry matter 28 and bile acids 35. Ca balance remained unchanged. 4. It may be concluded from these results that dietary fibre is largely metabolized in the human gut and dietary pectin completely so. This could explain its lack of effect on bowel habit and Ca balance. Other changes in the faeces may be related to an increase in bacterial mass.

Influence of diets high and low in animal fat on bowel habit, gastrointestinal transit time, fecal microflora, bile acid, and fat excretion

Epidemiological observations and animal experiments suggest that large bowel cancer is related to serveral factors. Among them, high dietary intakes of animal fat, the presence in the colon of relatively high levels of bile acids, specific patterns of intestinal microflora, slow transit through the gut, and low stool weights. Under metabolic conditions we have observed the effect on these variables of dietes containing 62 or 152 g/day of fat mainly of animal origin in six healthy young men over 4-wk periods. No change attributable to the diet was observed in the subjects' bowel habit, fecal weight, mean transit time through the gut, or in the excretion of dry matter. Total fecal bile acid excretion was significantly higher on the high fat diet (320 +/- 120 mg/day) than on the low fat diet (139.7) +/- 63 mg/day) t test = 7.78 P less than 0.001 as also was the total fecal fatty acid excretion, 3.1+/-0.71 and 1.14+/-0.35 g/day, respectively t test = 11.4 P less than 0.001). The fecal microflora including the nuclear dehydrogenating clostridia were unaltered by the dietary changes as was fecal beta-glucuronidase activity. Dietary changes which increase animal fat intake clearly influence fecal bile acid excretion in a way that would favor the development of large bowel cancer if current theories prove to be true. Dietary fat however has no effect on overall colonic function so other components of the diet must be responsible for the observed associations of bowel cancer with slow transit and reduced fecal bulk.

Colonic response to dietary fibre from carrot, cabbage, apple, bran

Approximately 20 g/day of concentrated dietary fibre from carrot, cabbage, apple, bran, and guar gum was added to the controlled basal diet of nineteen healthy volunteers. Faecal weight increased by 12% on bran, 69% on cabbage, 59% on carrot, 40% on apple, and 20% on guar gum. These changes in faecal weight were correlated with an increased intake of pentose-containing polysaccharides from the fibre. On the basal diet there were pronounced individual differences in faecal weight, and from these the response of subjects to the fibre preparations could be predicted. Addition of fibre shortened mean transit-time through the gut and significantly diluted an inert marker in the faeces. Diet-induced changes in colonic function may explain international differences in the prevalence of colonic disease, whilst personal variation in the response to dietary fibre may determine individual susceptibility to large-bowel disease within a community.

Effectiveness of aides in a perceptual motor training program for children with learning disabilities

A program for children with learning disabilities associated with perceptual deficits was designed that included elements of gross and fine motor coordination, visual and somatosensory perceptual training, dance, art, music and language. The effectiveness of nonprofessional "perceptual-aides," who were trained in this program, was evaluated. Twenty-eight children with learning disabilities associated with perceptual deficits were treated by occupational, physical, recreational and language therapists; and 27 similarly involved children were treated by two aides, under supervision, after training by therapists. Treatment in both groups was for four hours weekly over a four to seven month period. There was significant improvement in motor skills, visual and somatosensory perception, language and educational skills in the two programs. Although there was no significant difference between the two groups, there was a slight advantage to the aide program. The cost of the aide program was 10 percent higher than the therapist program during the first year, but 22 percent lower than the therapist program during the second year.