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Levy J, Lebeaux R, Christensen B, Tosteson T, Bryan Y. Journey across epidemiology's third variables: an anesthesiologist's guide for successfully navigating confounding, mediation, and effect modification. Reg Anesth Pain Med 2021; 46:936-940. [PMID: 34021076 DOI: 10.1136/rapm-2020-101984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/23/2023]
Abstract
Observational clinical research studies aim to assess which exposures (treatments or other factors; independent variable) affect patient outcomes (dependent variable). These exposures include medical interventions in situations where clinical trials are not possible or prior to their conduct and completion. However, the assessment of the relationship between exposures and outcomes is not straightforward, as other variables may need to be considered prior to reaching valid conclusions. Here, we present three hypothetical scenarios in regional anesthesia to review the epidemiological concepts of confounding, mediation, and effect modification. Understanding these concepts is critical for assessing the design, analysis, and interpretation of clinical studies. These terms may be confusing to anesthesiologists and researchers alike, where such confusion could affect the conclusions of a clinical study, mislead the target audience, and ultimately impact patient health.
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Affiliation(s)
- Joshua Levy
- Department of Epidemiology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA .,Program in Quantitative Biomedical Sciences, Dartmouth College Geisel School of Medicine, Hanover, NH, USA.,Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Rebecca Lebeaux
- Department of Epidemiology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,Program in Quantitative Biomedical Sciences, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Brock Christensen
- Department of Epidemiology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,Department of Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, NH, USA.,Department of Community and Family Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Tor Tosteson
- Department of Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,The Dartmouth Institute, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Yvon Bryan
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Kline AD, Calof AL, Lander AD, Gerton JL, Krantz ID, Dorsett D, Deardorff MA, Blagowidow N, Yokomori K, Shirahige K, Santos R, Woodman J, Megee PC, O'Connor JT, Egense A, Noon S, Belote M, Goodban MT, Hansen BD, Timmons JG, Musio A, Ishman SL, Bryan Y, Wu Y, Bettini LR, Mehta D, Zakari M, Mills JA, Srivastava S, Haaland RE. Clinical, developmental and molecular update on Cornelia de Lange syndrome and the cohesin complex: abstracts from the 2014 Scientific and Educational Symposium. Am J Med Genet A 2015; 167:1179-92. [PMID: 25899772 DOI: 10.1002/ajmg.a.37056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/23/2015] [Indexed: 11/08/2022]
Abstract
Cornelia de Lange Syndrome (CdLS) is the most common example of disorders of the cohesin complex, or cohesinopathies. There are a myriad of clinical issues facing individuals with CdLS, particularly in the neurodevelopmental system, which also have implications for the parents and caretakers, involved professionals, therapists, and schools. Basic research in developmental and cell biology on cohesin is showing significant progress, with improved understanding of the mechanisms and the possibility of potential therapeutics. The following abstracts are presentations from the 6th Cornelia de Lange Syndrome Scientific and Educational Symposium, which took place on June 25-26, 2014, in conjunction with the Cornelia de Lange Syndrome Foundation National Meeting in Costa Mesa, CA. The Research Committee of the CdLS Foundation organizes the meeting, reviews and accepts abstracts, and subsequently disseminates the information to the families through members of the Clinical Advisory Board. In addition to the scientific and clinical discussions, there were educationally focused talks related to practical aspects of behavior and development. AMA CME credits were provided by Greater Baltimore Medical Center, Baltimore, MD.
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Affiliation(s)
- Antonie D Kline
- Harvey Institute for Human Genetics, Greater Baltimore Medical Center, Baltimore, Maryland
| | - Anne L Calof
- Department of Anatomy & Neurobiology, and the Center for Complex Biological Systems, University of California, Irvine, California
- Department of Developmental & Cell Biology, and the Center for Complex Biological Systems, University of California, Irvine, California
| | - Arthur D Lander
- Department of Developmental & Cell Biology, and the Center for Complex Biological Systems, University of California, Irvine, California
| | - Jennifer L Gerton
- Stowers Institute for Medical Research, University of Kansas School of Medicine, Kansas City, Missouri
- Department of Biochemistry and Molecular Biology, University of Kansas School of Medicine, Kansas City, Missouri
| | - Ian D Krantz
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Dale Dorsett
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Matthew A Deardorff
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Natalie Blagowidow
- Harvey Institute for Human Genetics, Greater Baltimore Medical Center, Baltimore, Maryland
| | - Kyoko Yokomori
- Department of Biologic Chemistry, University of California, Irvine, California
| | - Katsuhiko Shirahige
- Institute of Molecular and Cellular Biosciences, The University of Tokyo, and CREST, Japanese Science and Technology Agency, Tokyo, Japan
| | - Rosaysela Santos
- Department of Developmental & Cell Biology, and the Center for Complex Biological Systems, University of California, Irvine, California
| | - Julie Woodman
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Denver, Colorado
| | - Paul C Megee
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Denver, Colorado
| | - Julia T O'Connor
- Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alena Egense
- Division of Human Genetics, Department of Pediatrics, University of Maryland Medical Center, Baltimore, Maryland
| | - Sarah Noon
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maurice Belote
- California Deaf-Blind Services, San Francisco State University, San Francisco, California
| | | | - Blake D Hansen
- Department of Counseling Psychology and Special Education, Brigham Young University, Provo, Utah
| | - Jenni Glad Timmons
- University of Minnesota Doctor of Nursing Practice-Health Innovation and Leadership, Minneapolis, Minnesota
| | - Antonio Musio
- Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche, Pisa, Italy
| | - Stacey L Ishman
- Departments of Otolaryngology and Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Yvon Bryan
- Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Yaning Wu
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura R Bettini
- Department of Pediatrics, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Devanshi Mehta
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Musinu Zakari
- Stowers Institute for Medical Research, University of Kansas School of Medicine, Kansas City, Missouri
| | - Jason A Mills
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
OBJECTIVE To develop and validate the Critical Care Family Satisfaction Survey as a proxy for patient satisfaction. DESIGN Instrument validation study. SETTING AND TIME FRAME: The Medical Intensive Care, Shock Trauma, Acute Coronary Care, Central Nervous System, Surgical Intensive Care, and Special Care units of Lehigh Valley Hospital (Allentown, PA), for the period December 1997 through September 1998. PATIENTS/PARTICIPANTS One family member for each of 237 critical care patients. INTERVENTION(S) Content and construct validity were examined on 37 items and 6 constructs thought to measure family satisfaction with the quality of critical care in hospitals. Initially, 14 items and 1 construct were removed from the questionnaire based on this analysis. It was then administered to 237 family members. MEASUREMENTS AND MAIN RESULTS Factor analysis and confirmatory factor analysis using path models were performed. Internal consistency using Pearson correlations and Cronbach's alpha, and discriminant validation were also calculated. Factor analysis yielded a single eigenvalue >1 (3.712), whereas confirmatory factor analysis led to the final instrument being reduced to 20 items and 5 subscale constructs. One subscale ("Comfort") performed poorly, indicating the possible need for a four-factor model. Subsequently, internal consistency assessed by Cronbach's alpha was 0.9101 for the five-factor model and 0.9327 for the four-factor model. Subscale correlations were no lower than 0.750 for the five-factor model and 0.856 for the four-factor model. CONCLUSIONS This study provides support that the Critical Care Family Satisfaction Survey-which yields five subscales, "Assurance," "Information," "Proximity," "Support," and "Comfort"--is reliable and valid. Using five constructs rather than four is recommended because of the following: a) the internal consistency loss of 0.0226 for the "Comfort" subscale is not enough to warrant its removal, b) a four-factor questionnaire can be administered and totaled independently of this subscale, c) the need for the fifth construct is indicated by this study's results, and d) including the extra data may allow for more detailed analysis.
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Affiliation(s)
- T Wasser
- Department of Health Studies, Lehigh Valley Hospital, Allentown, PA 18014, USA
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Pugh LC, Tringali RA, Boehmer J, Blaha C, Kruger NR, Capauna TA, Bryan Y, Robinson J, Belmont D, Young M, Xie S. Partners in care: a model of collaboration. Holist Nurs Pract 1999; 13:61-5. [PMID: 10196904 DOI: 10.1097/00004650-199901000-00010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
It is estimated that 3 million persons in the United States have congestive heart failure. This diagnosis accounts for more than 5% of total health expenditures. A method to decrease the costs of health care was initiated through the partners-in-care model of collaborative practice. A research study exploring the use of nurse case managers in collaboration with cardiologists and primary care physicians is being conducted with persons older than 65 years. This care encompasses both inpatient and outpatient care. The intervention comprises nurse visits in the hospital and in the home as well as telephone support for 6 months after the index hospitalization. The outcomes of quality of life, functional status, mortality, morbidity, and costs are being examined. Collaborative health care partnerships may be an effective strategy to decrease health care costs and improve quality of life and functional status of older persons with congestive heart failure.
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Affiliation(s)
- L C Pugh
- Center for Nursing Research, Penn State Geisinger Health System, Hershey, Pennsylvania, USA
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Grindel CG, Bayley E, Kingston MB, Tuck MB, Wood L, Bryan Y. Nurses preparing for change: their needs and concerns. Medsurg Nurs 1997; 6:278-83, 286-7. [PMID: 9384154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
As a result of decreased lengths of stay and cost-containment initiatives, fewer nurses are needed in acute care settings. The trend for community-based health care is broadening employment opportunities for nurses to work in community settings. As nurses are considering options to base their practice in community settings, it is important to understand their concerns about making this transition. The results of a qualitative study conducted to examine the concerns and educational needs of acute care nurses related to working in the community are reported. Clinical, professional, and intrapersonal skills important for a successful transition to community-based practice are identified and discussed.
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Affiliation(s)
- C G Grindel
- College of Nursing, Northeastern University, Boston, MA, USA
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