Methods to assess dermal exposures in occupational settings: a scoping review

OBJECTIVES

The dermal exposure route is expected to become increasingly significant relative to total worker exposure as inhalational exposure limits continue to decrease. However, standardization of occupational exposure assessment methods and scientific consensus are needed. This is the first scoping review mapping the literature across all dermal exposure assessment methods and their targeted substances/chemicals in occupational settings.

METHODS

Eligibility criteria broadly included studies reporting any noninvasive dermal exposure assessment method in an occupational setting. The literature search (Web of Science and MEDLINE) was restricted to peer-reviewed, primary literature published in the last 20 years (2002-2022). Titles/abstracts were dual independently screened. Data charting was performed by a single reviewer using standard template. All stages were pilot tested. The JBI (formerly, the Joanna Briggs Institute) scoping review methods and PRISMA-ScR checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) were used.

RESULTS

In total, 493 articles were data charted and categorized by 4 study types: methods development (22%), exposure assessment (51%), health outcomes (21%), and controls assessment (6%). Fourteen types of dermal exposure assessment methods were charted with biomarkers (51%), dosimeters (21%), and qualitative assessments such as questionnaires or surveys (17%) most common. Seventeen different chemicals/substances were charted; pesticides (28%) and polycyclic aromatic hydrocarbons (PAHs) (22%) associated with crude oil products and combustion were most common. Mapping between substances and exposure assessment method categories, pesticide dosimeters (11%), and PAH biomarker studies (14%) were most reported. Literature gaps were identified for cleaning agents, hair dyes, glycol ether, N,N-dimethylformamide/N-methyl-2-pyrrolidone, dioxins, and bisphenol A.

CONCLUSIONS

To foster scientific consensus, standardization across study reporting is needed for describing: (i) exposure assessment methods used, (ii) worker tasking/conditions, (iii) targeted substances and substance state, and (iv) targeted exposure routes. Overall, this review categorizes, maps, and defines the scope of literature for occupational dermal exposure assessment methods.

Review of patient-reported outcomes (PROs) and non-PROs in randomized controlled trials addressing head/neck cancers

BACKGROUND

To assess the frequency of patient-reported outcomes (PROs) and non-PROs in randomized controlled trials (RCTs) addressing head/neck cancers.

METHODS

We included RCTs about interventions to treat head/neck cancers. PubMed was searched on September 16, 2022 and included studies published during three periods (2000-2002, 2010-2012, and 2020-2022). Data on types of outcomes and instruments to measure them were extracted and organized into PROs and non-PROs, and temporal trends for reporting outcomes were determined.

RESULTS

There was a reduction in the frequency of non-PROs (40% to 22%) and an increase in PROs (5% to 19%) over 20 years. The frequency of reporting both non-PROs and PROs seemed to be stable over the same period (55% to 58%). A great variety of instruments to measure PROs and non-PROs was identified.

CONCLUSIONS

There has been a growth in the types of PROs in more recent years, and they were more frequently reported in RCTs. However, head/neck cancer trials with a combination of PROs and non-PROs were the most prevalent.

How Does the Breastfeeding Environment Affect Satisfaction? A Scale Development Study

BACKGROUND

Women need a safe and comfortable environment to breastfeed their babies. The quality of breastfeeding environments in social areas is important for women's breastfeeding satisfaction.

AIM

The aim of this study was to develop a measurement tool for the evaluation of breastfeeding environments and to examine the impact of the quality of breastfeeding environments in social areas on breastfeeding satisfaction.

METHOD

The first phase of the study was conducted in methodological design and the second phase in cross-sectional design. The draft scale was applied to 365 women who had breastfeeding experiences in social environments during the postpartum 6 months-3 years period. In the first stage, scale development analyses were applied. In the second stage, the developed scale was applied to 255 women. Frequency, percentage, Cronbach's α coefficient, and correlation analysis were used in the analysis of the data.

RESULTS

The Ideal Breastfeeding Environment Assessment Scale, consisting of 23 items and four subdimensions, was obtained in the study. As a result of the application of the scale in the second stage, the mean score of the breastfeeding environments evaluated by the women was 23.43 ± 8.36. A statistically significant moderate-weak correlation was found between the ideality of breastfeeding environments and the satisfaction levels of women (p < .001).

CONCLUSION

It was determined that the developed scale is a valid and reliable measurement tool that can be used to evaluate breastfeeding environments. As the quality of breastfeeding environments increases, women's breastfeeding satisfaction increases.

Evidence of validity of the Smoking Cessation Counseling scale - Brazilian version

OBJECTIVE

to evaluate the evidence of validity of the internal structure and reliability of the Brazilian version of the Smoking Cessation Counseling instrument.

METHOD

psychometric study of confirmatory factor analysis and reliability carried out on 250 nurses in clinical practice. For the analysis of the convergent validity of the factor model, Average Variance Extracted values were calculated, and discriminant analysis was carried out using the Fornell-Larcker criterion. Reliability was examined using Cronbach's alpha coefficient and composite reliability.

RESULTS

it was necessary to exclude seven items from the Advanced Counseling domain and one item from the Basic Counseling domain in order to properly obtain the Average Variance Extracted values and the Fornell-Larcker criterion. The composite reliability ranged from 0.76 to 0.86 and the overall Cronbach`s alpha coefficient was 0.86, ranging from 0.53 to 0.84 depending on the domain assessed. The final version of the instrument was made up of 16 items divided into 4 domains.

CONCLUSION

the Brazilian version of Smoking Cessation Counseling obtained adequate psychometric evidence of validity and reliability. Further studies are needed to refine the instrument.

BACKGROUND

(1) Instrument shows adequate internal consistency and validity.

BACKGROUND

(2) Evaluate counseling practices and their impact on patient care.

BACKGROUND

(3) Instrument for evaluating smoking cessation counseling.

BACKGROUND

(4) Provides important information for planning nursing care.

Modification of the Public Attitude Towards Vaccination Scale for use in adult vaccines

BACKGROUND

Vaccination is a crucial protective intervention to prevent adult mortality and morbidity. Personal perceptions and resources have an important place in the vaccination decision.

AIM

This study aimed to modify the Public Attitude Towards Vaccination-Health Belief Model scale for adult vaccines and evaluate its psychometric properties.

METHODS

Overall, 626 people participated in this methodological study. Content validity index, confirmatory factor analysis, internal consistency and item-total score correlation were used for validity and reliability. The independent samples t test, logistic regression analysis and ROC analysis were used for criterion and concurrent validity.

RESULTS

In confirmatory factor analysis, values of fit indices were excellent or acceptable. The Cronbach alpha value was between 0.83 and 0.92. According to criterion validity, the susceptibility, severity, benefit, and health motivation scores of those with the vaccine were higher than those without, whereas their barrier score was lower. The barrier subscale was a risk factor, whereas the benefit score was a protective factor that increased the likelihood of vaccination. The concurrent validity of the scale was tested with the COVID-19 vaccine. While the barrier subscale's ability to distinguish between vaccinated (specificity) and unvaccinated (sensitivity) individuals is excellent, it is acceptable for the other subscales.

CONCLUSION

Modified PAVS-HBM is valid and reliable for adult vaccines. This scale was associated with vaccination behaviour and distinguished between vaccinated and unvaccinated individuals.

The Berlin-Brandenburg Air Study-A Methodological Study Paper of a Natural Experiment Investigating Health Effects Related to Changes in Airport-Related Exposures

Objectives: This paper presents the study design of the Berlin-Brandenburg Air study (BEAR-study). We measure air quality in Berlin and Brandenburg before and after the relocation of aircraft (AC) traffic from Tegel (TXL) airport to the new Berlin-Brandenburg airport (BER) and investigate the association of AC-related ultrafine particles (UFP) with health outcomes in schoolchildren. Methods: The BEAR-study is a natural experiment examining schoolchildren attending schools near TXL and BER airports, and in control areas (CA) away from both airports and associated air corridors. Each child undergoes repeated school-based health-examinations. Total particle number concentration (PNC) and meteorological parameters are continuously monitored. Submicrometer particle number size distribution, equivalent black carbon, and gas-phase pollutants are collected from long-term air quality monitoring stations. Daily source-specific UFP concentrations are modeled. We will analyze short-term effects of UFP on respiratory, cardiovascular, and neurocognitive outcomes, as well as medium and long-term effects on lung growth and cognitive development. Results: We examined 1,070 children (as of 30 November 2022) from 16 schools in Berlin and Brandenburg. Conclusion: The BEAR study increases the understanding of how AC-related UFP affect children's health.

Assessing IgE sensitization profiles to birch and timothy grass pollen allergens in birch pollen allergic blood donors using an oligoplex specific IgE assay

IgE sensitization profiles to single birch allergens in birch-sensitized patients differ among European countries. The aim of this study was to determine the distribution of specific IgE antibodies to major and minor birch pollen allergens in a population of allergic Norwegian individuals by using a birch allergic blood donor population as a surrogate sample. Sixty blood donors were recruited and sampled based on birch allergy symptoms such as rhinitis, rhinoconjunctivitis and/or mild asthma in previous seasons. All sera were collected before start of the pollen season and tested using a line blot assay (Euroimmun AG, Lübeck, Germany) for IgE to birch and timothy pollen. Both extracts, single allergens, and cross-reacting carbohydrate determinants (CCD) were analysed. Only donors with specific IgE to birch and/or timothy grass were further evaluated. Specific IgE to birch pollen extract was found in 52 sera, and sensitization to timothy grass in 40 sera. Specific IgE to Bet v 1 was predominant in contrast to Bet v 4 which was absent. However, sensitization to the minor allergens Bet v 2 and 6 was always found together with high levels of IgE to Bet v 1. Subjects sensitized to the profilin Bet v 2 from birch were also sensitized to Phl p 12 from timothy grass. In conclusion, there was predominantly Bet v 1 sensitization in this cohort and low sensitization to minor allergens and cross-reactive allergens (Bet v 2, Bet v 4, Phl p 7 and Phl p 12).

Critical appraisal tools used in systematic reviews of in vitro cell culture studies: A methodological study

Systematic reviews (SRs) of preclinical studies are marked with poor methodological quality. In vitro studies lack assessment tools to improve the quality of preclinical research. This methodological study aimed to identify, collect, and analyze SRs based on cell culture studies to highlight the current appraisal tools utilized to support the development of a validated critical appraisal tool for cell culture in vitro research. SRs, scoping reviews, and meta-analyses that included cell culture studies and used any type of critical appraisal tool were included. Electronic search, study selection, data collection and methodological quality (MQ) assessment tool were realized. Further, statistical analyses regarding possible associations and correlations between MQ and collected data were performed. After the screening process, 82 studies remained for subsequent analysis. A total of 32 different appraisal tools were identified. Approximately 60% of studies adopted pre-structured tools not designed for cell culture studies. The most frequent instruments were SYRCLE (n = 14), OHAT (n = 9), Cochrane Collaboration's tool (n = 7), GRADE (n = 6), CONSORT (n = 5), and ToxRTool (n = 5). The studies were divided into subgroups to perform statistical analyses. A significant association (OR = 5.00, 95% CI = 1.54-16.20, p = 0.008) was found between low MQ and chronic degenerative disorders as topic of SR. Several challenges in collecting information from the included studies led to some modifications related to the previously registered protocol. These results may serve as a basis for further development of a critical appraisal tool for cell culture studies capable of capturing all the essential factors related to preclinical research, therefore enhancing the practice of evidence-based.

Pairwise approach for analysis and reporting of child's free sugars intake from a birth cohort study

OBJECTIVES

The prospective cohort design is an important research design, but a common challenge is missing data. The purpose of this study is to compare three approaches to managing missing data, the pairwise (n = 1386 children), the partial or modified pairwise (n = 1019) and the listwise (n = 546), to characterize the trajectories of children's free sugars intake (FSI) across early childhood.

METHODS

By applying the Group-based Trajectory Model Technique to three waves of data collected from a prospective cohort study of South Australian children, this study examined the three approaches in managing missing data to validate and discuss children's FSI trajectories.

RESULTS

Each approach identified three distinct trajectories of child's FSI from 1 to 5 years of age: (1) 'low and fast increasing', (2) 'moderate and increasing' and (3) 'high and increasing'. The trajectory memberships were consistent across the three approaches, and were for the pairwise scenario (1) 15.1%, (2) 68.3% and (3) 16.6%; the partial or modified pairwise (1) 15.9%, (2) 64.1% and (3) 20.0%; and the listwise (1) 14.9%, (2) 64.9% and (3) 20.2% of children.

CONCLUSIONS

Given the comparability of the findings across the analytical approaches and the samples' characteristics between baseline and across different data collection waves, it is recommended that the pairwise approach be used in future analyses to optimize the sample size and statistical power when examining the relationship between FSI in the first years of life and health outcome such as dental caries.

Psychometric testing of the Persian version of the Nursing Care Quality Scale: A methodological study

AIM

To evaluate the psychometric properties of the Persian version of the Cambodian Nursing Care Quality Scale.

DESIGN

Methodological design.

METHODS

This study was carried out in several steps: a forward-backward translation was done, face and construct validity was measured using exploratory and confirmatory factor analysis and the reliability was evaluated. A convenience sampling method was employed to recruit 350 nurses from May 2021 to March 2022.

RESULTS

The exploratory factor analysis extracted six factors that explained 60.76% of the total variance. The six-factor model is supported by confirmatory factor analysis. The Cronbach's alpha and the intra-class correlation coefficient were 0.94 and 0.85, respectively.

PATIENT OR PUBLIC CONTRIBUTION

Evaluation of the quality of care can lead to the enhancement of the quality of nursing services and patient safety. This will subsequently increase the patients' and community satisfaction.

Evaluating the Methodological Approaches of Cross-Cultural Adaptation of the Bedside Handover Attitudes and Behaviours Questionnaire into Portuguese

Nurse managers need culturally adapted assessment instruments to support the implementation of change to Nursing Bedside Handover (NBH) in healthcare institutions. This study aimed to cross-culturally adapt the Bedside Handover Attitudes and Behaviours (BHAB) questionnaire to the Portuguese context and evaluate the methodological approaches used for this purpose. To guide this study, we followed a guideline for cross-cultural translation and adaptation measurement instruments in healthcare. The results of the content validity testing suggested that the BHAB questionnaire is a valid instrument for use in the Portuguese context. To obtain these results we showed 1) using of a new methodological approach, the dual focus, to resolve the divergences and ambiguities in the translators' committee and the multi-professional committee; 2) the lack of a conceptual definition of the construct of the instrument as a requirement to retain items with I-CVI <0.70 after validity relevance pretesting and 3) the cognitive debriefing and relevance pretesting as methodological approaches which can be used alone or together to reinforce the evaluation of cultural relevance of the items. We concluded there is a need for guidelines to support the decision-making process of healthcare researchers with comprehensive information about the different methodological approaches they can follow.

Development of a semi-quantitative food frequency questionnaire for dietary intake of elementary school children: data from the Seventh Korea National Health and Nutrition Examination Survey

BACKGROUND/OBJECTIVES

In Korea, studies of diet in elementary school children are hindered by the need for a comprehensive dietary assessment tool. Thus, the aim of this study was to develop a semi-quantitative food frequency questionnaire (FFQ) for Korean elementary school children.

SUBJECTS/METHODS

The 24-h recall data for 1,624 subjects aged 6-11 yrs from the seventh Korea National Health and Nutrition Examination Survey were used to extract the items included in the questionnaire. The FFQ items were developed by selecting major dishes based on the results of nutritional contribution and between-person variability for energy and 14 nutrients (carbohydrate, protein, fat, crude fiber, calcium, phosphorous, iron, sodium, potassium, vitamin A, thiamin, riboflavin, niacin, and vitamin C). We selected the major dishes with over 90% of the total contribution to each nutrient and with over 90% of the accumulated R² for each nutrient. Among the 452 dishes, we selected 248 dishes contributing more than 1% of the total consumption.

RESULTS

Finally, the FFQ included 107 items combined from 248 dishes based on nutrient profile and recipe. The FFQ items accounted for an average of 88.6% of the energy, 14 nutrient intakes, and 91.4% of the between-person variability. Quantities of dietary intake were assessed by 9 categories of frequency and 3 categories of portion size. Percentages of coverage for energy, protein, fat, carbohydrate, and calcium were 90.2%, 87.8%, 89.9%, 90.8%, and 88.7%, respectively.

CONCLUSIONS

We developed a dish-based, semi-quantitative FFQ comprising 107 items for Korean elementary school children aged 6 to 11. Further studies are needed to evaluate the reproducibility and validity of this FFQ for elementary school children.

Psychometric Evaluation of Turkish Version of the Cultural Competence Assessment Tool: CCA-EUnurse Project

It is important to understand nurses' cultural competency all across the world, as globalization and international migration are increasing day by day. The evaluation of the cultural competence of nurses is necessary to provide better quality and adequate health services to individuals, and to improve patient satisfaction and health outcomes. The aim of this study is to evaluate the validity and reliability of the Turkish version of the "Cultural Competence Assessment Tool". The methodological study was performed to assess instrument adaptation and validity and reliability testing. This study was conducted in a university hospital in western region of Turkey. The study sample consisted of 410 nurses who worked in this hospital. Validity was tested using content validity index, Kendall's W test and exploratory and confirmatory factor analyses. Reliability was tested using item-total and interitem correlations, Cronbach's α coefficient of reliability and test-retest analysis. The results of this research demonstrated that the Cultural Competence Assessment Tool showed a good construct validity, internal reliability and test-retest reliability. Confirmatory factor analysis indicated that a construct with four factors showed an acceptable model fit. In conclusion, this study concluded that the Turkish version of the Cultural Competence Assessment Tool is a valid and reliable measurement tool.

A Serious Game About Hematology for Health Care Workers (SUPER HEMO): Development and Validation Study

BACKGROUND

Complete blood count (CBC) and hemostatic screening tests are among the most commonly prescribed blood tests worldwide. All health care workers (nurse practitioners, pharmacists, dentists, midwives, and physicians) are expected to correctly interpret the results in their daily practice. Currently, the undergraduate hematology curriculum consists predominantly of lecture-based teaching. Because hematology combines basic science (blood cells and hemostasis physiology) and clinical skills, students report that they do not easily master hematology with only lecture-based teaching. Having interviewed students at the University of Lorraine, we considered it necessary to develop new teaching approaches and methods.

OBJECTIVE

We aimed to develop and validate a serious game about CBC analysis for health care students. Our primary objective was to help students perceive hematology as being a playful and easy topic and for them to feel truly involved in taking care of their patients by analyzing blood tests. We considered that this game-based approach would be attractive to students as an addition to the classic lecture-based approach and improve their knowledge and skills in hematology.

METHODS

We developed an adventure game called SUPER HEMO, a video game in which the player assumes the role of a protagonist in an interactive story driven by exploration and problem-solving tests. Following validation with beta testing by a panel of volunteer students, we used a novel, integrated teaching approach. We added 1.5 hours of gaming to the standard curriculum for a small group of volunteer students. Physician and pharmacy students in their third year at a single French university were invited to attend this extracurricular course. Pregame and postgame tests and satisfaction surveys were immediately recorded. Final hematology exam results were analyzed.

RESULTS

A total of 86 of 324 physician students (26.5%) and 67 of 115 pharmacy students (58%) opted to participate. Median scores on the pre- and posttests were 6 out of 10 versus 7 out of 10, respectively, for the physician students, (P<.001) and 7.5 out of 10 versus 8 out of 10, respectively, for the pharmacy students (P<.001). At the final hematology evaluation, physician students who played SUPER HEMO had a slightly better median score than those who did not: 13 out of 20 versus 12 out of 20, respectively (P=.002). Pharmacy students who played SUPER HEMO had a median score of 21.75 out of 30; this was not significantly different from pharmacy students who did not play SUPER HEMO (20/30; P=.12). Among the participants who answered the survey (n=143), more than 86% (123/143) believed they had strengthened their knowledge and nearly 80% (114/143) of them had fun.

CONCLUSIONS

Feedback from this game session provided evidence to support the integration of interactive teaching methods in undergraduate hematology teaching. The development of SUPER HEMO is intended to be completed so that it can become a support tool for continuing education.

Development and psychometric properties of the sleep problems and coping with sleep problem scales for pregnant women

AIMS

The aim of this study is to develop a sleep problems scale and a coping with sleep problems scale for pregnant women and assess their reliability and validity.

DESIGN

An empirical research quantitative design.

REVIEW METHODS

Self-reported instruments were developed through (1) item generation, (2) preliminary item evaluation and (3) scale refining and evaluation. Item pools were created via literature review, opinions of experts and women with experience in pregnancy sleep. Content, construct and criterion validities were tested. Reliability was assessed using Cronbach's alpha, split-half reliability and corrected item-total correlation.

DATA SOURCES

Data were collected between January 23 and July 22, 2020, at a hospital's obstetrics polyclinic. In the pilot and main study, 30 and 368 pregnant women (gestational age: 8-42 weeks) were included, respectively.

RESULTS

The content validity index was >0.9 for each scale. Factor analysis showed 24 and 18 items in the two scales, both with four subdimensions. The corrected item-total correlations were acceptable, and Cronbach's alpha coefficient was 0.883 and 0.799, respectively.

CONCLUSION

Both scales developed in this study are valid and reliable for the Turkish society. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE/GLOBAL CLINICAL COMMUNITY: This study's findings may prevent the lack of validated screening instruments to identify pregnancy-specific sleep features.

IMPACT

We developed two scales to assess sleep problems in pregnant women. These were valid and reliable, can be routinely used by health professionals and may guide nurses and midwives in assessing and managing sleep problems during pregnancy.

REPORTING METHOD

The study conforms to the COSMIN checklist.

PATIENT OR PUBLIC CONTRIBUTION

Data were collected during face-to-face surveys. Ten women contributed to the item pool generation, 30 pregnant women participated in the pilot study, and 368 antenatal service users participated in the main study.

Characterization of Hyperreflective Dots by Structural and Angiographic Optical Coherence Tomography in Patients with Diabetic Retinopathy and Healthy Subjects

Hyperreflective dots are a common but highly variable feature of optical coherence tomography (OCT) scans of the retina. We studied the spatial characteristics and perfusion of hyperreflective dots using both structural and angiographic OCT B-scans of the macula in 16 eyes in 8 healthy subjects and 8 patients with diabetic retinopathy without macular edema. Hyperreflective dots were manually graded in a 1000 µm parafoveal area by number, diameter, location and perfusion status and traced through adjacent B-scans at 11 µm intervals to determine their length. Thereby, this study defined a procedure to identify granular and elongated hyperreflective elements and differentiate between presumably perfused and occluded capillaries. The latter were only found in the diabetic patients. This classification can potentially be automated to non-invasively identify capillary non-perfusion in vivo.

Scale of Adherence to Good Hospital Practices for COVID-19: Psychometric Properties

To avoid hospital transmission, all COVID-19 prevention measures should be followed. This study aimed to evaluate the psychometric properties of a novel scale developed to assess adherence to good practices for COVID-19 in the hospital setting. A methodological cross-sectional study was conducted at a public hospital in the state of São Paulo, Brazil, with 307 healthcare providers. Data were collected using a questionnaire addressing sociodemographic/occupational data and the Adherence to Standard Precautions for COVID-19 scale. Cronbach's alpha coefficients and the intraclass correlation coefficients were used to measure internal consistency and temporal stability (test-retest analysis), respectively. Concurrent validity was evaluated using Spearman's correlation coefficients between the scores of the overall scale and its domains. Factorial structure was evaluated using exploratory factor analysis and goodness-of-fit of the model was tested using confirmatory factor analysis. Cronbach's alpha coefficients for the scale and its domains were higher than 0.7, except the psychosocial domain (0.61). All intraclass correlation coefficients were higher than 0.7. Strong correlations were found between the total score and the personal (0.84) and organizational (0.90) domains of the scale and a good correlation was found with the psychosocial domain (0.66). The fit of the multidimensional model was satisfactory for all parameters and the three-dimensional structure of the scale was confirmed by the fit of the factor loadings. The novel scale is a valid and reliable instrument for assessing adherence to good hospital practices for COVID-19.

The Doctors' Effect on Patients' Physical Health Outcomes Beyond the Intervention: A Methodological Review

Background

Previous research suggests that when a treatment is delivered, patients’ outcomes may vary systematically by medical practitioner.

Objective

To conduct a methodological review of studies reporting on the effect of doctors on patients’ physical health outcomes and to provide recommendations on how this effect could be measured and reported in a consistent and appropriate way.

Methods

The data source was 79 included studies and randomized controlled trials from a systematic review of doctors’ effects on patients’ physical health. We qualitatively assessed the studies and summarized how the doctors’ effect was measured and reported.

Results

The doctors’ effects on patients’ physical health outcomes were reported as fixed effects, identifying high and low outliers, or random effects, which estimate the variation in patient health outcomes due to the doctor after accounting for all available variables via the intra-class correlation coefficient. Multivariable multilevel regression is commonly used to adjust for patient risk, doctor experience and other demographics, and also to account for the clustering effect of hospitals in estimating both fixed and random effects.

Conclusion

This methodological review identified inconsistencies in how the doctor’s effect on patients’ physical health outcomes is measured and reported. For grading doctors from worst to best performances and estimating random effects, specific recommendations are given along with the specific data points to report.

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Validity and Reliability of the Korean Version of the Holistic Nursing Competence Scale

This methodological study aimed to verify the validity and reliability of the Korean version of the Holistic Nursing Competence Scale (HNCS), which comprises five dimensions and 36 items. The English version of the HNCS was forward and backward translated and administered to 251 participants with more than a year of work experience in a general hospital. Data were analyzed using SPSS WIN 24.0(Chicago, IL, USA), and AMOS program was used for confirmatory factor analysis. Additionally, the “Task Performance Evaluation Instrument for Clinical Nurses” was used for concurrent validity. Reliability assessed using Cronbach’s α was 0.969. Convergent, discriminant, and concurrent validity were good. Average variance extracted and construct reliability ranged from 0.845 to 0.932 and 0.980 to 0.987, respectively. The model was suitable with the chi-square value being 1216.563 (df = 584, p < 0.001), and Q value being less than three. Goodness-of-fit index, root mean square residual, and root mean square error of approximation were 0.784, 0.066, and 0.066, respectively. Moreover, comparative fit index, Tucker−Lewis index, and incremental fit index were 0.913, 0.906, and 0.913, respectively. Thus, this study verified the validity and reliability of the Korean version of the HNCS. Our findings suggest that the scale is helpful in measuring and developing the holistic nursing competence of clinical nurses.

A Serious Game (Immunitates) About Immunization: Development and Validation Study

Background

Vaccination is a fundamental part of all levels—local to worldwide—of public health, and it can be considered one of humanity's greatest achievements in the control and elimination of infectious diseases. Teaching immunization and vaccination can be monotonous and tiring. It is necessary to develop new approaches for teaching these themes in nursing school.

Objective

We aimed to develop and validate a serious game about immunization and vaccination for Brazilian nursing students.

Methods

We developed a quiz-type game, Immunitates, using design and educational theoretical models and Brazilian National Health Guidelines. The game’s heuristics and content were evaluated with 2 different instruments by a team of experts. A sample of nursing students evaluated the validity of the game’s heuristics only. We calculated the content validity index (CVI) for each evaluation.

Results

The study included 49 experts and 15 nursing students. All evaluations demonstrated high internal consistency (Cronbach α≥.86). The game’s heuristics (experts: CVI 0.75-1.0; students: CVI 0.67-1.0) and the game’s contents demonstrated validity (experts: CVI 0.73-1.0). Participants identified some specific areas for improvement in the next version.

Conclusions

The serious game appears to be valid. It is intended as a support tool for nursing students in the teaching–learning process and as a tool for continuing education for nurses.

Early Optimistic Effect in Periodontology and Implant Dentistry Trials

Differences in effect estimates between early primary trials included in a meta-analysis and the pooled estimate of meta-analysis might indicate potential novelty bias. The objective of this study was to assess the presence of novelty bias in a sample of studies published in periodontology and implant dentistry. On August 7, 2020, we searched the PubMed database for meta-analyses of clinical studies published between August 2015 and August 2020. Meta-analyses with at least 4 primary studies were selected for assessment. We fitted logistic regression models using trial characteristics as predictors to assess the association between these characteristics and 1) the odds of the first trial's estimate to be included in the meta-analysis confidence interval (CI) and 2) the odds of overlap between the first trial's CI and the meta-analysis prediction interval (PI). Ninety-two meta-analyses provided data for assessment. In absolute values, 70% of the meta-analyses have a pooled estimate smaller than the corresponding estimate of the first trial, although there was overlap of the CI of estimates from the first trial and the meta-analysis in 87% of the cases. This is probably due to the small number of trials in most meta-analyses and the subsequently large uncertainty associated with the pooled effect estimate. As the number of trials in the meta-analysis increased, the odds of the treatment effect estimate of the first trial to be included in the meta-analysis CI decreased by 15% for every additional trial (odds ratio, 0.85; 95% CI, 0.73 to 0.96). Meta-analytic effect estimates appear to be more conservative than those from the first trial in the meta-analysis. Our findings show evidence of novelty bias in periodontology and implant dentistry; therefore, clinicians should be aware of the risk of making decisions based on the information reported in new trials because of the risk of exaggerated estimates in these trials.

Reproducibility and Validity of a Food Frequency Questionnaire (FFQ) Developed for Middle-Aged and Older Adults in Semarang, Indonesia

We assessed the reproducibility and validity of a food frequency questionnaire (FFQ) among middle-aged and older adults in Semarang, Indonesia. A total of 259 subjects aged 40-80 years completed two FFQs (nine-month apart) and nine 24 h dietary recalls (24HDRs, as a reference method). The reproducibility of the FFQ was analyzed using correlation coefficient, intra-class correlation coefficient (ICC), weighted kappa statistics and misclassification analysis. The validity was estimated by comparing the data acquired from FFQ1 and 24HDRs. The crude Pearson's correlation coefficients and ICC for total energy and nutrients between FFQ1 and FFQ2 ranged from 0.50 to 0.81 and 0.44 to 0.78, respectively. Energy adjustment decreased the correlation coefficients for most nutrients. The crude, energy-adjusted and de-attenuated correlation coefficients for FFQ1 and 24HDRs ranged from 0.41 to 0.70, 0.31 to 0.89 and 0.54 to 0.82, respectively. The agreement rates for the same or adjacent quartile classifications were 81.1-94.6% for two FFQs and 80.7-89.6% for FFQ1 and 24HDRs. The weighted kappa values were 0.21 to 0.42 for two FFQs and 0.20 to 0.34 for FFQ1 and 24HDRs. A positive mean difference was found in the Bland-Altman analyses for energy and macronutrients. The FFQ could be acceptable for nutritional epidemiology study among Indonesians.

The methodology of a "living" COVID-19 registry development in a clinical context

OBJECTIVE

The aim of this study was to describe an innovative methodology of a registry development, constantly updated for the scientific assessment and analysis of the health status of the population with COVID-19.

STUDY DESIGN AND SETTING

A methodological study design to develop a multi-site, Living COVID-19 Registry of COVID-19 patients admitted in Fondazione Don Gnocchi centres started in March 2020.

RESULTS

The integration of the living systematic reviews and focus group methodologies led to a development of a registry which includes 520 fields filled in for 748 COVID-19 patients recruited from 17 Fondazione Don Gnocchi centres. The result is an evidence and experience-based registry, according to the evolution of a new pathology which was not known before outbreak of March 2020 and with the aim of building knowledge to provide a better quality of care for COVID-19 patients.

CONCLUSION

A Living COVID-19 Registry is an open, living and up to date access to large-scale patient-level data sets that could help identifying important factors and modulating variable for recognising risk profiles and predicting treatment success in COVID-19 patients hospitalized. This innovative methodology might be used for other registries, to be sure which the data collected is an appropriate means of accomplishing the scientific objectives planned.

CLINICAL TRIAL REGISTRATION NUMBER

not applicable.

Development of the Scientific Research Competency Scale for nurses

BACKGROUND

The planning, implementation, finalisation and reporting of high-quality research depends on the knowledge, skills and competencies of the many individuals who make carrying out the research possible.

AIMS

This study aims to develop a valid and reliable scale in order to identify the scientific research competencies of nursing professionals at undergraduate and graduate level.

METHODS

This methodological study was carried out on 937 nursing personnel, 422 (45%) of whom were academic members and 515 (55%) were undergraduate students. The Anxiety Scale Towards Research and the Attitude Scale Towards Scientific Research were used for the criterion validity.

RESULTS

The Scientific Research Competency Scale comprises 57 items in four sub-dimensions named as 'technical skills', 'attitude and behaviours', 'estimation capacity' and 'foreign language skill'. The Cronbach alpha, Guttmann split-half and Spearman Brown reliability coefficients for the scientific research competency scale were, respectively, 0.98, 0.96 and 0.96. The sensitivity and specificity value, by which the research competency of individuals could be determined with minimum error, was indicated to be at 190 breakpoints of the scientific research competency scale.

CONCLUSIONS

As a result, the scientific research competency scale developed is a valid and reliable tool that can be used to determine the scientific research competencies of nursing professionals.

Adherence to the CONSORT statement and extension for nonpharmacological treatments in randomized controlled trials of bariatric surgery: A systematic survey

Reporting is critical for establishing the value of randomized controlled trials (RCTs). This study evaluated the adherence of bariatric surgery RCT reporting to the CONsolidated Standards Of Reporting Trials (CONSORT) statement 2010 and its 2017 extension for non-pharmacologic treatments (NPT extension). We identified all RCTs comparing bariatric surgery with conservational therapy or alternative bariatric surgery up to June 30, 2020. Reporting quality was assessed using criteria developed from the CONSORT statement and the NPT extension and scored as a percentage. The factors associated with reporting quality were explored by univariate and multivariate analysis. In total, 102 RCTs of bariatric surgery were included. The median scores according to the CONSORT statement and NPT extension were 63.3 and 26.8 of a maximum possible 100, respectively. Two-thirds of NPT extension items were reported in less than 25% of the RCTs. The median score improved over time for the CONSORT statement but not the NPT extension. A higher CONSORT score was associated with publication in core clinical journals, protocol registration, and funding. No factors associated with the NPT extension score were identified. Substantial efforts are warranted from authors, journals, registration platforms, and funders to overcome the flaws in the reporting of bariatric surgery RCTs.

Assessing Face Validity of the HexCom Model for Capturing Complexity in Clinical Practice: A Delphi Study

Capturing complexity is both a conceptual and a practical challenge in palliative care. The HexCom model has proved to be an instrument with strong reliability and to be valid for describing the needs and strengths of patients in home care. In order to explore whether it is also perceived to be helpful in enhancing coordinated and patient-centred care at a practical level, a methodological study was carried out to assess the face validity of the model. In particular, a Delphi method involving a group of 14 experts representing the full spectrum of healthcare professionals involved in palliative care was carried out. The results show that there is a high level of agreement, with a content validity index-item greater than 0.92 both with regard to the complexity model and the HexCom-Red, HexCom-Basic, and the HexCom-Clin instruments, and higher than 0.85 regarding the HexCom-Figure and the HexCom-Patient instruments. This consensus confirms that the HexCom model and the different instruments that are derived from it are valued as useful tools for a broad range of healthcare professional in coordinately capturing complexity in healthcare practice.

Using the Choice Sequence in Time Trade-Off as Discrete Choices: Do the Two Stories Match?

OBJECTIVES

The EQ-5D-5L valuation protocol recommends combining time trade-off (TTO) and discrete choice experiments (DCEs). DCEs that include a duration attribute (DCE_TTO) allow modeling on the quality-adjusted life-year scale. Because the choice sequence in a TTO can be construed as a series of DCE_TTO, we used data from a single TTO study to investigate the extent to which DCE values match TTO values when based on identical preferences.

METHODS

In a TTO design in which a fixed set of choices were administered without termination at preference indifference, 202 individuals each valued 10 EQ-5D health states. From identified indifference points, we estimated three sets of TTO values: (i) plotting means and (ii) applying censored regressions at -1 and 1. Using all strict preferences, we (iii) estimated DCE_TTO values with a logit model and a bootstrap procedure.

RESULTS

Estimated DCE_TTO and TTO values agreed well at the severe end of the quality-adjusted life-year scale, but with decreasing severity, DCE_TTO values were higher than TTO-values, with the difference peaking at 0.37 for the mildest health state. Left-censoring TTO values at -1 worsen the agreement for the worst health states and did not affect health states. Right censoring at 1 improved the agreement for mild states.

CONCLUSIONS

TTO and the DCE_TTO values estimated from the same preference data diverged, with increasing difference for milder health states. Although the values converged when applying censored regression at +1, we question the validity of this adjustment.

Validity and Reliability of a Food Frequency Questionnaire (FFQ) to Assess Dietary Intake of Preschool Children

As there are few food frequency questionnaires (FFQ) to assess the dietary intake of preschool children, this study examined the validity and reliability of an FFQ for this purpose. A total of 210 preschoolers aged 4 to 6 years participated in the validation study, while a subsample of 66 participants joined the reliability study. The FFQ is modified from the ToyBox-study and South East Asian Nutrition Surveys (SEANUTS), and comprised 108 food items from 13 food groups. A three-day estimated dietary record (3DR) was used as reference and reliability was assessed through a second administration of the FFQ (FFQ2), four weeks after the first administration (FFQ1). For the validation study, Spearman’s correlation coefficients showed moderate to high correlations (p < 0.001) between FFQ and 3DR. Cross-classification of quartile analysis showed moderate agreement between the two methods. As for reliability, Spearman’s correlation coefficients showed moderate to high correlations (p < 0.001) between FFQ1 and FFQ2. Cronbach’s alpha values (0.708 to 0.824) and intraclass correlation coefficients (0.710 to 0.826) showed good agreement between repeated FFQs. The results suggest that the FFQ has acceptable validity and good reliability. Hence, the FFQ can be used to assess preschool children’s food intake.

Psychometric evaluation of the Informed Consent Process Scale in Chinese

BACKGROUND

Informed consent is essential for the ethical conduct of clinical research and is a culturally sensitive issue. But, a measurable Chinese version of the scale to evaluate the informed consent process has not yet been explored in the existing literature.

RESEARCH OBJECTIVES

This study aimed to develop and psychometrically test the Chinese version of the Informed Consent Process Scale.

RESEARCH DESIGN

Back-translation was conducted to develop the Chinese version of the questionnaire. A cross-sectional survey was administered, after which an exploratory factor analysis was conducted.

PARTICIPANTS

We recruited a total of 375 participants who had experience in signing an informed consent form within the previous 3 years in Taiwan.

ETHICAL CONSIDERATIONS

This study was approved by two Institutional Review Boards and the autonomy of the participants was respected.

FINDINGS

The Chinese version of the Informed Consent Process Scale is composed of three factors with 23 items showing evidence of acceptable reliability and validity. Three major factors were extracted and labeled: Factor 1 - 'Understanding of the research', Factor 2 - 'Trust and confidence' and Factor 3 - 'Doubt and uncertainty'. The three factors accounted for is 52.954 of the total variance with Cronbach's α of .917.

DISCUSSION AND CONCLUSION

The finding corroborates previous studies showing that participants had too little understanding on the informed consent forms they signed and implied the need to clarify the critical points in clinical research. The psychometric results indicated good internal consistency and validity for this newly constructed instrument, and it was found worthy of conducting further testing and application.

Generation and application of human induced-stem cell memory T cells for adoptive immunotherapy

Adoptive T-cell therapy is an effective strategy for cancer immunotherapy. However, infused T cells frequently become functionally exhausted, and consequently offer a poor prognosis after transplantation into patients. Adoptive transfer of tumor antigen-specific stem cell memory T (T_SCM ) cells is expected to overcome this shortcoming as T_SCM cells are close to naïve T cells, but are also highly proliferative, long-lived, and produce a large number of effector T cells in response to antigen stimulation. We previously reported that activated effector T cells can be converted into T_SCM -like cells (iT_SCM ) by coculturing with OP9 cells expressing Notch ligand, Delta-like 1 (OP9-hDLL1). Here we show the methodological parameters of human CD8⁺ iT_SCM cell generation and their application to adoptive cancer immunotherapy. Regardless of the stimulation by anti-CD3/CD28 antibodies or by antigen-presenting cells, human iT_SCM cells were more efficiently induced from central memory type T cells than from effector memory T cells. During the induction phase by coculture with OP9-hDLL1 cells, interleukin (IL)-7 and IL-15 (but not IL-2 or IL-21) could efficiently generate iT_SCM cells. Epstein-Barr virus-specific iT_SCM cells showed much stronger antitumor potentials than conventionally activated T cells in humanized Epstein-Barr virus transformed-tumor model mice. Thus, adoptive T-cell therapy with iT_SCM offers a promising therapeutic strategy for cancer immunotherapy.

What Temperature of Coffee Exceeds the Pain Threshold? Pilot Study of a Sensory Analysis Method as Basis for Cancer Risk Assessment

The International Agency for Research on Cancer (IARC) evaluates “very hot (>65 °C) beverages” as probably carcinogenic to humans. However, there is a lack of research regarding what temperatures consumers actually perceive as “very hot” or as “too hot”. A method for sensory analysis of such threshold temperatures was developed. The participants were asked to mix a very hot coffee step by step into a cooler coffee. Because of that, the coffee to be tasted was incrementally increased in temperature during the test. The participants took a sip at every addition, until they perceive the beverage as too hot for consumption. The protocol was evaluated in the form of a pilot study using 87 participants. Interestingly, the average pain threshold of the test group (67 °C) and the preferred drinking temperature (63 °C) iterated around the IARC threshold for carcinogenicity. The developed methodology was found as fit for the purpose and may be applied in larger studies.

Validity and Reliability of the Turkish Chronic Pain Acceptance Questionnaire

Background:

Pain acceptance is the process of giving up the struggle with pain and learning to live a worthwhile life despite it. In assessing patients with chronic pain in Turkey, making a diagnosis and tracking the effectiveness of treatment is done with scales that have been translated into Turkish. However, there is as yet no valid and reliable scale in Turkish to assess the acceptance of pain.

Aims:

To validate a Turkish version of the Chronic Pain Acceptance Questionnaire developed by McCracken and colleagues.

Study Design:

Methodological and cross sectional study.

Methods:

A simple randomized sampling method was used in selecting the study sample. The sample was composed of 201 patients, more than 10 times the number of items examined for validity and reliability in the study, which totaled 20. A patient identification form, the Chronic Pain Acceptance Questionnaire, and the Brief Pain Inventory were used to collect data. Data were collected by face-to-face interviews. In the validity testing, the content validity index was used to evaluate linguistic equivalence, content validity, construct validity, and expert views. In reliability testing of the scale, Cronbach’s α coefficient was calculated, and item analysis and split-test reliability methods were used. Principal component analysis and varimax rotation were used in factor analysis and to examine factor structure for construct concept validity.

Results:

The item analysis established that the scale, all items, and item-total correlations were satisfactory. The mean total score of the scale was 21.78. The internal consistency coefficient was 0.94, and the correlation between the two halves of the scale was 0.89.

Conclusion:

The Chronic Pain Acceptance Questionnaire, which is intended to be used in Turkey upon confirmation of its validity and reliability, is an evaluation instrument with sufficient validity and reliability, and it can be reliably used to examine patients’ acceptance of chronic pain.

Factors Associated With Dropout During Recruitment and Follow-Up Periods of a mHealth-Based Randomized Controlled Trial for Mobile.Net to Encourage Treatment Adherence for People With Serious Mental Health Problems

Background

Clinical trials are the gold standard of evidence-based practice. Still many papers inadequately report methodology in randomized controlled trials (RCTs), particularly for mHealth interventions for people with serious mental health problems. To ensure robust enough evidence, it is important to understand which study phases are the most vulnerable in the field of mental health care.

Objective

We mapped the recruitment and the trial follow-up periods of participants to provide a picture of the dropout predictors from a mHealth-based trial. As an example, we used a mHealth-based multicenter RCT, titled “Mobile.Net,” targeted at people with serious mental health problems.

Methods

Recruitment and follow-up processes of the Mobile.Net trial were monitored and analyzed. Recruitment outcomes were recorded as screened, eligible, consent not asked, refused, and enrolled. Patient engagement was recorded as follow-up outcomes: (1) attrition during short message service (SMS) text message intervention and (2) attrition during the 12-month follow-up period. Multiple regression analysis was used to identify which demographic factors were related to recruitment and retention.

Results

We recruited 1139 patients during a 15-month period. Of 11,530 people screened, 36.31% (n=4186) were eligible. This eligible group tended to be significantly younger (mean 39.2, SD 13.2 years, P<.001) and more often women (2103/4181, 50.30%) than those who were not eligible (age: mean 43.7, SD 14.6 years; women: 3633/6514, 55.78%). At the point when potential participants were asked to give consent, a further 2278 refused. Those who refused were a little older (mean 40.2, SD 13.9 years) than those who agreed to participate (mean 38.3, SD 12.5 years; t1842=3.2, P<.001). We measured the outcomes after 12 months of the SMS text message intervention. Attrition from the SMS text message intervention was 4.8% (27/563). The patient dropout rate after 12 months was 0.36% (4/1123), as discovered from the register data. In all, 3.12% (35/1123) of the participants withdrew from the trial. However, dropout rates from the patient survey (either by paper or telephone interview) were 52.45% (589/1123) and 27.8% (155/558), respectively. Almost all participants (536/563, 95.2%) tolerated the intervention, but those who discontinued were more often women (21/27, 78%; P=.009). Finally, participants’ age (P<.001), gender (P<.001), vocational education (P=.04), and employment status (P<.001) seemed to predict their risk of dropping out from the postal survey.

Conclusions

Patient recruitment and engagement in the 12-month follow-up conducted with a postal survey were the most vulnerable phases in the SMS text message-based trial. People with serious mental health problems may need extra support during the recruitment process and in engaging them in SMS text message-based trials to ensure robust enough evidence for mental health care.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 27704027; http://www.isrctn.com/ISRCTN27704027 (Archived by WebCite at http://www.webcitation.org/6oHcU2SFp)

New portable system for dental plaque measurement using a digital single-lens reflex camera and image analysis: Study of reliability and validation

Background:

The quantification of the dental plaque (DP) by indices has limitations: They depend on the subjective operator's evaluation and are measured in an ordinal scale. The purpose of this study was to develop and evaluate a method to measure DP in a proportional scale.

Materials and Methods:

A portable photographic positioning device (PPPD) was designed and added to a photographic digital single-lens reflex camera. Seventeen subjects participated in this study, after DP disclosure with the erythrosine, their incisors, and a calibration scale ware photographed by two operators in duplicate, re-positioning the PPPD among each acquisition. A third operator registered the Quigley-Hein modified by Turesky DP index (Q-H/TPI). After tooth brushing, the same operators repeated the photographs and the Q-H/TPI. The image analysis system (IAS) technique allowed the measurement in mm² of the vestibular total tooth area and the area with DP.

Results:

The reliability was determined with the intra-class correlation coefficient that was 0.9936 (P < 0.05) for the intra-operator repeatability and 0.9931 (P < 0.05) for inter-operator reproducibility. The validity was assessed using the Spearman's correlation coefficient that indicated a strong positive correlation with the Q-H/TPI r_s = 0.84 (P < 0.01). The sensitivity of the IAS was evaluated with two sample sizes, only the IAS was able to detect significant differences (P < 0.05) with the sample of smaller size (n = 8).

Conclusions:

Image analysis system showed to be a reliable and valid method to measure the quantity of DP in a proportional scale, allowing a more powerful statistical analysis, thus facilitating trials with a smaller sample size.

The use of double-balloon enteroscopy in retrieving mucosal biopsies from the entire human gastrointestinal tract

OBJECTIVE

The aim of this explorative study was to evaluate double-balloon enteroscopy (DBE) as a new tool for collecting mucosal biopsies from well-defined parts of the entire small and large bowel in patients with type 2 diabetes and in matched healthy subjects.

MATERIAL AND METHODS

Twelve subjects with type 2 diabetes and 12 body mass index and age-matched healthy subjects underwent anterograde and retrograde DBE under nurse-administered propofol sedation on two separate days. We attempted to collect two mucosal biopsies from every 30 cm from pylorus to rectum.

RESULTS

A mean of 21 biopsy sites were sampled in the diabetic group versus 25 in the healthy group. In 4 out of 24 patients (2 [17%] from each group) sampling from the entire gastrointestinal system was possible. Mean depth of maximal insertion (anterograde) was 478 ± 32 cm in patients with type 2 diabetes versus 465 ± 44 cm in healthy subjects (p = 0.81) and with retrograde access 230 ± 36 cm (type 2 diabetes) versus 207 ± 26 cm (healthy subjects).

CONCLUSIONS

DBE is a minimally invasive way of collecting fresh biopsies from the entire gastrointestinal tract and, thus provides research and clinical communities with a new possibility to access hitherto unexplored human anatomy and physiology.

Adaptation and validation of the Spanish version of the Dieting Peer Competitiveness Scale to adolescents of both genders

This study examined the Dieting Peer Competitiveness Scale; it is an instrument for evaluating this social comparison in young people. This instrumental study has two aims: The objective of the first aim was to present preliminary psychometric data from the Spanish version of the Dieting Peer Competitiveness Scale, including statistical item analysis, research about this instrument's internal structure, and a reliability analysis, from a sample of 1067 secondary school adolescents. The second objective of the study corresponds to confirmatory factor analysis of the scale's internal structure, as well as analysis for evidence of validity from a sample of 1075 adolescents.

Using pathway-specific comprehensive exposure scores in epidemiology: application to oxidative balance in a pooled case-control study of incident, sporadic colorectal adenomas

Identifying associations of risk factors sharing the same pathway with disease risk is complicated by small individual effects and intercorrelated components; this can be addressed by creating comprehensive exposure scores. We developed and validated 3 novel weighting methods (literature review-derived, study data-based, and a Bayesian method that combines prior knowledge with study data) to incorporate components into a pathway score for oxidative balance in addition to a commonly used method that assumes all components contribute equally to the score. We illustrate our method using pooled data from 3 US case-control studies of sporadic colorectal adenoma (1991-2002). We created 4 oxidative balance scores (OBS) to reflect combined summary measures of dietary and nondietary antioxidant and prooxidant exposures. A higher score represents a predominance of antioxidant exposures over prooxidant exposures. In the pooled data, the odds ratios comparing the highest tertile of OBS with the lowest for adenoma risk ranged from 0.38 to 0.54 for the 4 measures; all were statistically significant. These findings suggest that 1) OBS are indicators of oxidative balance and may be inversely associated with colorectal adenoma risk and 2) using comprehensive exposure scores may be preferable to investigating individual component-disease associations for complex exposures, such as oxidative balance.

Selection of neighborhood controls for a population-based Lyme disease case-control study by using a commercial marketing database

The selection of controls is an important methodological consideration for case-control studies. Neighborhood-matched control selection is particularly crucial for studies of vector-borne disease, such as Lyme disease, for which risk is intrinsically linked to geographical location. The matching of case-control pairs on neighborhood can help control for variation in ecological risk factors that are tied to geographical location, like vector and host habitat in the peridomestic environment. Random-digit dialing has been used to find neighborhood controls by using the area code and exchange of the case to generate lists of potential control households. An alternative to random-digit dialing is the purchase of residential telephone numbers from a commercial marketing database. This report describes the utility of the InfoUSA.com (InfoGroup, Papillion, Nebraska) commercial marketing database for neighborhood control recruitment in a Lyme disease case-control study in Connecticut during 2005-2007.

Using qualitative research to inform development of a diagnostic algorithm for UTI in children

BACKGROUND

Diagnostic and prognostic algorithms can help reduce clinical uncertainty. The selection of candidate symptoms and signs to be measured in case report forms (CRFs) for potential inclusion in diagnostic algorithms needs to be comprehensive, clearly formulated and relevant for end users.

OBJECTIVE

To investigate whether qualitative methods could assist in designing CRFs in research developing diagnostic algorithms. Specifically, the study sought to establish whether qualitative methods could have assisted in designing the CRF for the Health Technology Association funded Diagnosis of Urinary Tract infection in Young children (DUTY) study, which will develop a diagnostic algorithm to improve recognition of urinary tract infection (UTI) in children aged <5 years presenting acutely unwell to primary care.

METHODS

Qualitative methods were applied using semi-structured interviews of 30 UK doctors and nurses working with young children in primary care and a Children's Emergency Department. We elicited features that clinicians believed useful in diagnosing UTI and compared these for presence or absence and terminology with the DUTY CRF.

RESULTS

Despite much agreement between clinicians' accounts and the DUTY CRFs, we identified a small number of potentially important symptoms and signs not included in the CRF and some included items that could have been reworded to improve understanding and final data analysis.

CONCLUSIONS

This study uniquely demonstrates the role of qualitative methods in the design and content of CRFs used for developing diagnostic (and prognostic) algorithms. Research groups developing such algorithms should consider using qualitative methods to inform the selection and wording of candidate symptoms and signs.

Uses and misuses of the STROBE statement: bibliographic study

Objectives Appropriate reporting is central to the application of findings from research to clinical practice. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations consist of a checklist of 22 items that provide guidance on the reporting of cohort, case-control and cross-sectional studies, in order to facilitate critical appraisal and interpretation of results. STROBE was published in October 2007 in several journals including The Lancet, BMJ, Annals of Internal Medicine and PLoS Medicine. Within the framework of the revision of the STROBE recommendations, the authors examined the context and circumstances in which the STROBE statement was used in the past. Design The authors searched the Web of Science database in August 2010 for articles which cited STROBE and examined a random sample of 100 articles using a standardised, piloted data extraction form. The use of STROBE in observational studies and systematic reviews (including meta-analyses) was classified as appropriate or inappropriate. The use of STROBE to guide the reporting of observational studies was considered appropriate. Inappropriate uses included the use of STROBE as a tool to assess the methodological quality of studies or as a guideline on how to design and conduct studies. Results The authors identified 640 articles that cited STROBE. In the random sample of 100 articles, about half were observational studies (32%) or systematic reviews (19%). Comments, editorials and letters accounted for 15%, methodological articles for 8%, and recommendations and narrative reviews for 26% of articles. Of the 32 observational studies, 26 (81%) made appropriate use of STROBE, and three uses (10%) were considered inappropriate. Among 19 systematic reviews, 10 (53%) used STROBE inappropriately as a tool to assess study quality. Conclusions The STROBE reporting recommendations are frequently used inappropriately in systematic reviews and meta-analyses as an instrument to assess the methodological quality of observational studies.

Syndromic surveillance for emerging infections in office practice using billing data

PURPOSE

We wanted to evaluate the feasibility of conducting syndromic surveillance in a primary care office using billing data.

METHODS

A 1-year study was conducted in a primary care practice; comparison data were obtained from emergency department records of visits by county residents. Within the practice, a computer program converted billing data into de-identified daily summaries of International Classification of Diseases, Ninth Revision (ICD-9) codes by sex and age-group; and a staff member generated daily summaries and e-mailed them to the analysis team. For both the practice and the emergency departments, infection-related syndromes and practice-specific thresholds were calculated using the category 1 syndrome codes and an analytical method based upon the Early Aberration Reporting System of the Centers for Disease Control and Prevention.

RESULTS

A mean of 253 ICD-9 codes per day was reported. The most frequently recorded syndromes were respiratory illness, gastrointestinal illness, and fever. Syndromes most commonly exceeding the threshold of 2 standard deviations for the practice were lymphadenitis, rash, and fever. Generating a daily summary took 1 to 2 minutes; the program was written by the software vendor for a fee of dollar 1,500. During the 2003-2004 influenza season, trend line patterns of the emergency department visits reflected a pattern consistent with that of the state, whereas the trend line in primary case practice cases was less consistent, reflecting the variation expected in data from a single clinic. Still, spikes of activity that occurred in the practice before the emergency department suggest the practice may have seen patients with influenza earlier.

CONCLUSIONS

This preliminary study showed the feasibility of implementing syndromic surveillance in an office setting at a low cost and with minimal staff effort. Although many implementation issues remain, further development of syndromic surveillance systems should include primary care offices.

Patients' perceptions of cholesterol, cardiovascular disease risk, and risk communication strategies

PURPOSE

Despite some recent improvement in knowledge about cholesterol in the United States, patient adherence to cholesterol treatment recommendations remains suboptimal. We undertook a qualitative study that explored patients' perceptions of cholesterol and cardiovascular disease (CVD) risk and their reactions to 3 strategies for communicating CVD risk.

METHODS

We conducted 7 focus groups in New England using open-ended questions and visual risk communication prompts. The multidisciplinary study team performed qualitative content analysis through immersion/crystallization processes and analyzing coded reports using NVivo qualitative coding software.

RESULTS

All participants were aware that "high cholesterol" levels adversely affect health. Many had, however, inadequate knowledge about hypercholesterolemia and CVD risk, and few knew their cholesterol numbers. Many assumed they had been tested and their cholesterol concentrations were healthy, even if their physicians had not mentioned it. Standard visual representations showing statistical probabilities of risk were assessed as confusing and uninspiring. A strategy that provides a cardiovascular risk-adjusted age was evaluated as clear, memorable, relevant, and potentially capable of motivating people to make healthful changes. A few participants in each focus group were concerned that a cardiovascular risk-adjusted age that was greater than chronological age would frighten patients.

CONCLUSIONS

Complex explanations about cholesterol and CVD risk appear to be insufficient for motivating behavior change. A cardiovascular risk-adjusted age calculator is one strategy that may engage patients in recognizing their CVD risk and, when accompanied by information about risk reduction, may be helpful in communicating risk to patients.