Recommendations for translation and reliability testing of International Spinal Cord Injury Data Sets

OBJECTIVE

To provide recommendations regarding translation and reliability testing of International Spinal Cord Injury (SCI) Data Sets.

SETTING

The Executive Committee for the International SCI Standards and Data Sets.

RECOMMENDATIONS

Translations of any specific International SCI Data Set can be accomplished by translation from the English version into the target language, and be followed by a back-translation into English, to confirm that the original meaning has been preserved. Another approach is to have the initial translation performed by translators who have knowledge of SCI, and afterwards controlled by other person(s) with the same kind of knowledge. The translation process includes both language translation and cultural adaptation, and therefore shall not be made word for word, but will strive to include conceptual equivalence. At a minimum, the inter-rater reliability should be tested by no less than two independent observers, and preferably in multiple countries. Translations must include information on the name, role and background of everyone involved in the translation process, and shall be dated and noted with a version number.

CONCLUSION

By following the proposed guidelines, translated data sets should assure comparability of data acquisition across countries and cultures. If the translation process identifies irregularities or misrepresentation in either the original English version or the target language, the working group for the particular International SCI Data Set shall revise the data set accordingly, which may include re-wording of the original English version in order to accomplish a compromise in the content of the data set.

A phase I study evaluating a novel schedule of oral eniluracil (EU) combined with escalating doses of oral 5-fluorouracil (5- FU)

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Background: 5-FU, a commonly utilized cytotoxic, is rapidly catabolized by dihydropyrimidine dehydrogenase (DPD), and requires anabolic conversion for anti-tumor activity. It has poor oral bioavailability due to DPD in the GI tract and liver, and toxicities such as hand-foot skin reaction. In addition, high levels of DPD are associated with 5-FU resistance. EU is a mechanism-based irreversible inactivator of DPD. Early studies in combination with oral 5-FU demonstrated activity; however, 3 Phase 3 studies were negative, due to an unrecognized inhibition of 5-FU anabolic activation by EU (Fourie et al; 2006 ASCO Proceedings; a 2058). Lower doses of eniluracil given 12–20 hrs prior to 5- FU preserves the desired DPD inhibition, without inhibiting these anabolic enzymes. Methods: The objectives are to determine the dose limiting toxicities (DLTs) and maximum tolerated dose (MTD), safety, tolerability, pharmacokinetics (PK), and DPD activity in peripheral blood mononuclear cells (PBMCs) following administration of a fixed dose of EU in combination with escalating doses of 5-FU. The combination of oral 5.0 mg EU 12 to 20 hours prior to oral 5-FU, is given qW for 3 weeks in 28 day cycles. Results: Twenty subjects have been enrolled, at 5-FU doses of 30, 40, 50, 60, and 70 mg. A total of 39 cycles have been administered, with 4 patients currently on study. The oral combination of EU and 5-FU has been well tolerated. All toxicities have been grade 1 or 2 with the exception of two grade 3 toxicities reported at the 50mg dose (anemia and neutropenia). The grade 3 neutropenia is the only observed DLT and resulted in a 1 week delay in initiation of cycle 2. No CR or PR noted, but 4 patients (2 previously treated with 5-FU) with 4 cycles of SD. 95–100% of DPD inhibition achieved at the time of 5-FU dosing and PK results demonstrate a dose proportional increase in 5-FU Cmax and AUC, and a half life of ∼3.5 hours. Conclusions: The oral combination of 5mg of EU given 12–20 hrs prior to 5-FU has been well tolerated and achieves full functional inhibition of DPD in all patients. The MTD is not yet defined and the next cohort is enrolling at the 80mg dose. EU in combination with 5-FU may provide a promising therapeutic option for patients with tumors known to be resistant to 5-FU due to high levels of DPD.

No significant financial relationships to disclose.

International Spinal Cord Injury Core Data Set

STUDY DESIGN

Survey of expert opinion, feedback, and development of final consensus.

OBJECTIVE

Present the background, purpose, development process, and results for the International Spinal Cord Injury (SCI) Core Data Set.

SETTING

International.

METHODS

A committee of experts was established to select and define data elements to be included in an International SCI Core Data Set. A draft core data set was developed and disseminated to appropriate organisations for comment. All suggested revisions were considered, and a final version of the core data set was disseminated again for approval and adoption.

RESULTS

The core data set consists of 24 variables, including basic demographic characteristics, dates of admission and discharge from initial acute and rehabilitation care, cause of injury, place of discharge, presence of vertebral fractures and associated injuries, occurrence of spinal surgery, and measures of neurological and ventilator status.

CONCLUSION

Collection of the core data set should be a basic ingredient of all future studies of SCI to facilitate accurate description of patient populations and comparison of results across published studies from around the world.

International Spinal Cord Injury Data Sets

STUDY DESIGN

Discussion and development of final consensus.

OBJECTIVE

Present the background, purpose, and process for the International Spinal Cord Injury (SCI) Data Sets development.

SETTING

International.

METHODS

An international meeting on SCI data collection and analysis occurred at a workshop on May 2, 2002, before the combined meeting of the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) in Vancouver, British Columbia, Canada. At this meeting, a process was developed for selection of data elements to be included in International SCI Data Sets.

RESULTS

An overall structure and terminology has been developed following the format of the International Classification of Functioning, Disability and Health (ICF). This includes definitions of the Core Data Set, as well as Modules with Basic Questions or Data Sets and Expanded Data Sets. The Core Data Set has been developed and will be presented separately. Working groups for additional modules are being established as well as general guidelines for the development of the modules.

CONCLUSION

The presented format should help in developing data sets and modules within various topics related to SCI.

The impact of airbags and seat belts on the incidence and severity of maxillofacial injuries in automobile accidents in New York State

OBJECTIVE

To evaluate the effect driver-side and passenger-side airbags have had on the incidence and severity of maxillofacial trauma in victims of automobile accidents.

DESIGN

Retrospective analysis of all automobile (passenger cars and light trucks) accidents reported in 1994.

SETTING

New York State.

PATIENTS

Of the 595910 individuals involved in motor vehicle accidents in New York in 1994, 377054 individuals were initially selected from accidents involving cars and light trucks. Of this subset, 164238 drivers and 62755 right front passengers were selected for analysis.

MAIN OUTCOME MEASURES

Each case is described in a single record with approximately 100 variables describing the accident, eg, vehicle, safety equipment installed and utilized or deployed, occupant position, patient demographics, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses, and procedural treatments rendered. A maxillofacial trauma severity scale was devised, based on the ICD-9-CM diagnoses.

RESULTS

Individuals using airbags and seat belts sustained facial injuries at a rate of 1 in 449, compared with a rate of 1 in 40 for individuals who did not use seat belts or airbags (P<.001). Those using airbags alone sustained facial injuries at the intermediate rate of 1 in 148, and victims using seat belts without airbags demonstrated an injury rate of 1 in 217 (P<.001).

CONCLUSION

Use of driver-side airbags, when combined with use of seat belts, has resulted in a decrease in the incidence and severity of maxillofacial trauma.

Preliminary study of in vivo autofluorescence of nasopharyngeal carcinoma and normal tissue

BACKGROUND AND OBJECTIVE

In nasopharyngeal cancer, conventional white light endoscopy does not provide adequate information to detect the flat/small lesion and identify the margin of observable tumor. In the present study, we evaluate the potential of light-induced fluorescence spectroscopic imaging for the localization of cancerous nasopharyngeal tissue.

STUDY DESIGN/MATERIALS AND METHODS

We built a multiple channel spectrometer specifically for the investigation of fluorescence collected by a conventional endoscopic system. Nasopharyngeal fluorescence were measured in vivo from 27 subjects during the routine endoscopy. The biopsy specimens for histologic analysis were taken from the tissue sites where the fluorescence were measured.

RESULTS

Two algorithms to discriminate the nasopharyngeal carcinoma from normal tissue were created based on the good correlation between the tissue autofluorescence and histologic diagnosis. For the two-wavelength algorithm, carcinoma can be differentiated from normal tissue with a sensitivity and specificity of 93% and 92%, respectively. For the three-wavelength algorithm with compensation of variation of blood content in tissue, a sensitivity of 98% and specificity of 95% were achieved.

CONCLUSION

Fluorescence endoscopic imaging used with the algorithms developed in this report is an efficient method for detecting the nasopharyngeal carcinoma.

Management of an unstable lumbar fracture with a laminar split

This is a case report describing the injury sustained by a 36-year-old man injured in a motorcycle crash who sustained a fracture dislocation of L2 upon L3, associated with a split in the lamina of L3. His neurologic lesion was T12 ASIA B: with a motor score of 52 but with preservation of sensory function (sensory score 96) in most parts of his lower extremities. He also suffered a lower extremity fracture. Imaging of the spine is presented showing a multiplanar fracture associated with translation and with a defect in the lamina that may be seen in certain AO type B or type C fractures, that may entrap the lumbar spinal nerve roots. Discussants of this case comment on the classification and clinical significance of this fracture pattern. and present their operative approaches, both for management of this particular fracture pattern and for any associated dural tear. The issues of steroid use and the place of rehabilitation are also discussed.

The influence of surveillance methods on surgical wound infection rates in a tertiary care spinal surgery service

STUDY DESIGN

A 1-year prospective study of the influence of surveillance methods on the surgical wound infection rates in a tertiary care spinal surgery unit.

OBJECTIVES

To assess the effect of postdischarge surveillance, the diagnostic indications for surgery, and the type of procedure on the surgical wound infection rates.

SUMMARY OF BACKGROUND DATA

Use of the National Nosocomial Infection Surveillance system for surgical wound infection resulted in infection rates above the published values for procedures performed by the Spinal Surgical Service. A preliminary review failed to find causes for these higher rates, and a study was undertaken to assess the influence of the surveillance methods used.

METHODS

Patient information collected by the Spinal Surgical Service and surveillance data obtained by infection control were combined in a relational database. Surveillance after discharge was performed by regularly sending questionnaires to surgeons' offices. The diagnostic indications were assessed by dividing all patients into three groups: Class D (disc disease or spinal stenosis). Class T (spinal trauma within 60 days), and Class M (mostly complex spinal procedures for deformity and instability). Infection rates for the three diagnostic indication classes and for procedures with and without instrumentation were calculated.

RESULTS

Postdischarge surveillance significantly increased the infection rates, mostly by detecting superficial infections that did not require readmission. Significant differences were noted between Class T and Class M patients undergoing lumbar posterior segmental instrumentation, despite the fact that they had a similar incidence of risk factors according to the National Nosocomial Infection Surveillance system. The surgical wound infection rates of the National Nosocomial Infection Surveillance system may not be appropriate standards for specialized units with a high incidence of complex clinical problems and complicated surgical procedures.

CONCLUSIONS

Postdischarge surveillance, surgical procedure classification methods, and the indications for surgery (e.g., trauma, congenital deformity) influence the surgical wound infection rate. Current adjustments for some of these factors in the National Nosocomial Infection Surveillance system appear to be inadequate when used in a tertiary care facility.

Anesthesia providers, patient outcomes, and costs: a critique

The June 1996 article in Anesthesia and Analgesia by Abenstein and Warner entitled "Anesthesia Providers, Patient Outcomes, and Costs" presents important information about anesthesia services, but it contains a number of errors and questionable interpretations that could lead to inappropriate programs and policies. Among the most important points of fact we clarify in our paper are: 1. Three organizations that accredit, certify, and govern nurse anesthetists are organized in similar fashion to three comparable bodies governing anesthesiologists. There is no justification for the implication that the AANA somehow controls the accreditation and certification of CRNAs. 2. The conclusion that anesthesiologistled care teams are the preferred model for all anesthesia services and settings because of improved patient outcomes is overly simplistic and is not borne out in the literature. 3. The attribution of reduced mortality from anesthesia over the past 40 years to the increase in numbers of anesthesiologists is not justified. Many other factors, including new anesthetic agents and improved patient monitoring, also are important. 4. The use of a hypothetical example related to Medicare reimbursement in New York to justify the implication that CRNA-delivered services are more costly than anesthesiologist-delivered services is misleading and not borne out in the literature. We hope that planners and policy makers will read the article by Abenstein and Warner with extreme caution. Taking some of their statements and conclusions seriously could lead to policies and programs that are not focused in science.

Graduate medical education and physician supply in New York State

OBJECTIVES

To estimate the supply of physicians and residents in New York State and to assess the impact of state policies on the supply and distribution of physicians in the state.

DESIGN

A comparison of the number of residents in New York State for 1988 and 1994 (from the American Medical Association Medical Education Database) and the number of active patient care physicians in New York by specialty and age (from the 1995 New York State Physician File).

MAIN OUTCOME MEASURES

Changes in the number of residents in New York State between 1988 and 1994 by specialty and medical school location; estimates of the numbers of physicians by age and specialty in New York for 1995; the migration of new physicians into and out of the state.

RESULTS

The number of residents in New York State grew by nearly 21% between 1988 and 1994, despite a number of policies and programs encouraging maintenance of production levels. This growth is attributed to increases in the number of international medical graduates (IMGs) entering residency training through a widening "IMG window." Projection models show that, if production of new physicians continues as current levels, the supply of physicians will grow substantially during the next 2 decades.

CONCLUSIONS

Past policies to influence the supply, production, and distribution of physicians in New York State have not had their desired effects. Future policies and incentives must be carefully framed and coordinated to avoid similar failures.

Long term stability of somatosensory evoked potentials and the effects of microgravity

BACKGROUND

Exposure to microgravity causes a height increase of up to 70 mm that places traction on the spine and may possibly lead to spinal cord dysfunction. Somatosensory evoked potentials (SSEP) have been widely used to monitor spinal cord function. This study was carried out to determine the long-term stability of the latency of SSEP's in individual subjects and the feasibility of recording SSEP's in a microgravity environment.

METHODS

Baseline values and variability of the latency of the cortical evoked potentials were established in seven subjects over periods of 1-2.5 years. These values were then compared with measurements made in six of the subjects during periods of microgravity on a KC-135 aircraft. The latency of the cortical potentials was also measured in the evening and in the morning before rising in a separate group of seven subjects, to determine whether there was any diurnal variation.

RESULTS

The mean coefficient of variance of the latency of the SSEP was approximately 1.5% of the latency, and there were no changes in the latency over the period studied. There was no evidence of diurnal variation in the latency of the cortical SSEP. Satisfactory recordings of the SSEP were obtained in five of six subjects tested in microgravity. In three of these five subjects there was a significant decrease in the latency of the cortical SSEP in microgravity.

CONCLUSIONS

In individual subjects the latency of the cortical SSEP varies within very small limits (1.5%) over 1-2.5 years. The results demonstrate the feasibility of recording SSEP's in the microgravity state. They show that relatively small changes (2-3 ms) in the latency of the SSEP can be detected when prior baseline values are established for each subject. The reason for the decrease in latency of the cortical SSEP in some subjects on the KC-135 is not known.

A pilot study of anabolic steroids in elderly patients with hip fractures

OBJECTIVE

To determine the safety and efficacy of the anabolic steroid nandrolone in elderly patients with hip fractures.

DESIGN

A randomized double-blind placebo-controlled trial.

SETTING

The orthopedic ward of a university teaching hospital.

PARTICIPANTS

29 frail elderly females with hip fractures.

INTERVENTION

Subjects received nandrolone 2 mg/kg (n = 15) or placebo (n = 14) by weekly injection for 4 weeks or until discharge.

MEASURES

Baseline functional status was assessed by the Lawton-Brody ADL and IADL. Hemoglobin, transferrin, thyroid-binding prealbumin, albumin, liver function tests, creatinine, weight, MAMC, bioelectric impedance, standard anthropometrics and grip strength were measured at baseline and weekly intervals. Rehabilitation parameters and length of stay were recorded.

RESULTS

The placebo and nandrolone groups were similar in age, although the control group had slightly higher baseline ADL scores. There was no difference between groups in biochemical parameters, anthropometrics, body composition, grip strength, rehabilitation end points or length of stay. One subject in the nandrolone group had a doubling of AST and was withdrawn from the study.

CONCLUSIONS

Nandrolone can be given safely to frail elderly subjects with hip fractures but is likely to be of minimal benefit at the doses we employed.

Diurnal changes in the profile shape and range of motion of the back

The diurnal height change reported to occur in young adults was investigated to characterize changes in the lumbar range of motion, spinal profile, and range of motion of the back. Twelve subjects aged 18-22 years were measured using stereophotography and standard clinical examinations in the evening and after a minimum of 8 hours of complete bed rest. The average increase in height was 20 mm. Forty percent of the height increase took place in the lumbar spine without change in the depth of the lordosis, and forty percent took place in the thoracic curve with a decrease in the kyphosis. The remaining 20% of the height increase was not located, but no measurements were taken of the cervical spine. Range of motion studies revealed that lumbar flexion, as measured using the lumbar flexion increment, was decreased in the morning, and straight leg raise was decreased when measured clinically but not when measured photographically. Extension, rotation, and femoral stretch test were not affected. The authors conclude that stereophotogrammetry offers an accurate, noninvasive way to study spinal profiles. Further work is needed to assess and quantify the relative motion of the skin and the underlying structures.

Investigation of the Knoll Assessment Scale in a tertiary care facility

The purpose of this study was to assist in assessing the validity and reliability of adaptation of the Knoll Tool, Assessment of Pressure Ulcer Potential. Data were retrospectively collected from charts of a random sample of patients (n = 62) who were admitted to a tertiary care facility. Total risk scores ranged from 0 to 22 with a mean of 8.7 and a standard deviation of 6.37. The alpha for the total assessment tool was .6352 with a standardized item alpha of .5973. Discriminant analysis predicted group membership at 62.9%. Group membership was most accurately predicted in Group 1 (76.9%). Discriminant analysis using a score of 11 predicted only 46.8% of group membership, although Group 1 predicted 88.5% and Group 4 predicted 85.7%. Low predictions may be related to small sample size.

Predictive value of the Glasgow Coma Scale for tracheotomy in head-injured patients

Patients with severe head trauma often require prolonged intubation and subsequent tracheotomy. The Glasgow Coma Scale (GCS), an indicator of the severity of head injury, may help identify that subpopulation of trauma victims who will ultimately undergo tracheotomy. This retrospective study demonstrates through discriminant analysis that the likelihood of tracheotomy is significantly greater in patients with a GCS rating less than or equal to 7 than it is in patients with a GCS rating greater than 7 (p = .0001). Conversely, the presence of thoracoabdominal or maxillofacial injury is associated with but not predictive of eventual tracheotomy. In the hope of minimizing complications and enhancing the utilization of hospital resources, this study argues for early tracheotomy in patients with a GCS score less than or equal to 7 who do not undergo craniotomy and are otherwise stable.

The availability of physician services: a geographic analysis

This article describes a new technique for estimating the availability of physician services in small geographic areas. Given counts or estimates of the number of physicians practicing in small geographic areas (e.g., zip codes), the technique allocates a portion of the services of each physician in an area to his home area and to nearby areas in proportion to both the propensity of patients to travel for medical care and the availability of potential patients. The longer the time required for a patient to travel to the physician, the smaller the proportion of the physician's services allocated to the patient's area, with the precise relationship determined by a special analysis. The final estimate of the availability of physician services in each small area is the sum of the service proportions of every physician in all of the small areas. The total supply of physician services is the same as the original total, but the distribution is adjusted to reflect the time that patients are willing to spend traveling to obtain medical care. Although this technique requires considerable data processing, it permits more accurate estimation of the supply of physician services in small geographic areas than is possible with traditional methods. It better represents the probabilistic and interpenetrating nature of physician service areas than alternative techniques and appears to be particularly applicable in estimating the supply of primary care physician services. Actual data for pediatricians and children in northeastern New York using zip codes as the geographic units illustrate the technique. Limitations, applications, and possible extensions are discussed.

Computer simulation of hospital patient scheduling systems

A method of analyzing alternative systems of scheduling hospital admissions by means of a computer simulation is described. The simulation is divided into three programs, dealing sequentially with requests for admission, scheduling, and evaluation of costs of three basic scheduling systems and using the output of each phase of the simulation as input to the following phase. The feasibility of using the scheduling program in a real-time automated patient-scheduling system is discussed, with indications of adaptations required and additional functions that could be handled by the system.