Children's drawings as a measure of anxiety level: a clinical pilot study

BACKGROUND: No simple method exists to distinguish children in need for premedication. The present study was planned to detect preoperative anxiety levels of children by rating their drawings. METHODS: Sixty ASA I children aged 4-7 years undergoing adenoidectomy were divided into AGIT and CALM groups according to agitation level observed during venous cannulation. All children drew a picture at three different times: (i) just after arrival in the day-case unit, (ii) 10 min before operation and, (iii) prior to leaving for home. The children were also randomized to three premedication groups: group D, rectal diazepam 0.5 mg x kg(-1); group P, 0.9% NaCl 0.1 ml x kg(-1) rectally; group NT, no premedication. Five features (size of the drawing, form of the drawing line, colors used, mark of the pen and clarity of the picture) from the children's drawings were rated with a 3-point scale. The ratings of each feature were made to form a sum score of anxiety ranging from 0 to 10. In the analysis of variance for repeated measures both the premedication group and agitation score were taken into the model as factors. RESULTS: The anxiety score of the drawings of the agitated children (during venous cannulation) was significantly higher already after arrival in the hospital [AGIT 4.76 (95% CI: 3.56-5.96) Vs CALM 3.67 (95% CI: 2.97-4.37) P = 0.029], but there were no statistical differences between the different premedication groups. CONCLUSIONS: When routine sedative premedication is not used the drawings of the children might detect the children needing sedative premedication.     

Intra-abdominal pressure measurement: validation of intragastric pressure as a measure of intra-abdominal pressure

Background: The diagnosis of abdominal compartment syndrome depends uponthe demonstration of an elevated intra-abdominal pressure (IAP).Direct measures of IAP are impractical in the critical careunit; intravesical pressure (IVP) and intragastric pressure(IGP) should represent acceptable surrogate measures. IVP isthe preferred measure of IAP in critical care. We consideredthat IGP represents a practical alternative. The objective ofthis preliminary study was to observe the relationship betweenIGP and IAP. Methods: After Institutional Ethics Board approval, 29 patients havingelective laparoscopic surgery were recruited. IAP was measureddirectly via the abdominal trochar. This was compared with IGPmeasured via a commercial balloon catheter placed into the stomach. Results: Measured IGP was always more positive than IAP; both showedlinear correlation (r²>0.9). When IGP was calibrated againstIAP, an estimated difference between the IGP and IAP of ±2.5 mm Hg for 95% of the measurements was seen. Conclusions: The study demonstrates the strength of the relationship betweenIGP and IAP in normal individuals. Application of IGP measurementin the critical care patient is necessary to demonstrate itssuitability for continuous IAP assessment.     

A maze test as a measure of recovery from anesthesia

This study investigated whether a paper and pencil maze test measuring the path length traced in 1 minute is a useful test of postoperative recovery from anesthesia. Fifty volunteer nonsurgical subjects were tested with four similar mazes to detect any improvement of scores with practice and learning. This improvement was found to occur in 46% of subjects and could be compensated for by a single practice attempt before taking the baseline score. The maze test was then evaluated in a double-blind randomized study of adult day surgery patients using two different anesthetics. There was a correlation between postoperative maze scores and a patient-assessed visual analogue sedation scale, and both the maze test and the sedation scale showed a significant difference between the two different anesthetic techniques 30 minutes after anesthesia. The postoperative maze scores were found to be normally distributed. Postoperative maze scores usually returned to preoperative baseline values before patients assessed themselves fully recovered from anesthesia. It is concluded that the maze test can be used as a reliable and valid test of early postoperative recovery but it is not useful for assessing late recovery or street fitness.     

The bubble test as a measure of amniotic fluid surfactant and as a predictor of hyaline membrane disease

The bubble test was compared with the lecithin-sphingomyelin (L/S) ratio and total phospholipids (TPL) test as a measure of fetal lung surfactant in the amniotic fluid. Of 161 patients, all but 1 with a bubble score of 2 + or more also had mature L/S ratios and TPL values, whereas those with a bubble score of 0 - 1 + had L/S ratios and TPL values ranging from immature to mature. A total of 161 patients who delivered within 72 hours of TPL test and bubble test were assessed for the presence of hyaline membrane disease (HMD). No cases of HMD were associated with a bubble score of 2+ or more. However, the fetuses of 10 of 66 patients with a bubble score of 0 or 1 + developed HMD.     

The "forgotten joint" as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure

With improving patient outcome after joint arthroplasty, new assessment tools with increased discriminatory power especially in well-performing patients are desirable. The goal of the present study was to develop and validate a new score ("Forgotten Joint Score," or FJS) introducing a new aspect of patient-reported outcome: the patient's ability to forget the artificial joint in everyday life. After a pilot study, the FJS was validated and showed high internal consistency (Cronbach α = .95). Ceiling effects were considerably lower for the FJS (9.2%) compared with the Western Ontario and McMaster Universities subscales (16.7%-46.7%). Known-group comparisons proved the FJS to be highly discriminative in a validation sample of 243 patients. The FJS not only reflects differences between "good" and "bad" but also between "good," "very good," and "excellent" outcomes. This concise score is appealing for its more adequate measurement range and because it measures the new, promising concept of the "forgotten joint."     

Productivity versus availability as a measure of faculty clinical responsibility

Faculty clinical time is an extremely valuable commodity. Most departments quantify faculty clinical time on an "availability" basis (e.g., number of days in the operating room or nights on call). We hypothesize that a productivity measure (i.e., determination of actual clinical care delivered rather than availability of such care) would produce different results than the availability system. The "billable hour" was chosen as the measurement device. It was defined as time that anesthesia was actually given, as obtained from the anesthetic record. After collecting data for a year, we found that despite parity using the availability system, the billable hour system detected significant differences between faculty within and between groups. We conclude that "availability" and "productivity" systems produce different conclusions regarding the relative contributions of an individual faculty or subspecialty group. IMPLICATIONS: Accountability of clinical activities by faculty is crucial to the financial status of any department of anesthesia. We hypothesized that methods of availability (e.g., amount of time scheduled for clinical activities) versus productivity measure (actual amount of clinical care delivered) would be quite different between faculty and differing subspecialty groups. Even though the availability system distributed clinical time on an equal basis, there was a wide difference of clinical productivity within and between specialty groups. We conclude that a productivity measure (i.e., billable hours) is a more accurate reflection of faculty productivity than an availability system and is more in line with departmental sources of financial income.     

Digital image analysis versus clinical assessment of wound epithelialization: a validation study

To evaluate the progress in wound healing, wound assessment is mandatory. Epithelialization is traditionally assessed subjectively by the clinician. In a previous study, subjective assessment of epithelialization was shown to be reliable. In this study, reliability of epithelialization measured by digital image analysis was investigated and then, we validated the subjective evaluation by comparing this assessment to measurements with digital image analysis. Clinicians assessed epithelialization in 50 burn wounds that were treated with a split skin graft. Epithelialization of these wounds was also measured by three observers using digital image analysis. Reliability of digital image analysis was tested using the intraclass correlation (IC). To test validity, subjective clinical assessment was correlated with digital image analysis (IC). The results showed that interobserver reliability of epithelialization measured by digital image analysis was good (IC coefficient 0.74). Subjective clinical assessment of epithelialization showed a strong correlation with digital image analysis (IC coefficient 0.80). In conclusion, subjective clinical evaluation of wound epithelialization is as good as an objective measure, in this study digital image analysis. Since digital image analysis is more time-consuming, we recommend the use of the subjective evaluation for daily practice.     

A new clinical test for radial tunnel syndrome--the Rule-of-Nine test: a cadaveric study

PURPOSE: Radial tunnel syndrome refers to pain on the lateral aspect of the forearm as a result of compression of the posterior interosseous nerve within a tunnel with specific anatomical boundaries. Diagnosis of the condition is difficult because of its close association with lateral epicondylitis, which warrants different methods of treatment. Based on a cadaveric study, a new clinical test, the Rule-of-Nine test, is proposed to improve the diagnostic accuracy in radial tunnel syndrome. The test involves constructing 9 equal squares on the anterior aspect of the forearm and noting those squares where tenderness can be elicited. METHODS: 19 upper limbs were dissected to delineate the path of the posterior interosseous nerve through the radial tunnel, and the relationship of the path of the nerve with the 9 squares. RESULTS: A consistent mapping of the posterior interosseous nerve to the lateral column of 3 squares was observed. CONCLUSION: The Rule-of-Nine test is proposed as a reliable method of diagnosing radial tunnel syndrome.     

The six-minute walk test as a measure of postoperative recovery after colorectal resection: further examination of its measurement properties

Introduction

Patients, clinicians and researchers seek an easy, reproducible and valid measure of postoperative recovery. The six-minute walk test (6MWT) is a low-cost measure of physical function, which is a relevant dimension of recovery. The aim of the present study was to contribute further evidence for the validity of the 6MWT as a measure of postoperative recovery after colorectal surgery.

Methods

This study involved a sample of 174 patients enrolled in three previous randomized controlled trials. Construct validity was assessed by testing the hypotheses that the distance walked in 6 min (6MWD) at 4 weeks after surgery is greater (1) in younger versus older patients, (2) in patients with higher preoperative physical status versus lower, (3) after laparoscopic versus open surgery, (4) in patients without postoperative complications versus with postoperative complications; and that 6MWD (5) correlates cross-sectionally with self-reported physical activity as measured with a questionnaire (CHAMPS). Statistical analysis was performed using linear regression and Spearman’s correlation. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to guide the formulation of hypotheses and reporting of results.

Results

One hundred and fifty-one patients who completed the 6MWT at 4 weeks after surgery were included in the analysis. All hypotheses tested for construct validity were supported by the data. Older age, poorer physical status, open surgery and occurrence of postoperative complications were associated with clinically relevant reduction in 6MWD (>19 m). There was a moderate positive correlation between 6MWD and patient-reported physical activity (r = 0.46).

Conclusions

This study contributes further evidence for the construct validity of the 6MWT as a measure of postoperative recovery after colorectal surgery. Results from this study support the use of the 6MWT as an outcome measure in studies evaluating interventions aimed to improve postoperative recovery.

     

The ICI classification for calcaneal injuries: a validation study

IntroductionThe integral classification of injuries (ICI), by Zwipp et al. has been developed as a classification system for injuries of the bones, joints, cartilage and ligaments of the foot. It follows the principles of the comprehensive classification of fractures by Müller et al. The ICI was developed for ‘everyday use’ and scientific purposes. Our aim was to perform a validation study for this classification system applied to the calcaneal injuries.MethodsA panel of five experienced trauma and orthopaedic surgeons evaluated the ICI score in 20 calcaneal injuries. After 2 months, a second classification was performed in a different order. Inter- and intra-observer variability were evaluated by kappa statistics.ResultsPanel members were not able to evaluate capsule and ligamental injuries based on X-ray and computed tomography (CT) films. Two injuries were excluded for logistical reasons. The inter-observer agreement based on 18 injuries of bone and joints was slight; kappa 0.14 (90% confidence interval (CI): 0.05–0.22). The intra-observer agreement was fair; kappa 0.31 (90% CI: 0.22–0.41). Overall, the panel rated the system as very complicated and not practical.ConclusionThe ICI is a complicated classification system with slight to fair inter- and intra-observer variabilities. It might not be a practical classification system for calcaneal injuries in ‘everyday use’ or scientific purposes.     

The administration and interpretation of the rapid exchange grip test: a national survey

The purpose of the present study was to determine if the administration and interpretation of the rapid exchange grip (REG) test vary among hand therapists nationally. The REG is used to determine sincerity of effort of grip strength. There are inconsistencies in the literature regarding the administration and interpretation of the REG, as various studies use different testing protocols and diverse interpretation criteria for what constitutes a sincere effort. As a result, we expected to find a lack of standardization in the administration and interpretation of the REG in clinical practice. We conducted a random nationwide survey of 200 hand therapists. The questionnaire items regarding the administration of the REG included patient position, test instructions, handle settings, handling of the dynamometer, hand switch rate, number of repetitions, and techniques used to record the score. The items for the interpretation of the REG involved questions regarding comparative tests. We found that the REG test lacks standardized administration protocols and interpretation criteria among therapists nationwide. The lack of standardization is likely to affect the reliability and validity of the REG and to hinder the therapist's ability to accurately report its outcomes. The implications of lack of standardization in assessment techniques to the profession are discussed.     

Deaths certified as asthma and use of medical services: a national case-control study

BACKGROUND: Studies have linked asthma death to either increased or decreased use of medical services. METHODS: A population based case-control study of asthma deaths in 1994-8 was performed in 22 English, six Scottish, and five Welsh health authorities/boards. All 681 subjects who died were under the age of 65 years with asthma in Part I on the death certificates. After exclusions, 532 hospital controls were matched to 532 cases for age, district, and date of asthma admission/death. Data were extracted blind from primary care records. RESULTS: The median age of the subjects who died was 53 years; 60% of cases and 64% of controls were female. There was little difference in outpatient attendance (55% and 55%), hospital admission for asthma (51% and 54%), and median inpatient days (20 days and 15 days) in the previous 5 years. After mutual adjustment and adjustment for sex, using conditional logistic regression, three variables were independently associated with asthma death: fewer general practice contacts (odds ratio 0.82 (95% confidence interval (CI) 0.74 to 0.91) per 5 contacts) in the previous year, more home visits (1.14 (95% CI 1.08 to 1.21) per visit) in the previous year, and fewer peak expiratory flow recordings (0.83 (95% CI 0.74 to 0.92) per occasion) in the previous 3 months. These associations were similar after adjustment for markers of severity, psychosocial factors, systemic steroids, short acting bronchodilators and antibiotics, although the association with peak flow was weakened and just lost significance. CONCLUSION: Asthma death is associated with less use of primary care services. Both practice and patient factors may be involved and a better understanding of these may offer possibilities for reducing asthma death.