Participation in pediatric epidemiologic research: the SEARCH for Diabetes in Youth Study experience

BackgroundWe evaluated the association of demographic and clinical characteristics with participation in an epidemiologic study of diabetes mellitus among youth.MethodsSEARCH for Diabetes in Youth is a multicenter study of physician-diagnosed diabetes in youth under the age of 20 comprising a surveillance and a cohort component. At each center, we enumerated all prevalent cases of diabetes in 2001 (n = 6266) and all incident cases between 2002 and 2004 (n = 3668). After confirmation of eligibility and validation, we invited each case to complete a survey and participate in a study visit. Here we evaluate how age, sex, race, and diabetes type are associated with participation in the survey and study visit.ResultsAmong prevalent cases, participation in the survey was 68% and 41% in the study visit. Among 2002 to 2004 incident cases, participation varied for the survey (76%, 81%, and 82%) and study visit (52%, 60%, and 60%). In multivariate logistic regression analyses among all incident cases, older age was associated with a lower odds of participation in the study visit (15–17 vs. < 10 years: OR 0.5, 95% CI 0.4–0.7; 18–19 vs. < 10 years: OR 0.3, 95% CI 0.2–0.5), as was having type 2 diabetes vs. type 1 diabetes (OR 0.5, 95% CI 0.4–0.7) and being of African American race vs. non-Hispanic White (OR 0.6, 95% CI 0.4–0.8). Results were very similar among prevalent cases.ConclusionsElucidating the relationship between individual characteristics and participation is essential for evaluating nonresponse bias, correcting for it, and for planning and implementing recruitment strategies.     

Design, feasibility, and acceptability of an intervention using personal digital assistant-based self-monitoring in managing type 2 diabetes

BackgroundThe information processing demands associated with behavioral self-management of diabetes are extensive. Pairing personal digital assistant (PDA)-based self-monitoring with a behavioral self-management intervention may improve adherence and patient outcomes.MethodsENHANCE is a randomized controlled trial to test an intervention designed to improve regimen adherence in adults with type 2 diabetes. The intervention, based on Social Cognitive Theory (SCT), is paired with PDA-based self-monitoring. In this paper we describe the: (a) manner in which PDA-based self-monitoring is integrated within the SCT-based intervention, (b) feasibility and acceptability of PDA-based dietary self-monitoring, and (c) issues encountered in teaching participants to self-monitor using a PDA.ResultsDuring the first 30 months of this 5-year study, 232 participants were screened and 151 were randomized. To date, 6 cohorts have completed the study. The retention rate is 85% (n = 129). Of those randomized to the intervention (n = 74) and completing the study (n = 61), 88% reported understanding the usefulness of PDA-monitoring, 85% reported ease in entering foods into the device, 70% reported ease in interpreting feedback graphs, and 82% indicated that they would continue to use the PDA for self-monitoring after the study concluded. Assuming 3 meals per day, participants entered an average of 58% of their meals in their PDA, and 43% were entered assuming 4 meals per day. If we eliminate from the analysis those individuals who entered less than 10% of their expected meals (n = 12), the average rate of self-monitoring was 69% assuming 3 meals per day, and 52% assuming 4 meals per day.ConclusionsPDA-based dietary monitoring is perceived by participants to be useful and acceptable. The approach used to instruct participants in use of the PDA and lessons learned are discussed. PDA technology shows promise as a tool for assisting those with type 2 diabetes in their efforts to manage their disease.     

Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate among Healthy Young Adults without Cervical or Lumbar Symptoms

This study examined the false positive rate of the upper limb neural tension test (ULNTT) and seated slump test (SST) among healthy young adults with no history of cervical, lumbar, or peripheral symptoms. Eighty-four subjects (27 men and 57 women) with a mean age of 22.9 years participated in the investigation. All participants completed a screening questionnaire designed to exclude subjects with a history of cervical or lumbar spine pain or injury, or upper or lower extremity neurological symptoms. The ULNTT and the SST were performed on the left upper and lower extremity of each participant. Of the 84 participants tested, 73 (86.9%) were found to have a positive ULNTT at some point in the available range of elbow extension. Twenty-eight (33.3%) of the 84 subjects had a positive SST at some point in the available range of knee extension. The mean knee extension angle for those subjects with a positive SST was 15.1° with a 95% confidence interval (CI) of 12.3 and 19.7°. The mean elbow extension angle for those with a positive ULNTT was 49.4° with a 95% CI of 44.8 and 54.0°. The number of positive tests for both the ULNTT and the SST was found to be high in this sample of asymptomatic healthy young adults. Based on the results of this investigation, the authors suggest that the current criteria for determining a positive test for both the ULNTT and the SST should be examined using the proposed range of motion cut-off scores.Key Words: Neural Tension Testing, Neurodynamics, Radiculopathy, Test ValidityPhysical therapists and other healthcare providers use neural tension tests (neurodynamic tests) as part of the clinical examination to help differentiate the underlying pathoanatomic structures^1–7. The most common neural tension tests include the straight leg raise test (SLR), the seated slump test (SST), and the upper limb neural tension test (ULNTT)^1–7. The advancement of neural tension testing, particularly the SST and ULNTT, is credited to Butler^1,2, Elvey³, Shacklock^6,7, and Maitland^5,8,9. Today, neural tension testing has become a ubiquitous part of the orthopedic physical therapy examination. Despite numerous publications and the common use of these tests, there is relatively little scientific evidence available to support the diagnostic accuracy of these tests⁶.Several investigations have shown that a combination of specific body movements can create tension and gliding of neural tissues within the confines of the musculoskeletal system^10,11. If a nerve or nerve root becomes inflamed or damaged by chemical mediators, macroscopic or microscopic trauma, or entrapment, normal functional movements can produce or exacerbate neural mediated signs or symptoms^1,3,11–13. Chronic repetitive compression or traction can result in both intraneural and extraneural pathology^1,12. Nerve injury of this type is often manifested by sensory changes such as paresthesias and neurological signs such as motor weakness; and altered deep tendon reflexes can result from prolonged neural insult^11–13. Therefore, neural tension testing that places mechanical tension on the nervous system has the potential to serve as a useful clinical test to help differentiate between neural and non-neural anatomic structures^1,4,6,12.There are three common upper limb tension tests that assess neural tissues originating from the C5 to T1 nerve roots^1,4. The most commonly used ULNTT has been defined as (ULNTT 1) and is thought to emphasize tension on the median nerve^1,2,6,14. This test consists of a combination of scapular depression, shoulder abduction and external rotation, elbow extension, forearm supination, wrist and finger extension, and cervical lateral flexion first away from the tested extremity and then toward the tested extremity^1,2. Although the literature is not consistent, the ULNTT is often considered positive when there is a production of neural-mediated symptoms during elbow extension, and reduction of symptoms or an increase in elbow extension when the cervical spine is laterally flexed toward the involved extremity^1,2. This last maneuver is referred to as structural differentiation and is used to differentiate a neurodynamic response from a musculoskeletal response⁶.Shacklock⁶ stated that a musculoskeletal response (symptoms, range of motion, or resistance to movement) remains constant during differentiation, while a neurodynamic response is present when the symptoms, range of motion, or resistance to movement changes during structural differentiation. According to Shacklock, an overt abnormal neurodynamic response requires positive structural differentiation and reproduction of the patient''s symptoms⁶.Sandmark and Nisell¹⁵ determined that the ULNTT 1 has a sensitivity of 0.77 and a specificity of 0.94 in a sample of patients with neck pain. The intra-tester reliability of the ULNTT 1 in asymptomatic subjects has been reported to be 0.98^16,17. Hines et al¹⁸ reported poor inter-tester reliability when assessing resistance to movement rather than patient response based on structural differentiation.The SST is thought to examine the sensitivity of neural structures including meningeal tissues, nerve roots, and the sciatic and tibial nerves^4,5. The SST involves the patient sitting on the edge of the examination plinth in a slumped or slouched position (flexion of the thoracic and lumbar spine and a posterior pelvic tilt), flexion of the cervical spine with gentle manual overpressure, and passive extension of the subject''s knee, while the ankle is dorsiflexed. This sequence is referred to as ST1 by Butler¹. A positive test again requires structural differentiation by noting a change in symptoms, range of motion, or resistance when the cervical spine is extended and that reproduces the patient''s symptoms⁶.In a study examining patients with suspected herniated nucleus pulposus, Stankovic et al¹⁹ found the diagnostic sensitivity of the SST to be 0.83 and the specificity to be 0.55. Additionally, a study performed by Gabbe et al²⁰ found the intra-rater reliability using ICC_(3,1) as 0.95 and 0.80, while the inter-rater reliability was found as 0.92 using ICC_(2,1). Philip and Lew²¹ found strong agreement among physical therapists (Kappa = 0.89) when defining a positive test as reduction of symptoms and increased knee ROM upon cervical extension.As stated previously, several modifications have been proposed for both the SST and the ULNTT; thus, there is not a universally accepted procedure for either test^1,5. One suggested modification is to have proximal or distal initiation of the testing sequence⁶. In the distal-initiated SST, the subject''s ankle is dorsiflexed first for pretension of the sciatic and tibial nerves. In the proximal-initiated test, the subject is asked to flex the cervical spine first for pretension of the dura. A second alteration of the SST is to have the subject axially rotate the thoracic spine²². The order in which the test is performed is believed to influence the direction of neural glide but it may also affect symptom reproduction⁶.Clinical observation and experience teaching neural tension testing for many years led the present investigators to observe that many asymptomatic subjects without frank cervical, lumbar, or peripheral symptoms present with neural-mediated symptoms and positive structural differentiation when full-range testing of the SST and ULNTT is performed. Thus, clinical observation indicated that there might be an unusually high false positive rate among these tests when performing full-range testing of the elbow (ULNTT) and the knee (SST). Shacklock⁶ referred to the production of neural-mediated symptoms among asymptomatic subjects as a normal positive test and suggested reproduction of the patient''s symptoms should be an integral part of the diagnostic criteria. It should be noted that reproduction of symptoms is impossible in asymptomatic subjects (no pathology); therefore, this criteria cannot be used when examining the rate of false positive tests. Therefore, the purpose of this investigation was to determine the false positive rate of the SST and ULNTT in otherwise healthy young adults without cervical, lumbar, or peripheral symptoms and to identify possible cut-off scores based on knee (SST) and elbow (ULNTT) range of motion.     

Getting it right under pressure: action research and reflection in palliative nursing

This article describes a qualitative research project using a combination of reflection and action research. Eight experienced registered nurses identified their need to 'get it right under pressure' in their work in palliative care. Participants collaborated in generating and evaluating an action plan to enhance the likelihood of getting palliative nursing care right, under pressure, more often.     

The tibial neuroma transposition (TNT) model of neuroma pain and hyperalgesia

Peripheral nerve injury may lead to the formation of a painful neuroma. In patients, palpating the tissue overlying a neuroma evokes paraesthesias/dysaesthesias in the distribution of the injured nerve. Previous animal models of neuropathic pain have focused on the mechanical hyperalgesia and allodynia that develops at a location distant from the site of injury and not on the pain from direct stimulation of the neuroma. We describe a new animal model of neuroma pain in which the neuroma was located in a position that is accessible to mechanical testing and outside of the innervation territory of the injured nerve. This allowed testing of pain in response to mechanical stimulation of the neuroma (which we call neuroma tenderness) independent of pain due to mechanical hyperalgesia. In the tibial neuroma transposition (TNT) model, the posterior tibial nerve was ligated and transected in the foot just proximal to the plantar bifurcation. Using a subcutaneous tunnel, the end of the ligated nerve was positioned just superior to the lateral malleolus. Mechanical stimulation of the neuroma produced a profound withdrawal behavior that could be distinguished from the hyperalgesia that developed on the hind paw. The neuroma tenderness (but not the hyperalgesia) was reversed by local lidocaine injection and by proximal transection of the tibial nerve. Afferents originating from the neuroma exhibited spontaneous activity and responses to mechanical stimulation of the neuroma. The TNT model provides a useful tool to investigate the differential mechanisms underlying the neuroma tenderness and mechanical hyperalgesia associated with neuropathic pain.