Reliability and validity of pressure ulcer diagnosis and grading: an image-based survey

BACKGROUND: The reliability and validity of pressure ulcer diagnosis and grading are major methodological issues in studies and reports on pressure ulcer frequency. OBJECTIVES: The aim of the study was to estimate the reliability and validity of pressure ulcer diagnosis and grading within the interdisciplinary pressure ulcer project of the University Clinics of Essen, Germany. DESIGN: Fifty images of wounds from the foot/heel region and 50 images of wounds from the buttock/hip region were classified using a 4-grade scale. A gold standard was established by consensus of two senior physicians. SETTINGS: The images were assessed PC-based, independently by each rater. PARTICIPANTS: Five nursing experts and two physicians participated. METHODS: Mean simple Kappa and per cent agreement were calculated to assess reliability and validity. RESULTS: Mean simple Kappa values showed a moderate interrater agreement for grading and a fair interrater agreement for diagnosis. The percentage of agreements was highest for pressure ulcer diagnosis in the buttock/hip region with 90.5% and lowest for pressure ulcer grading in the buttock/hip region with 63.5%. No differences could be found between nurses and physicians. CONCLUSIONS: The differentiation between pressure ulcers and other skin lesions is rather difficult. It is important to assign the lower grade when the available information does not definitely support the higher grade. The level of agreement found was intermediate in the range of published results. A substantial level of agreement should be obtainable through further standardisation and training. Future studies should control for dependency in the assessment situation and dispense with the category "uncertain".     

Satisfaction and coercion among voluntary, persuaded/pressured and committed patients in acute psychiatric treatment

Rationale: Whereas the distinction between committed and voluntary admissions in mental health is clear from a legal point of view, this clarity is not always present in the patients’ experiences. Voluntary patients may be pressured or persuaded and committed patients may want admission. Aims: To compare three groups of patients – committed, voluntary and persuaded – admitted to acute psychiatric inpatient care as regards different aspects of satisfaction, treatment and experienced coercion. Method: The Sjukvårdens Planerings‐ och Rationaliseringsinstitut form and the Coercion Ladder were administered to all admitted patients on two acute wards. A total of 189 patients participated (86%). Data were analysed with nonparametric (Kruskal–Wallis, chi‐square) and parametric tests (multinominal regression). Results: A substantial proportion of the patients did not know of their legal status. Many reported restrictions on movement, forced medication and patronising communication. Satisfaction with the treatment was generally high. Compared to the voluntary patients, the two other groups were characterized by lack of influence, forced medication and high satisfaction with the key worker. Conclusion: Involuntariness was associated with increased likelihood of feeling excluded from participation in the treatment. The key worker seems to have an important position with regard to committed and pressured patients. Limitations: The data were limited to the patients’ subjective reports.     

Diabetes and impaired glucose tolerance among the inuit population of Greenland

OBJECTIVE: To assess the prevalence of diabetes and impaired glucose tolerance (IGT) among the Inuit population of Greenland and to determine risk factors for developing glucose intolerance. RESEARCH DESIGN AND METHODS: This cross-sectional study included 917 randomly selected adult Inuit subjects living in three areas of Greenland. Diabetes and IGT were diagnosed using the oral glucose tolerance test. BMI and waist-to-hip ratio were measured and blood samples were taken from each subject. Sociodemographic characteristics were investigated using a questionnaire. RESULTS: The age-standardized prevalences of diabetes and IGT were 10.8 and 9.4% among men and 8.8 and 14.1% among women, respectively. Of those with diabetes, 70% had not been previously diagnosed. Significant risk factors for diabetes were family history of diabetes, age, BMI, and high alcohol consumption, whereas frequent intake of fresh fruit and seal meat were inversely associated with diabetic status. Age, BMI, family history of diabetes, sedentary lifestyle, and place of residence were significant predictors of IGT. CONCLUSIONS: The prevalence of diabetes is high among the Inuit of Greenland. Heredity was a major factor, while obesity and diet were important environmental factors. The high proportion of unknown cases suggests a need for increased diabetes awareness in Greenland.     

Validation of the arthritis self-efficacy short-form scale in German fibromyalgia patients.

Self-efficacy is assumed to account for significant variance in the treatment outcome of chronic pain patients. The aim of this study was to provide a German version of an approved measure of disease-related self-efficacy in fibromyalgia (FM) patients which assesses treatment outcomes and specific differences compared to other pain patients. The 8-item short-form of the arthritis self-efficacy scale was translated into German (ASES-D) and administered to 148 FM patients and 53 patients with rheumatoid arthritis (RA). In addition, similar cognitive constructs (locus of control, optimism/pessimism, and general self-efficacy) and disease-related variables (pain, functioning, depression, and coping) were assessed. The instrument was further applied to 43 FM patients who underwent interdisciplinary group therapy. Validation methods consisted of correlation, principal component analysis and difference testing between the disease groups. The instrument met good psychometric properties. Evidence for construct validity was provided. Self-efficacy was sensitive to changes and could be used in predicting the treatment outcome in FM patients. The German short-form ASES-D is a further step toward an internationally comparable assessment of disease-related self-efficacy in FM.     

Experimental investigation of intravascular OCT for imaging of intracranial aneurysms

Purpose

Rupture risk assessment of an intracranial aneurysm (IA) is an important factor for indication of therapy. Until today, there is no suitable objective prediction method. Conventional imaging modalities cannot assess the IA’s vessel wall. We investigated the ability of intravascular optical coherence tomography (OCT) as a new tool for the characterization and evaluation of IAs.

Materials and methods

An experimental setup for acquisition of geometrical aneurysm parameters was developed. Object of basic investigation was a silicone phantom with six IAs from patient data. For structural information, three circle of Willis were dissected and imaged postmortem. All image data were postprocessed by medical imaging software.

Results

Geometrical image data of a phantom with six different IAs were acquired. The geometrical image data showed a signal loss, e.g., in aneurysms with a high bottleneck ratio. Imaging data of vessel specimens were evaluated with respect to structural information that is valuable for the characterization of IAs. Those included thin structures (intimal flaps), changes of the vessel wall morphology (intimal thickening, layers), adjacent vessels, small vessel outlets, arterial branches and histological information.

Conclusion

Intravascular OCT provides new possibilities for diagnosis and rupture assessment of IAs. However, currently used imaging system parameters have to be adapted and new catheter techniques have to be developed for a complete assessment of the morphology of IAs.

     

Small- and Large-Fiber Neuropathy After 40 Years of Type 1 Diabetes: Associations with glycemic control and advanced protein glycation: the Oslo Study

OBJECTIVE

To study large- and small-nerve fiber function in type 1 diabetes of long duration and associations with HbA_1c and the advanced glycation end products (AGEs) N-ε-(carboxymethyl)lysine (CML) and methylglyoxal-derived hydroimidazolone.

RESEARCH DESIGN AND METHODS

In a long-term follow-up study, 27 persons with type 1 diabetes of 40 ± 3 years duration underwent large-nerve fiber examinations, with nerve conduction studies at baseline and years 8, 17, and 27. Small-fiber functions were assessed by quantitative sensory thresholds (QST) and intraepidermal nerve fiber density (IENFD) at year 27. HbA_1c was measured prospectively through 27 years. Serum CML was measured at year 17 by immunoassay. Serum hydroimidazolone was measured at year 27 with liquid chromatography–mass spectrometry.

RESULTS

Sixteen patients (59%) had large-fiber neuropathy. Twenty-two (81%) had small-fiber dysfunction by QST. Heat pain thresholds in the foot were associated with hydroimidazolone and HbA_1c. IENFD was abnormal in 19 (70%) and significantly lower in diabetic patients than in age-matched control subjects (4.3 ± 2.3 vs. 11.2 ± 3.5 mm, P < 0.001). IENFD correlated negatively with HbA_1c over 27 years (r = −0.4, P = 0.04) and CML (r = −0.5, P = 0.01). After adjustment for age, height, and BMI in a multiple linear regression model, CML was still independently associated with IENFD.

CONCLUSIONS

Small-fiber sensory neuropathy is a major manifestation in type 1 diabetes of 40 years duration and more prevalent than large-fiber neuropathy. HbA_1c and the AGEs CML and hydroimidazolone are important risk factors in the development of large- and small-fiber dysfunction in long-term type 1 diabetes.Peripheral neuropathy is one of many complications of type 1 diabetes, resulting in significant morbidity and mortality. Small-diameter nerve fibers represent 70–90% of all peripheral nerve fibers and are believed to be the earliest fibers to be damaged in diabetes (1). Small-fiber injury has also been associated with neuropathic pain (2,3), which is one of the most disabling symptoms in patients with diabetic neuropathy.The severity of diabetic polyneuropathy increases with the duration of diabetes and degree of hyperglycemic exposure (4). In the Oslo Study, intensified insulin treatment with insulin pumps during 2 years improved large-fiber neuropathy at an early stage (5). After 8 years, near normoglycemia delayed progression of neuropathy (6), and after 18 years of fair glycemic control the peripheral nerve function was preserved for those with a mean HbA_1c <8.4% (68 mmol/mol) (7). In the Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications Study (EDIC) study, the benefits of previous intensive insulin treatment persisted for 13–14 years after DCCT closeout and provided further evidence of a durable effect of prior intensive treatment and that good glycemic control is important to prevent development of neuropathy (8). The EURODIAB study reported higher cumulative incidence of neuropathy related to higher HbA_1c value (9). Controversies exist regarding whether there is a definitive threshold of glycemic exposure for any diabetes complication to develop. Orchard et al. (10) did show that the average number of total glycemic exposure did not vary for the different microvascular complications to develop. They suggested an integrated measure of glycemic control called “A1c months” (both duration and degree) and that a value <1,000 A1c months was a minimal treatment goal (10).How hyperglycemia may cause damage to the nervous system is not fully understood. One consequence of hyperglycemia is the generation of advanced glycation end products (AGEs) that can form nonenzymatically between glucose, lipids, and amino groups. It is believed that AGEs are involved in the pathophysiology of neuropathy. AGEs tend to affect cellular function by altering protein function (11). One of the AGEs, N-ε-(carboxymethyl)lysine (CML), has been found in excessive amounts in the human diabetic peripheral nerve (12). High levels of methylglyoxal in serum have been found to be associated with painful peripheral neuropathy (13).In recent years, differentiation of affected nerves is possible by virtue of specific function tests to distinguish which fibers are damaged in diabetic polyneuropathy: large myelinated (Aα, Aβ), small thinly myelinated (Aδ), or small nonmyelinated (C) fibers. The DCCT/EDIC, EURODIAB, and other cohort studies have not focused especially on small-fiber damage. Therefore, little data are available on the prevalence and mechanisms of small-fiber dysfunction in long-term type 1 diabetes.Our aims were to evaluate large- and small-nerve fiber function in long-term type 1 diabetes and to search for longitudinal associations with HbA_1c and the AGEs CML and methylglyoxal-derived hydroimidazolone.     

Psychometric Properties,Norms, and Factor Structure of the Diabetes Eating Problem Survey–Revised in a Large Sample of Children and Adolescents With Type 1 Diabetes

OBJECTIVE

The purpose of this study was to examine the psychometric properties of the Diabetes Eating Problem Survey–Revised (DEPS-R) in a large sample of young patients with type 1 diabetes, to establish norms, and to validate it against the Eating Attitudes Test–12 (EAT-12).

RESEARCH DESIGN AND METHODS

A total of 770 children and adolescents aged 11–19 years with type 1 diabetes completed the DEPS-R and the EAT-12. In addition, age- and sex-standardized BMI and HbA_1c data were obtained from the Norwegian Childhood Diabetes Registry. In addition to tests of validity, principal axis factoring was conducted to investigate the factor structure of the 16-item DEPS-R.

RESULTS

The DEPS-R demonstrated satisfactory Cronbach α (0.89) and was significantly correlated with the EAT-12 (0.65; P < 0.01), indicating convergent validity. The mean (SD) DEPS-R scores were 11.0 (10.7) for the total sample and 7.7 (7.4) and 14.2 (2.4) for males and females, respectively.

CONCLUSIONS

This study replicates and extends previous research demonstrating the psychometric properties of the abbreviated 16-item DEPS-R. Findings support the utility of this important screening tool to identify disturbed eating in young patients with type 1 diabetes.Numerous studies indicate that type 1 diabetes is a risk factor for the development of disturbed eating behavior (DEB) (1,2), a term that will be used here to refer to the entire range of clinical and subclinical eating pathologies. DEB is common and persistent among young women with type 1 diabetes, with prevalences being more than double those in nondiabetic populations (3,4). Studies indicate that males with type 1 diabetes may also have an increased risk of developing DEB (5). When DEB and type 1 diabetes occur together, morbidity and mortality are dramatically increased. The study by Nielsen et al. (6) of comorbid type 1 diabetes and anorexia nervosa showed crude mortalities at 10-year follow-up of 2.5% for type 1 diabetes and 6.5% for anorexia nervosa; however, the mortality rose to 34.8% when these conditions occurred together.The presence of DEB can severely impair metabolic control and advance the onset of long-term complications (7). Insulin restriction is an efficient weight loss strategy uniquely available to patients with type 1 diabetes, and this behavior is reported in as many as 37% of adolescents and young adult females with type 1 diabetes (4,8,9). Insulin restriction is associated with physical complications, and in previous research self-reported insulin restriction at baseline led to a threefold increased risk of mortality during 11 years of follow-up (9).Given the deleterious effects of comorbidity, routine screening is important to identify DEB in individuals with type 1 diabetes to facilitate early intervention and prevent the development of serious physical complications. In a clinical setting, with limited time and resources, it is important to have access to a valid and sensitive screening instrument that requires few resources and is easy to administer and interpret. There are several screening instruments for the detection of eating pathology, such as the Eating Disorder Examination Questionnaire (10), the SCOFF questionnaire (the acronym was created from the questions) (11), the Eating Attitudes Test (EAT) (12), and the Diabetes Eating Problem Survey–Revised (DEPS-R) (13). In contrast to traditional eating disorders screening measures, such as the Eating Disorder Examination Questionnaire and the EAT, the DEPS-R is designed to assess disturbed eating specific to type 1 diabetes, including insulin restriction to lose weight. Insulin restriction is not likely to be detected by use of generic screening measures of eating pathology, and this represents a serious limitation of those instruments. The Diabetes Eating Problem Survey (DEPS) was first developed in 2001 and consisted of 28 items but was recently revised and shortened to the DEPS-R by Markowitz et al. (13). The original validation study of the DEPS-R included 112 youths (aged 13–19 years) with type 1 diabetes, and results showed that the DEPS-R correlated positively with age, age- and sex-standardized BMI (zBMI), and HbA_1c, and that females scored significantly higher than did males. Despite promising initial psychometric properties of the DEPS-R, the instrument has not been validated against an established measure of eating pathology and remains limited by a small sample. We aimed to investigate the internal consistency and construct validity of the DEPS-R, to identify the factor structure, and to establish normative data in a large sample of young patients with type 1 diabetes.     

Migraine,headache and development of metabolic syndrome: An 11-year follow-up in the Nord-Trøndelag Health Study (HUNT)

Migraine with aura is associated with an increased incidence of stroke and cardiovascular disease, but the biological mechanisms are poorly understood. This study examined the incidence of metabolic syndrome and its relationship to migraine with and without aura and to nonmigraine headache. In the population-based the Nord-Trøndelag Health Study (HUNT), 19,895 individuals were followed for the development of metabolic syndrome, with a median follow-up time of 11.3 years. Headache diagnoses were based on a validated headache questionnaire, and metabolic syndrome was based on a modified version of the National Cholesterol Education Program’s Adult Treatment Panel (ATP) III criteria, using objective anthropometric measurements and blood biochemistry. Using the Poisson regression model, migraine with aura was associated with an increased risk for developing metabolic syndrome. The effect was modified by smoking, with an adjusted incident risk ratio (IRR) among smokers of 2.10 (95% CI 1.53-2.89) and among nonsmokers of 1.39 (95% CI 1.03-1.86), when compared to headache-free controls. A moderate risk increase was seen for migraine without aura (IRR 1.26, 95% CI 1.12-1.42) and nonmigraine headache (IRR 1.22, 95% CI 1.13-1.32), not modified by smoking. The results suggest that traditional risk factors may be one of the mechanisms through which migraine with aura is linked to an increased risk for cardiovascular disease. A heightened vigilance concerning cardiovascular risk factors in this patient group may be warranted.