Validation of a self-report questionnaire version of the Child Activity Limitations Interview (CALI): The CALI-21

The Child Activity Limitations Interview (CALI) is a measure designed to assess functional impairment due to chronic pain in school-age children. In this study, we present a self-report questionnaire version of the CALI (the CALI-21) that extends the original interview measure. The purpose of this study was to provide internal consistency, cross-informant reliability and construct validity of the CALI-21 on a clinical sample of children and adolescents with chronic pain conditions. One hundred fifty-five children and adolescents (65 males, 90 females; ages 8-18 years, M=14.31, SD=2.45) with chronic pain completed questionnaires as part of their clinic intake procedures at their consultation visit in a pediatric pain management clinic. An exploratory factor analysis was conducted to measure latent constructs within the broader domain of functional impairment. Results of the exploratory factor analysis yielded two factors representing limitation in Active and Routine activities on both parent and child reports. Parent and child total CALI scores correlated with measures of pain intensity, however, different patterns of correlations emerged between age, pain intensity, depressive symptoms, and the Active and Routine factors. The CALI-21 showed good internal consistency, high cross-informant reliability, and demonstrated construct validity. The CALI-21 provides increased flexibility via the questionnaire format in the assessment of pain-related activity limitations in children. Factor analysis extends information about specific types of activity limitations experienced by children.     

An Emergency Department–based Vaccination Program: Overcoming the Barriers for Adults at High Risk for Vaccine-preventable Diseases

Background: More than 10% of the population visit emergency departments (ED) every year. Many of these patients are not up‐to‐date on routine vaccinations that could prevent future illnesses. The ED could significantly impact these vaccination trends. Objectives: This study was a feasibility study to determine whether patients would be amenable to an ED‐based program that provided appropriate immunizations when they were at high risk for these diseases. In addition, the authors sought to identify barriers that predict high‐risk patients who did not receive immunizations before ED presentation and to identify barriers that predict those high‐risk unvaccinated patients who are unwilling to receive vaccinations when offered in the ED. Methods: This study was a prospective cross‐sectional study of all patients arriving in the ED at one inner‐city trauma center between 10 am and 10 pm over the course of a three‐week intervention period. The subjects completed a survey that included information about their risk of influenza (flu) and pneumococcal disease, their immunization history, and their perceptions of their need for immunization. Demographic information collected included insurance status, age, gender, and primary language. All high‐risk patients who were not current with their immunizations were offered vaccination. The primary outcome was improvement in vaccination coverage based on an ED surveillance and treatment system for vaccinations. The secondary outcomes were barriers to successful vaccination before ED presentation and barriers to acceptance of vaccination in the ED. Results were compared using chi‐square test and confidence interval analysis. Characteristics of barriers to immunization were determined using a logistic regression model. A p‐value < 0.05 was considered significant. Results: A total of 674 subjects were entered into the study. Vaccination of subjects at high risk for flu increased significantly from 16% before to 83% after ED evaluation and treatment, and vaccination of subjects at high risk for pneumococcal disease increased significantly from 18% before to 84% after ED evaluation and treatment. Significant barriers to vaccination before ED presentation were lack of insurance (odds ratio [OR] = 0.31 for flu, 0.22 for pneumococcal disease), age younger than 50 years (OR = 0.18 for flu, 0.24 for pneumococcal disease), and no perceived need for vaccination (OR = 0.07 for flu). The sole significant barrier to vaccine administration in the ED was perceived need for vaccination (OR = 0.32 for flu). Conclusions: An ED‐based vaccination program is both feasible and successful. Other than a shortage of vaccine, the only ED barrier to vaccination (perceived need) might be overcome with patient education.     

Effect of raloxifene on serum triglycerides in women with a history of hypertriglyceridemia while on oral estrogen therapy

OBJECTIVE: Raloxifene hydrochloride is a selective estrogen receptor modulator that to date has not been shown to cause hypertriglyceridemia in normal, diabetic, or hypertriglyceridemic women. This study was designed to assess the effect of raloxifene on serum triglycerides in postmenopausal women who have a history of increased hypertriglyceridemia with oral estrogen therapy. RESEARCH DESIGN AND METHODS: This was a single-center, uncontrolled, open-label study investigating the effects of 8 weeks of raloxifene (60 mg/day) therapy on plasma lipids. The study subjects were 12 postmenopausal women, ages 49-73 years, with a documented history of oral estrogen-induced hypertriglyceridemia (serum triglycerides > or =3.39 mmol/l [> or =300 mg/dl]). RESULTS: At week 2 of the study, three (25%) of the subjects withdrew from the trial because they developed marked hypertriglyceridemia (>or =11.3 mmol/l [> or =1,000 mg/dl]) during raloxifene therapy. These three women had higher baseline triglyceride and glucose levels, were not being treated with lipid-lowering agents, and were more likely to have diabetes than the other study subjects. The remaining nine patients (75%) completed the 8-week trial and experienced a nonsignificant increase in mean triglyceride levels from baseline to end point. Raloxifene treatment also resulted in a significant 16% decrease in hepatic lipase activity and a 26% increase in HDL(2) levels (P = 0.013 and 0.03, respectively). CONCLUSIONS: Patients with a previous history of hypertriglyceridemia on oral estrogen therapy should have serum triglyceride levels monitored closely after beginning raloxifene therapy and may even require fibrate therapy before beginning raloxifene.     

Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores

Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.     

Leisure Time Physical Activity in a Population-Based Sample of People With Spinal Cord Injury Part I: Demographic and Injury-Related Correlates

Martin Ginis KA, Latimer AE, Arbour-Nicitopoulos KP, Buchholz AC, Bray SR, Craven BC, Hayes KC, Hicks AL, McColl M, Potter PJ, Smith K, Wolfe DL. Leisure time physical activity in a population-based sample of people with spinal cord injury part I: demographic and injury-related correlates.

Objectives

To estimate the number of minutes a day of leisure time physical activity (LTPA) performed by people with chronic spinal cord injury (SCI) and to identify the demographic and injury-related characteristics associated with LTPA in a population-based sample of people with chronic SCI.

Design

Cross-sectional telephone survey.

Setting

General community.

Participants

Men and women with SCI (N=695).

Interventions

Not applicable.

Main Outcome Measures

The number of minutes/day of LTPA performed at a mild intensity or greater.

Results

Respondents reported mean minutes ± SD of 27.14±49.36 of LTPA/d; however, 50% reported no LTPA whatsoever. In a multiple regression analysis, sex, age, years postinjury, injury severity, and primary mode of mobility each emerged as a unique predictor of LTPA. Multiple correspondence analysis indicated that being a man over the age of 34 years and greater than 11 years postinjury was associated with inactivity, while being a manual wheelchair user and having motor complete paraplegia were associated with the highest level of daily LTPA.

Conclusions

Daily LTPA levels are generally low in people with SCI. Women, older adults, people with less recent injuries, people with more severe injuries, and users of power wheelchairs and gait aids are general subgroups that may require special attention and resources to overcome unique barriers to LTPA. Specific subgroups may also require targeted interventions.     

Evaluation of the Educational Utility of Patient Follow-up

OBJECTIVES: To date, no studies in emergency medicine (EM) have addressed the educational value of the Residency Review Committee for Emergency Medicine's (RRC-EM) requirement for patient follow-up (FU). The authors examined whether performance of patient FU improved EM resident education. METHODS: All EM resident FU encounters from September 25, 2001, through September 24, 2002, were documented and analyzed. All EM residents at a regional tertiary referral emergency department (ED) initiated patient FU encounters by entering information regarding patients' initial ED presentations into a Web-based follow-up system (WBFUS), subsequently entered FU information, and indicated whether they thought that the specific FU encounters improved their education (yes/no). Supervising faculty members then reviewed the residents' completed FU entries. Blinded to residents' responses regarding educational utility, faculty members evaluated whether they thought the specific FU encounters were educational for the residents (yes/no). Data entered into the WBFUS were then summarized as percentages. RESULTS: Eight hundred forty-seven FU encounters were completed by 18 EM residents and 29 EM faculty. Ninety-three percent of the FU entries were deemed by at least one evaluator (resident or faculty) to have educational value. Residents found the act of performing FU educational in 81.3% of cases, whereas faculty thought 80.4% were educational for the resident. Although the residents and faculty agreed on the educational value in 75.4% of cases, the overall strength of the agreement was slight to fair (kappa statistic = 0.21). CONCLUSIONS: This study indicates that EM residents and faculty believe that the act of performing patient FU has educational value for EM residents; however, the interobserver agreement between residents and faculty was low.     

Pharmacodynamic Profiling of a Siderophore-Conjugated Monocarbam in Pseudomonas aeruginosa: Assessing the Risk for Resistance and Attenuated Efficacy

The objective of this study was to investigate the risk of attenuated efficacy due to adaptive resistance for the siderophore-conjugated monocarbam SMC-3176 in Pseudomonas aeruginosa by using a pharmacokinetic/pharmacodynamic (PK/PD) approach. MICs were determined in cation-adjusted Mueller-Hinton broth (MHB) and in Chelex-treated, dialyzed MHB (CDMHB). Spontaneous resistance was assessed at 2× to 16× the MIC and the resulting mutants sequenced. Efficacy was evaluated in a neutropenic mouse thigh model at 3.13 to 400 mg/kg of body weight every 3 h for 24 h and analyzed for association with free time above the MIC (fT>MIC). To closer emulate the conditions of the in vivo model, we developed a novel assay testing activity mouse whole blood (WB). All mutations were found in genes related to iron uptake: piuA, piuC, pirR, fecI, and pvdS. Against four P. aeruginosa isolates, SMC-3176 displayed predictable efficacy corresponding to the fT>MIC using the MIC in CDMHB (R² = 0.968 to 0.985), with stasis to 2-log kill achieved at 59.4 to 81.1%. Efficacy did not translate for P. aeruginosa isolate JJ 4-36, as the in vivo responses were inconsistent with fT>MIC exposures and implied a threshold concentration that was greater than the MIC. The results of the mouse WB assay indicated that efficacy was not predictable using the MIC for JJ 4-36 and four additional isolates, against which in vivo failures of another siderophore-conjugated β-lactam were previously reported. SMC-3176 carries a risk of attenuated efficacy in P. aeruginosa due to rapid adaptive resistance preventing entry via the siderophore-mediated iron uptake systems. Substantial in vivo testing is warranted for compounds using the siderophore approach to thoroughly screen for this in vitro-in vivo disconnect in P. aeruginosa.     

Klebsiella pneumoniae Carbapenemase (KPC)-Producing K. pneumoniae at a Single Institution: Insights into Endemicity from Whole-Genome Sequencing

The global emergence of Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp) multilocus sequence type ST258 is widely recognized. Less is known about the molecular and epidemiological details of non-ST258 K. pneumoniae in the setting of an outbreak mediated by an endemic plasmid. We describe the interplay of bla_KPC plasmids and K. pneumoniae strains and their relationship to the location of acquisition in a U.S. health care institution. Whole-genome sequencing (WGS) analysis was applied to KPC-Kp clinical isolates collected from a single institution over 5 years following the introduction of bla_KPC in August 2007, as well as two plasmid transformants. KPC-Kp from 37 patients yielded 16 distinct sequence types (STs). Two novel conjugative bla_KPC plasmids (pKPC_UVA01 and pKPC_UVA02), carried by the hospital index case, accounted for the presence of bla_KPC in 21/37 (57%) subsequent cases. Thirteen (35%) isolates represented an emergent lineage, ST941, which contained pKPC_UVA01 in 5/13 (38%) and pKPC_UVA02 in 6/13 (46%) cases. Seven (19%) isolates were the epidemic KPC-Kp strain, ST258, mostly imported from elsewhere and not carrying pKPC_UVA01 or pKPC_UVA02. Using WGS-based analysis of clinical isolates and plasmid transformants, we demonstrate the unexpected dispersal of bla_KPC to many non-ST258 lineages in a hospital through spread of at least two novel bla_KPC plasmids. In contrast, ST258 KPC-Kp was imported into the institution on numerous occasions, with other bla_KPC plasmid vectors and without sustained transmission. Instead, a newly recognized KPC-Kp strain, ST941, became associated with both novel bla_KPC plasmids and spread locally, making it a future candidate for clinical persistence and dissemination.