Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy.

BACKGROUND: In previous studies, Propionibacterium acnes was cultured from intervertebral disc tissue of ~25% of patients undergoing microdiscectomy, suggesting a possible link between chronic bacterial infection and disc degeneration. However, given the prominence of P. acnes as a skin commensal, such analyses often struggled to exclude the alternate possibility that these organisms represent perioperative microbiologic contamination. This investigation seeks to validate P. acnes prevalence in resected disc cultures, while providing microscopic evidence of P. acnes biofilm in the intervertebral discs. METHODS: Specimens from 368 patients undergoing microdiscectomy for disc herniation were divided into several fragments, one being homogenized, subjected to quantitative anaerobic culture, and assessed for bacterial growth, and a second fragment frozen for additional analyses. Colonies were identified by MALDI-TOF mass spectrometry and P. acnes phylotyping was conducted by multiplex PCR. For a sub-set of specimens, bacteria localization within the disc was assessed by microscopy using confocal laser scanning and FISH. RESULTS: Bacteria were cultured from 162 discs (44%), including 119 cases (32.3%) with P. acnes. In 89 cases, P. acnes was cultured exclusively; in 30 cases, it was isolated in combination with other bacteria (primarily coagulase-negative Staphylococcus spp.) Among positive specimens, the median P. acnes bacterial burden was 350 CFU/g (12 - ~20,000 CFU/g). Thirty-eight P. acnes isolates were subjected to molecular sub-typing, identifying 4 of 6 defined phylogroups: IA1, IB, IC, and II. Eight culture-positive specimens were evaluated by fluorescence microscopy and revealed P. acnes in situ. Notably, these bacteria demonstrated a biofilm distribution within the disc matrix. P. acnes bacteria were more prevalent in males than females (39% vs. 23%, p = 0.0013). CONCLUSIONS: This study confirms that P. acnes is prevalent in herniated disc tissue. Moreover, it provides the first visual evidence of P. acnes biofilms within such specimens, consistent with infection rather than microbiologic contamination.

Prevalence of Propionibacterium acnes in Intervertebral Discs of Patients Undergoing Lumbar Microdiscectomy: A Prospective Cross-Sectional Study.

BACKGROUND: The relationship between intervertebral disc degeneration and chronic infection by Propionibacterium acnes is controversial with contradictory evidence available in the literature. Previous studies investigating these relationships were under-powered and fraught with methodical differences; moreover, they have not taken into consideration P. acnes' ability to form biofilms or attempted to quantitate the bioburden with regard to determining bacterial counts/genome equivalents as criteria to differentiate true infection from contamination. The aim of this prospective cross-sectional study was to determine the prevalence of P. acnes in patients undergoing lumbar disc microdiscectomy. METHODS AND FINDINGS: The sample consisted of 290 adult patients undergoing lumbar microdiscectomy for symptomatic lumbar disc herniation. An intraoperative biopsy and pre-operative clinical data were taken in all cases. One biopsy fragment was homogenized and used for quantitative anaerobic culture and a second was frozen and used for real-time PCR-based quantification of P. acnes genomes. P. acnes was identified in 115 cases (40%), coagulase-negative staphylococci in 31 cases (11%) and alpha-hemolytic streptococci in 8 cases (3%). P. acnes counts ranged from 100 to 9000 CFU/ml with a median of 400 CFU/ml. The prevalence of intervertebral discs with abundant P. acnes (≥ 1x103 CFU/ml) was 11% (39 cases). There was significant correlation between the bacterial counts obtained by culture and the number of P. acnes genomes detected by real-time PCR (r = 0.4363, p<0.0001). CONCLUSIONS: In a large series of patients, the prevalence of discs with abundant P. acnes was 11%. We believe, disc tissue homogenization releases P. acnes from the biofilm so that they can then potentially be cultured, reducing the rate of false-negative cultures. Further, quantification study revealing significant bioburden based on both culture and real-time PCR minimize the likelihood that observed findings are due to contamination and supports the hypothesis P. acnes acts as a pathogen in these cases of degenerative disc disease.

Prothrombin Time and Activated Partial Thromboplastin Time Testing: A Comparative Effectiveness Study in a Million-Patient Sample.

BACKGROUND: A substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful. METHODS AND FINDINGS: We evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1,053,472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682,049 patients (64.7%) had one or both tests done and history and physical (H&P) records available for analysis. Unnecessary tests for bleeding risk were defined as: PT tests done on patients with no history of abnormal bleeding, warfarin therapy, vitamin K-dependent clotting factor deficiency, or liver disease; or aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing. CONCLUSIONS: This study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.

The validity of the Computer Face Scale for measuring pediatric pain and mood.

OBJECTIVE: The aim was to assess the validity of the Computer Face Scale. METHODS: Forty children (5-13 years old) rated pain and mood prior to and twice following tonsillectomy. The children used the Computer Face Scale to adjust a cartoon face to rate pain and mood. During sessions one and two, the children also chose an expression on the Wong-Baker Faces Scale to rate their pain, and they reported their mood verbally on a seven-point scale. RESULTS: On average, the children reported no pain and a positive mood prior to surgery. Soon after surgery, they reported mild pain and a slightly negative mood. An hour later, they reported decreases in pain and return to a positive mood. The differences between presurgery and postsurgery ratings were statistically significant (P ≤ 0.001) for all measures. The correlation between the two mood measures was 0.88 before surgery and 0.78 afterward. The correlation between the two measures of pain was 0.83 after surgery (P's < 0.001). CONCLUSIONS: The results support the validity of the Computer Face Scale. The mean ratings of pain and mood followed the expected pattern from pre- to postsurgery, and there was a significant association between ratings obtained by different methods. The Computer Face Scale provides a simple-to-use scale with more resolution and electronic capture, which may provide advantages in numerous clinical and research applications.

Longitudinal changes in patient-reported dyspnea in patients with COPD.

BACKGROUND: Although guidelines recommend monitoring symptoms in patients with chronic obstructive pulmonary disease (COPD), there is limited information on the longitudinal changes in patient-reported dyspnea (PRD) related to activities of daily living. The hypothesis was that PRD scores on the modified Medical Research Council (mMRC) scale, the self-administered computerized (SAC) transition dyspnea index (TDI), and the University of California San Diego Shortness of Breath questionnaire (UCSD SOBQ) would demonstrate progression over two years. METHODS: Observational cohort study of symptomatic patients with stable COPD evaluated every 6 months for 2 years. Patients rated the impact of activities of daily living on dyspnea using three patient-reported instruments presented in random order, and then performed post-bronchodilator (pBD) spirometry. RESULTS: Seventy patients (37 female/33 male; age: 66 ± 9 years; and pBD forced expiratory volume in one second [(FEV1): 51 ± 16% predicted] participated. Using fixed effects regression modeling, there was significant worsening in the PRD scores with the SAC TDI (-0.9 ± 2.7; p = 0.03) and UCSD SOBQ (+5.7 ± 18.3; p = 0.001), but not with the mMRC scale (p = 0.52). Both pBD FEV1 (p = 0.19) and pBD forced vital capacity (p = 0.65) were unchanged. CONCLUSIONS: Multidimensional instruments (SAC TDI and UCSD SOBQ) demonstrated the frequently observed decline in PRD experienced by patients with COPD. The progression in PRD occurred despite stable lung function. Monitoring PRD provides unique clinical information and should be considered along with measuring lung function to assess patient status over time.

Neuromodulatory effect of endogenous opioids on the intensity and unpleasantness of breathlessness during resistive load breathing in COPD.

BACKGROUND: Endogenous opioids are naturally occurring peptides released by the brain in response to noxious stimuli. Although these naturally occurring peptides modulate pain, it is unknown whether endogenous opioids affect the perception of breathlessness associated with a specific respiratory challenge. The hypothesis is that intravenous administration of naloxone, used to block opioid signaling and inhibit neural pathways, will increase ratings of breathlessness during resistive load breathing (RLB) in patients with chronic obstructive pulmonary disease (COPD). METHODS: Fourteen patients with COPD (age, 64 ± 9 years) inspired through resistances during practice sessions to identify an individualized target load that caused ratings of intensity and/or unpleasantness of breathlessness ≥ 50 mm on a 100 mm visual analog scale. At two intervention visits, serum beta-endorphins were measured, naloxone (10 mg/25 ml) or normal saline (25 ml) was administered intravenously, and patients rated the two dimensions of breathlessness each minute during RLB. RESULTS: Patient ratings of intensity (p = 0.0004) and unpleasantness (p = 0.024) of breathlessness were higher with naloxone compared with normal saline. Eleven patients (79%) reported that it was easier to breathe during RLB with normal saline (p = 0.025). RLB led to significant increases in serum beta-endorphin immunoreactivity and decreases in inspiratory capacity. There were no significant differences in physiological responses between interventions. CONCLUSIONS: Endogenous opioids modulate the intensity and the unpleasantness of breathlessness in patients with COPD. Differences in breathlessness ratings between interventions were clinically relevant based on the patients' global assessment.

Reliability of a preliminary 3-D pain mapping program.

OBJECTIVE: The objective of this preliminary investigation was to evaluate the test-retest reliability of a new pain assessment method referred to as 3-D pain mapping. METHODS: In Study 1, 101 chronic noncancer pain patients from four sites reported their pain using the method on two occasions (separated by approximately 10 days). The patients marked intensity, surface location, and depth of pain on a 3-D computer display of a male or female body. The model body could be rotated in order to mark multiple pain locations. In Study 2, 25 patients from a single site were tested with a revised version of the mapping program used in Study 1. Each patient gave ratings on two occasions separated by approximately 1 week. RESULTS: In Study 1, the intra-class correlations of the 3-D pain mapping measures were moderate to high for maximum pain intensity (0.73), vertical location of the point of maximum pain (0.94), and the number of pain marks (0.84). Correlations were low for the horizontal location of the point of maximum pain (0.56) and for the depth of pain (0.50). In Study 2, using the revised program, intra-class correlations were moderate for pain intensity (0.76), and high for the vertical (0.99) and horizontal (0.98) locations of the point of maximum pain, number of pain marks (0.89), and the depth of pain (0.84). CONCLUSION: Three-dimensional pain mapping enables patients to report the location and intensity of their pain on all parts of the body, and such ratings are highly reliable. Future studies are needed to determine whether the clinical value of this method can improve the accuracy of pain diagnoses and the quality of pain management.

Mechanism of greater oxygen desaturation during walking compared with cycling in patients with COPD.

BACKGROUND: Patients with COPD exhibit greater oxyhemoglobin desaturation during walking than with cycling. The purpose of this investigation was to investigate differences in ventilatory responses and gas exchange as proposed mechanisms for this observation. METHODS: Arterial blood gas and lactate levels were measured in 12 patients with COPD (aged 68 ± 6 years) during incremental treadmill and cycle exercise. The primary outcome to assess the ventilatory response to exercise was Pao2. The primary outcome to assess impairment in exercise gas exchange was the difference between partial pressures of alveolar and arterial oxygen (Pao2 - Pao2). RESULTS: Pao2 in patients was significantly lower at peak exercise for treadmill walking (51.4 ± 6.8 mm Hg) compared with cycling (60.4 ± 10.7 mm Hg) (P = .002). The initial increase in Pao2 with cycling occurred prior to the onset of the anaerobic threshold. At peak exercise, Pao2 was significantly higher with cycling compared with walking (P = .004). The anaerobic threshold occurred at a lower oxygen consumption during cycling than walking (P = .001), and peak lactate levels were higher with cycling (P = .019). With progressive exercise, Pao2 - Pao2 increased similarly during treadmill and cycle exercise. CONCLUSIONS: The higher Pao2 during cycling minimized the magnitude of oxyhemoglobin desaturation compared with walking. The enhanced respiratory stimulation during cycling appears due to an initial neurogenic process, possibly originating in receptors of exercising muscles, and a subsequent earlier onset of anaerobic metabolism with higher lactate levels during cycling.

Advantages of endurance treadmill walking compared with cycling to assess bronchodilator therapy.

BACKGROUND: Walking is a familiar daily activity that is generally limited by breathlessness, whereas cycling is an uncommon physical effort typically limited by leg discomfort. The hypothesis was that patients with COPD would exhibit greater improvements in exercise endurance and relief of breathlessness with bronchodilator therapy during treadmill walking compared with cycling. METHODS: In this randomized, 2 x 2, double-blind, placebo-controlled, crossover trial, 20 patients with COPD (age, 64 +/- 7 years; FEV(1), 56 +/- 14% predicted) performed constant-load endurance exercise on the treadmill and cycle ergometer at 85% of capacity after inhaling normal saline (NS) or arformoterol (ARF) (15 microg). RESULTS: Increases in endurance times and consistency of responses were greater with treadmill walking (Delta: 157 +/- 286 s; P = .024; 80% improved) than with cycle exercise (Delta: 110 +/- 219 s; P = .038; 65% improved) with ARF compared with NS. However, these changes were not significantly different. The slope of breathlessness-time (mean Delta = -29%; P = .007) and the magnitude of oxygen desaturation were significantly lower with ARF compared with NS during treadmill, but not cycle, exercise. Inspiratory capacity values were similar between modes of exercise when comparing the same study medication. CONCLUSIONS: Improved endurance times support both constant-load treadmill and cycle exercise to assess the efficacy of bronchodilator therapy in patients with COPD. Unique differences in physiologic and perceptual responses with bronchodilation demonstrate advantages of treadmill walking as an exercise stimulus. TRIAL REGISTRATION: clinicaltrials.gov; Identifier: NCT00754546.

Patient-reported dyspnea in COPD reliability and association with stage of disease.

BACKGROUND: Although questionnaires are used frequently with patients to self-report the severity of dyspnea as related to activities of daily living, the reliability of these instruments has not been established. The two purposes of this study were to examine the test-retest reliability of three widely used dyspnea instruments and to compare dyspnea scores at different stages of disease. METHODS: At paired baseline visits, 101 stable patients with COPD were tested; at paired follow-up visits at 3 months, 89 of these patients were tested. At each visit, patients rated dyspnea with three instruments presented in random order and then performed post-bronchodilator therapy lung function tests. RESULTS: Patient-reported dyspnea scores and lung function were similar at baseline (interval, 6 +/- 5 days) and follow-up visits (interval, 4 +/- 2 days). Intraclass correlation coefficients at baseline and at follow-up were 0.82 and 0.82, respectively, for the modified Medical Research Council scale; 0.90 and 0.84, respectively, for the self-administered computerized versions of the baseline dyspnea index and transition dyspnea indexes; and 0.95 and 0.89 for the University of San Diego Shortness of Breath Questionnaire results. Dyspnea ratings were significantly related to the stage of disease severity based on percent predicted FEV(1) (p < 0.001). CONCLUSIONS: Test-retest reliability was acceptable for patient-reported dyspnea scores using three clinical instruments at baseline and at the 3-month follow-up. Our results demonstrate for the first time that patient-reported dyspnea ratings are related to the stage of disease severity.

Computer Face Scale for measuring pediatric pain and mood.

UNLABELLED: This investigation determined the psychometric properties and acceptability of an animated face scale presented on a hand-held computer as a means to measure pediatric pain and mood. In study 1, 79 hospitalized, pediatric patients indicated their levels of pain by adjusting the expression of an animated cartoon face. The first objective was to determine feasibility, concurrent validity, and acceptability of the method. All patients were tested both with the Computer Face Scale and the poster format of the Wong-Baker Faces Scale. A second objective was to evaluate test-retest reliability of the method. In study 2, 50 hospitalized, pediatric patients were tested on 2 occasions, but in this case the patients used the Computer Face Scale to indicate both their pain (how much they hurt) and their mood (how they felt). Children in study 1 were able to use the Computer Face Scale to express relative amounts of pain/hurt; the method showed concurrent validity with the Wong-Baker Face Scale; and most children expressed a preference for the Computer Face Scale. The method also showed adequate test-retest reliability. In study 2, adequate test-retest reliability was demonstrated for ratings of both pain and mood. PERSPECTIVE: The Computer Face Scale allows the health provider to obtain reliable and valid measures of pediatric pain and mood. The method can be understood and used by children as young as 3 years and is appropriate for use with adults.

Perceptual and physiologic responses during treadmill and cycle exercise in patients with COPD.

BACKGROUND: Although the cycle ergometer is the traditional mode for exercise testing in patients with respiratory disease, this preference over the treadmill does not consider perceptual responses. Our hypotheses were as follows: (1) the regression slope between breathlessness and oxygen consumption (Vo(2)) is greater on the treadmill than on the cycle ergometer; and (2) the regression slope between leg discomfort and Vo(2) is greater on the cycle ergometer than on the treadmill. METHODS: Twenty patients (10 men/10 women) with COPD (mean +/- SD postbronchodilator FEV(1), 50 +/- 15% of predicted) used a continuous method to report changes in breathlessness and in leg discomfort during cycle and treadmill exercise. RESULTS: Patients reported an earlier onset of breathlessness and leg discomfort during cycling. Peak ratings of breathlessness were higher on the treadmill, whereas peak ratings of leg discomfort were higher on the cycle ergometer. The regression slopes for breathlessness as a function of Vo(2) and of minute ventilation (Ve) were higher on the treadmill. The regression slopes between leg discomfort and Vo(2) were similar for treadmill and cycle exercise. Peak Vo(2) was significantly higher with treadmill exercise (mean Delta = 8%; p = 0.002). CONCLUSIONS: Patients with COPD exhibit different perceptual and physiologic responses during treadmill walking and cycling. Although ratings of breathlessness are initially higher with cycling at equivalent levels of Vo(2), the changes in breathlessness as a function of physiologic stimuli (Vo(2) and Ve) are greater during treadmill exercise. Leg discomfort is the predominant symptom throughout cycling.

Quality of chronic pain websites.

BACKGROUND: The Web not only can play a role in helping patients learn about their chronic pain, but can also be a source of misleading or untrue information. This study evaluates the quality of Internet information available concerning chronic pain at different sites, and determines the relation between quality and the source and character of the Websites. METHODS: A survey was conducted of patients seen at the Pain Management Center at Dartmouth-Hitchcock Medical Center (DHMC). Patients with access to the Internet identified the five most common keywords they used to look up information: pain, chronic pain, back pain, arthritis, and fibromyalgia. A focus group of pain clinicians at DHMC then chose the quality criteria to evaluate Websites. The criteria consisted of 16 items in five domains: etiology, diagnosis, goals of treatment, treatment options, and substance abuse. The first two pages of links displayed by each of three major search engines then were assessed for quality. RESULTS: A total of 240 Websites were evaluated. The mean score, the Quality Website Index (QWI), was 2.17 (SD = 3.3), (range from -16 [poorest] to +16 [best]). The overall quality of this group of Websites is rather poor, although there were several excellent sites. Websites located on the main search page had a significantly higher score than those in the sponsored section, and Websites based on standards had a significantly higher score than those that were not. CONCLUSION: Based on QWI scores, clinicians can recommend chronic pain Websites to provide their patients with accurate and pertinent information.

Do implantable devices improve mood? Comparisons of chronic pain patients with or without an implantable device.

Objective. This descriptive study compares outcome measures of a computerized assessment of pain, emotional distress, and quality of life between chronic noncancer pain patients who have received an implantable device (spinal cord stimulator or intrathecal pump; N = 143) and those who have not received a device (N = 130). Methods. Each patient marked the location of their pain on a body diagram and rated pain intensity, emotional distress, and impact of their pain on mood, sleep, and quality of life using a computerized pain assessment program. An electronic version of the Hospital Anxiety and Depression Scale (HADS) also was administered. Results. No significant differences were found on the pain variables between the two groups. Patients with an implantable device gave lower ratings (less impact) on emotional distress (p < 0.05) and rated their health quality of life as better compared with control patients (p < 0.05). The patients with implantable devices also scored lower on the HADS Depression Subscale. Conclusion. The results suggest that although patients with an implantable device seem to have more pathology and greater disability, they report less emotional distress and improved quality of life compared with patients with chronic pain without an implantable device. Future controlled trials are needed to establish the role that an implantable device plays in improving mood and quality of life.

Computer assessment and diagnostic classification of chronic pain patients.

OBJECTIVE: In order to establish a diagnosis of chronic pain, emphasis is placed on a patient's report of the pain's intensity, location, and character. The aim of this study was to evaluate the feasibility of a computer assessment method to collect self-reports of pain that were then used in discriminant analyses to distinguish among chronic pain diagnoses. METHODS: A convenience sample of 511 patients from two university-based pain clinics completed a computer pain assessment battery that elicited demographic information, pain drawings, pain and emotion intensity ratings, and intensity ratings of verbal descriptors. Patients classified themselves into one of six chronic pain diagnoses. Discriminant analyses were performed in an attempt to identify the unique features of patients' pain experience associated with each of the diagnostic categories. RESULTS: Pain drawings successfully classified patients into three of the diagnostic categories (back, head, and neck pain). In a second analysis, two pain descriptors (cramping and stabbing) separated rheumatoid arthritis patients from those with either fibromyalgia or neural pain. One descriptor of pain (cramping) and one descriptor of emotion (frustration) together distinguished between fibromyalgia and neural pain. CONCLUSIONS: 1) Computer assessment of a range of patient symptoms is feasible in the pain clinic. 2) Discriminant analysis based on pain drawings can distinguish among patient-reported diagnoses of back pain, headache, and neck pain. 3) Discriminant analysis based on three verbal descriptors can help to distinguish among diagnoses of fibromyalgia, neuralgia, and rheumatoid arthritis. 4) However, in general, most computerized descriptive information is not useful in distinguishing differences among pain patient diagnostic groups.

Development of a new computer method to assess children's pain.

OBJECTIVE: The primary objective of this study was to determine initial psychometric properties and feasibility of a new Computer Face Scale for measuring pediatric pain. Drawbacks to current measurement tools include a lack of continuous variables, suboptimal mode of implementation, and difficulty interpreting results. A computer method of pediatric pain measurement is presented that addresses these problems. Basic psychometric properties, feasibility, and children's preference when compared with Wong-Baker Faces Scale were determined. METHODS: Fifty-four hospitalized, pediatric inpatients were tested using both the Computer Face Scale and the Wong-Baker Faces Scale. An additional 30 children (not hospitalized) were tested using only the Computer Face Scale. RESULTS: Both hospitalized and nonhospitalized children between the ages of 3 and 17 years of age are able to use the Computer Face Scale to express relative amounts of pain/hurt and happiness. The Computer Face Scale shows acceptable psychometric properties and is preferred by most children. CONCLUSIONS: The Computer Face Scale offers advantages over traditional pediatric pain measurement tools. The opportunity for real time review, electronic and time-stamped recording, electronic display, and temporal comparisons of reports affords the potential for improvement in pediatric pain assessment and treatment.

Web-based health survey systems in outcome assessment and management of pain.

Pain is a complex phenomenon lacking a well-defined paradigm for diagnosis and management across medical disciplines. This is due in part to inconsistencies in the assessment of pain as well as in the measurement of related social and psychological states. Efforts to evaluate and measure pain through objective tests have been hindered by challenges such as methodological differences in data acquisition, and the lack of common, universally accepted information systems. Physicians and hospital administrators have expressed mixed reactions to the costs that inevitably accompany advances in medical technology. Nonetheless, computer systems are currently being developed for use in the quantitative assessment and management of pain, which can advance our understanding of the public health impact of pain, improve the care individual patients receive, and educate providers. The description of an interdisciplinary, integrated, health survey system illustrates the approach and highlights the advantages of using information technology in pain evaluation and management.

Validity and responsiveness of the self-administered computerized versions of the baseline and transition dyspnea indexes.

BACKGROUND: Numerous instruments have been developed to examine the impact of activities on breathlessness. The primary purpose of this study was to examine the validity and responsiveness of the self-administered computerized (SAC) versions of the multidimensional baseline dyspnea index (BDI) and the transition dyspnea index (TDI). METHODS: Sixty-five patients with COPD who complained of exertional breathlessness were evaluated at an initial visit and after receiving standard therapy at two academic medical centers. Dyspnea scores from the SAC versions were compared with those obtained with the Medical Research Council (MRC) scale and with the original interview versions of the BDI and TDI. RESULTS: At the initial visit, all three dyspnea instruments showed similar correlations among themselves and with lung function. At the follow-up visit (mean [+/- SD] time after initial visit, 48 +/- 16 days), breathlessness scores were improved on all three instruments. Correlations were consistently higher for both versions of the TDI, and changes in lung function compared with corresponding values for DeltaMRC scale. Although 55% of patients reported no change in breathlessness on the MRC scale following treatment, the mean SAC and interview TDI scores were increased by 1.0 +/- 2.4 and 1.4 +/- 2.5, respectively, in these same patients. CONCLUSIONS: Both versions of the BDI and the MRC scale showed concurrent validity at the initial visit. The SAC TDI demonstrated responsiveness to standard therapy that was comparable with the findings of the interview TDI, but was better than that recorded with the MRC scale. The advantages of the SAC TDI include a patient-reported score on a continuous scale using computer technology.