A controlled trial of a novel primary prevention program for Lyme disease and other tick-borne illnesses

To evaluate a theory-based educational program to prevent Lyme disease and other tick-borne illnesses (TBI), a randomized controlled trial of an educational program was delivered to ferry passengers traveling to an endemic area in southeastern Massachusetts. Rates of TBI and precautionary and tick check behaviors were measured over three summers in 30,164 passengers. There were lower rates of TBI among participants receiving TBI education compared with control participants receiving bicycle safety education (relative risk [RR] = 0.79) and a 60 per cent reduction in risk among those receiving TBI education who visited Nantucket Island for more than 2 weeks compared to control participants (RR = 0.41, 95 per cent confidence intervals = 0.18 to 0.95, p < .038). TBI-educated participants were also significantly more likely to take precautions (use repellent, protective clothing, limit time in tick areas) and check themselves for ticks. The study demonstrates that a theory-based Lyme disease prevention program can increase precautionary behavior and result in a significant reduction in TBI. (AU)

Validation of a Systemic Lupus Activity Questionnaire (SLAQ) for population studies.

The goal of this work was to develop an economical way of tracking disease activity for large groups of systemic lupus erythematosus (SLE) patients in clinical studies. A Systemic Lupus Activity Questionnaire (SLAQ) was developed to screen for possible disease activity using items from the Systemic Lupus Activity Measure (SLAM) and tested for its measurement properties. The SLAQ was completed by 93 SLE patients just prior to a scheduled visit. At the visit, a rheumatologist, blinded to SLAQ results, examined the subject and completed a SLAM. Associations among SLAQ, and SLAM (omitting laboratory items) and between individual items from each instrument were assessed with Pearson correlations. Correlations between pairs of instruments were compared using Student's t-tests. The mean score across all 24 SLAQ items was 11.5 (range 0-33); mean SLAM without labs was 3.0 (range 0-13). The SLAQ had a moderately high correlation with SLAM-nolab (r = 0.62, P < 0.0001). Correlations between patient-clinician matched pairs of items ranged from r = 0.06 to 0.71. Positive predictive values for the SLAQ ranged from 56 to 89% for detecting clinically significant disease activity. In studies of SLE, symptoms suggesting disease can be screened by self-report using the SLAQ and then verified by further evaluation.

Variable effects of social support by race, economic status, and disease activity in systemic lupus erythematosus.

OBJECTIVE: Health status and disease activity in patients with systemic lupus erythematosus (SLE) and other chronic diseases are strongly associated with social support, which suggests that enhanced social support in medical care might improve SLE outcome. There has been little or no study on identifying patients for whom social support would be most beneficial. It would allow practitioners to enable social support more effectively as a complement to disease management. METHODS: A retrospective cohort (200 patients with SLE from 5 centers), balanced by race and insurance status, was studied in a cross sectional design. Demographic, clinical, socioeconomic, and psychosocial factors and disease outcomes [Systemic Lupus Activity Measure (SLAM), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR), SF-36] were measured. Using multivariate linear regression and ANOVA (outcome = SF-36 physical function, mental health), we examined the interaction between social support and patients' characteristics, including race, age, income, occupation, insurance, employment, education, and social network, and characteristics of the disease itself such as disease activity (SLAM) at diagnosis, damage (SLICC/ACR) at diagnosis, and comorbidity. RESULTS: In multivariate models, higher social support was significantly associated (p < 0.05) with better physical function when respondents were white, had income above poverty level, had Medicare or private insurance (vs Medicaid or no insurance), and had low disease activity at diagnosis. Social support was associated with better mental health, although there was no significant interaction between social support and other predictors of mental health. CONCLUSION: The data suggest that social support is beneficial for mental health for all groups, but has the greatest opportunity for influence among those already possessing social, economic, and health advantages.

American Burn Association/Shriners Hospitals for Children burn outcomes questionnaire: construction and psychometric properties.

To develop a standardized, practical, self-administered questionnaire to monitor pediatric patients with burns and to evaluate the effectiveness of comprehensive pediatric burn management treatments, a group of experts generated a set of items to measure relevant burn outcomes. Children between the ages of 5 and 18 years were assessed in a cross-sectional study. Both parent and adolescent responses were obtained from children 11 to 18 years old. The internal reliability of final scales ranged from 0.82 to 0.93 among parents and from 0.75 to 0.92 among adolescents. Mean differences between parent and adolescent were small; the greatest difference occurred in the appearance subscale. Parental scales showed evidence of validity and potential for sensitivity to change. In an effort to support the construct validity of the new scales, they were compared with the Child Health Questionnaire and related to each other in clinically sensible ways. These burn outcomes scales reliably and validly assess function in patients with burns, and the scales have been developed in such a way that they are likely to be sensitive to change over time.

Rheumatologist-patient communication about exercise and physical therapy in the management of rheumatoid arthritis.

OBJECTIVE: Little is known about the features and role of exercise discussions between rheumatologists and patients. The goals of this study were to: 1) describe rheumatologists' and patients' attitudes and beliefs regarding exercise and physical therapy for rheumatoid arthritis (RA); 2) describe frequency and length of exercise discussions; 3) determine the accuracy of recall for exercise discussions; and 4) assess the influence of attitudes regarding exercise on communication about exercise. METHODS: Goals 1-3 were addressed with analysis of baseline questionnaires and audiotaped encounters. The influence of attitudes and beliefs regarding exercise on the frequency and length of exercise discussions was assessed prospectively. Patients and rheumatologists were enrolled from a large tertiary care institution. Clinical encounters were audiotaped, transcribed, coded, and analyzed to identify specific characteristics of the exercise discussions. RESULTS: One hundred thirty-two patients and 25 rheumatologists participated in the study. Rheumatologists and patients discussed exercise in 53% of the encounters. Rheumatologists' beliefs regarding the usefulness of exercise for RA varied, with the least positive beliefs being reported for aerobic exercise. Exercise discussions were more likely to occur if the patient was currently exercising, odds ratio (OR) = 2.4; 95% confidence interval (CI) (1.2-4.9), and when the rheumatologist believed aerobic exercises were useful in managing RA, OR = 1.4; 95% CI (1.1-1.9). Current exercise behavior was associated with patients' positive attitude toward exercise (chi 2 1 = 8.4; P = 0.004) and perceived social support for exercise (chi 2 1 = 4.5; P = 0.04). When rheumatologists initiated exercise discussions, there was nearly twice as much discussion (beta = -8.4; P = 0.001). CONCLUSIONS: Exercise talk was influenced by patients' and rheumatologists' beliefs and attitudes regarding the effectiveness of exercise and physical therapy in managing RA, patient experience with exercise, and by characteristics of the rheumatologist.

Discrepancies between self-reported and observed physical function in the elderly: the influence of response shift and other factors.

GOAL: To explore the influence of social, psychological, and health factors on self-report of function. SUBJECTS: A convenience sample of 289 community-dwelling elderly aged 65-97 years. METHODS: We compared a measure of function based on observed performance, the Physical Capacity Evaluation (PCE) with a self-reported measure of functional limitations (HAQ), in a cross-sectional study. Stepwise multiple regression identified variables predicting self-reported disability, controlling for observed function. RESULTS: Controlling for PCE, self-reports of greater disability (HAQ) were predicted by current joint pain or stiffness, use of prescription medications, urban dwelling, depression, female gender, lack of memory problems, arthritis and lack of exercise. A final model included recent decline in function, dissatisfaction with function, gender, joint pain or stiffness, and observed function, explaining 85% of the variance in self-reported disability. The hypothesis that aging is associated with declining expectations of functional ability was not supported. However, recent health problems affected participants' reporting of limitations, consistent with a recalibration-type response shift. Perceived decline in function over the past six months, a fall within the last month, illness in the last week and pain or stiffness on the day of the exam all raised self-reports of disability. As suggested by adaptation level theory, subjects with recent problems might have an inflated perception of limitations due to shifts in their internal standards. When administered first, the observed performance test improved correlations between observed and self-reported function, primarily among those who did not report a recent decline in function. This suggests that this group may have benefited more from salient information about their abilities provided by performing the PCE before self-report. CONCLUSION: Our data confirm the importance of social, psychological, and health influences in self-report of disability, and are consistent with the hypothesis that people may recalibrate their self assessments based on recent health problems.

Learning from unreliability: the importance of inconsistency in coping dynamics.

The role of response stability in the measurement of coping is examined with a focus on the unique information that can be gleaned from low test retest reliability ('inconsistency'). Data from two studies are presented in which a card sort measure of coping flexibility was used on people with three different chronic diseases and the elderly (n = 219). We begin by testing the hypothesis that the low stability reflects unreliability due to measurement artifacts, such as random error, low ecological validity, long test retest interval, surrogate assistance, or error due to completing the questionnaire in multiple sittings. Our findings suggest that surrogate assistance in completing questionnaires was the only measurement artifact associated with low stability. We then tested the proposition that low stability reflects a genuine behavior pattern (i.e. inconsistency). Hierarchical modeling revealed that measurement artifact accounted for less than one percent of the variance in inconsistency in reported coping behavior and that an additional 21% of the variance could be explained by the behavioral factors, including neuropsychological problems (9%), psychological morbidity (4%), locus of control (3%) and eudaimonistic well-being (5%). Thus inconsistency in reported coping behavior was better explained by behavioral and psychosocial factors than by the tested measurement artifacts. We conclude that inconsistency in reported coping behavior does indeed reflect a meaningful behavior pattern, rather than simply measurement artifact.

Determinants of cognitive performance in systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) may have a variety of neuropsychiatric syndromes. Assessment of cognitive functioning for these patients is complicated by increased prevalence and disease severity among groups obtained lower scores on measures of cognitive functioning in normative national samples. Cognitive ability was quantified in a diverse cohort of patients with SLE and a demographically matched group of control participants. Hierarchical regression demonstrated a small increase (6%) in explained variation in cognitive functioning when presence of SLE was added to the equation derived from demographic variables. No significant interaction was found between race and disease. These results suggest that increased frequency of cognitive impairment in African Americans with SLE is due to the additive effects of psychosocial variables.

The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change. Pediatric Outcomes Instrument Development Group. Pediatric Orthopaedic Society of North America.

The goal of orthopaedic interventions is to improve the functional health of patients, particularly physical function. The American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America (POSNA) commissioned a work group to construct functional health outcomes scales for children and adolescents, focusing on musculoskeletal health. The work group developed scales assessing upper extremity function, transfers and mobility, physical function and sports, comfort (pain free), happiness and satisfaction, and expectations for treatment. Parent and adolescent self-report forms were developed and tested on 470 subjects aged 2-18 years. The POSNA scales demonstrated good reliability, construct validity, sensitivity to change over a 9-month period, and ability to outperform a standard instrument, the Child Health Questionnaire physical functioning scale. They were useful for a wide variety of ages and diagnoses. They appear to be ideally suited for orthopaedic surgeons to assess the functional health and efficacy of treatment of their patients at baseline and follow-up.

The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis.

UNLABELLED: The influence of psychosocial variables in the outcome of surgery for lumbar stenosis (LSS) has not been evaluated. We studied 257 patients with LSS pre-operatively and at 6 months to: (a) relate patient expectations of surgery to baseline function and pain; and (b) determine how patient expectations and pre-operative function interact to predict post-operative outcomes. RESULTS: On average, patients experienced substantial pain relief, improved function and satisfaction. Patients with many pre-operative expectations, particularly patients with low baseline function, reported more improvement in post-operative function than patients with few expectations. More ambitious expectations for physical function were also associated with improved function and satisfaction at 6 months. Conversely, having more numerous pain relief expectations was associated with more pain and less satisfaction with pain relief. CONCLUSION: Patient expectations influence recovery from surgery at 6 months. To improve outcomes and satisfaction, clinicians should discuss expectations with patients pre-operatively.