Predicting high quality of participation in adaptive snow-sports for individuals with disabilities: An exploratory study.

OBJECTIVES: This exploratory study aimed to examine the individual, program and environmental (social and physical) characteristics which predict high quality of participation in adaptive snowsports for each dimension of the Quality of Participation in Parasport Framework (QPPF): autonomy, belongingness, mastery, challenge, engagement and meaning. METHODS: A survey was completed by 133 individuals with disabilities or their representatives on each dimension of the QPPF in adaptive snowsports and on the factors impacting the quality of participation. Descriptive statistics were used to describe the study participants, and a multivariate logistic regression model was constructed for each dimension of the QPPF to evaluate the relative contribution of individual, snowsport-related, program and environmental factors to each dimension. RESULTS: Individuals with disabilities in this study reported high quality of participation on all dimensions of the QPPF. The individual characteristics only predicted the QPPF dimension of challenge. However, the program and environmental characteristics such as equipment, number of instructors and barriers were robust predictors of quality of participation. CONCLUSION: Overall, participants experienced high quality participation. Supporting the adaptive snowsports programs while reducing the barriers faced by people with disabilities should be a continued effort to promote quality of participation.

Protocol for a randomized controlled trial to assess the effect of Self-Management for Amputee Rehabilitation using Technology (SMART): An online self-management program for individuals with lower limb loss.

BACKGROUND: Lower limb loss (LLL) is a distressing experience with psychological, physical, and social challenges. Education is needed to enhance the coping skills and confidence of patients to improve LLL outcomes. However, access to rehabilitation services and education is limited outside of urban centers. To address this service gap, we co-created an eHealth platform, called Self-Management for Amputee Rehabilitation using Technology (SMART). OBJECTIVES: First, we will test the effect of SMART and usual care compared with usual care only on walking capacity and confidence among individuals with LLL. Second, we will describe key implementation factors for program delivery and adoption at the person- and provider-level. METHODS: This is a Type 1 Effectiveness-Implementation Hybrid Design, mixed-methods, multi-site (British Columbia and Ontario, Canada), parallel, assessor-blinded randomized controlled trial. Participants will include adults with unilateral LLL, during early prosthetic fitting (<2 years after casting for initial prosthesis). Participants in both groups will receive usual care. The experimental group will receive SMART with weekly support sessions from a trained peer mentor for goal setting and action planning for six weeks. Participants will be encouraged to continue using SMART for an additional four weeks. The control group will receive usual care, and weekly social contacts for six weeks. The primary outcome measure is walking capacity operationalized as the performance based Timed Up and Go test. The secondary outcome is walking confidence using the Ambulatory Self-Confidence Questionnaire. Outcome measures will be assessed at baseline, immediately post-intervention, and four weeks follow-up. We will describe key implementation factors (such as, participant experience, intervention adoption, fidelity) throughout the study using questionnaires, semi-structured interviews, and direct observation. RESULTS: No participants have been enrolled. CONCLUSIONS: SMART has the potential to provide knowledge and skill development to augment rehabilitation outcomes for adults with LLL. TRIAL REGISTRATION: NCT04953364 in Clinical Trial Registry (https://clinicaltrials.gov/).

A Mixed-methods Study on Prosthesis Use Among Older Canadians With Lower-limb Amputations.

BACKGROUND: The prevalence of lower-limb amputations (LLA) in older adults is increasing. Due to the substantial resources required for rehabilitation, there is growing interest in exploring prosthesis use as well as the factors that impact use for individuals with LLA. OBJECTIVES: To examine how older adults, those over 50 years old, with a new LLA use their prostheses following rehabilitation and to identify factors that increase or decrease prosthesis use after discharge from a rehabilitation hospital. METHODS: The StepWatch Activity Monitor, the Prosthetic Profile of the Amputee Questionnaire, and a semi-structured interview were used to measure prosthesis use and factors affecting use at 12 weeks post-discharge from a rehabilitation hospital. Descriptive statistics were calculated for the quantitative data and the qualitative interviews were analyzed using the International Classification of Functioning and Disability. RESULTS: Two user profiles emerged from the 11 participants' use patterns. The Regular Users integrated their prosthesis into their lives, using it for various types of activities, while the Strategic Users wore their prosthesis to perform specific activities of daily and instrumental activities of daily living tasks. Body functions (e.g., pain), personal (e.g., feeling of independence), and environmental factors (e.g., home adaptations or social support) impacted prosthesis use. CONCLUSIONS: The emergence of profiles suggests variability in how older adults with LLA use their prosthesis after rehabilitation. However, the factors affecting prosthesis use were similar between the profiles. Therefore, while it is important for rehabilitation teams to consider patients' individual needs when setting goals for prosthetic training, they must also consider common factors affecting prosthesis use.

Adverse life events increase risk for postpartum psychiatric episodes: A population-based epidemiologic study.

BACKGROUND: Trauma histories may increase risk of perinatal psychiatric episodes. We designed an epidemiological population-based cohort study to explore if adverse childhood experiences (ACE) in girls increases risk of later postpartum psychiatric episodes. METHODS: Using Danish registers, we identified women born in Denmark between January 1980 and December 1998 (129,439 childbirths). Exposure variables were ACE between ages 0 and 15 including: (1) family disruption, (2) parental somatic illness, (3) parental labor market exclusion, (4) parental criminality, (5) parental death, (6) placement in out-of-home care, (7) parental psychopathology excluding substance use, and (8) parental substance use disorder. Primary outcome was first occurrence of in- or outpatient contact 0-6 months postpartum at a psychiatric treatment facility with any psychiatric diagnoses, ICD-10, F00-F99 (N = 651). We conducted survival analyses using Cox proportional hazard regressions of postpartum psychiatric episodes. RESULTS: Approximately 52% of the sample experienced ACE, significantly increasing risk of any postpartum psychiatric diagnosis. Highest risks were observed among women who experienced out-of-home placement, hazard ratio (HR) 2.57 (95% CI: 1.90-3.48). Women experiencing two adverse life events had higher risks of postpartum psychiatric diagnosis HR: 1.88 (95% CI: 1.51-2.36), compared to those with one ACE, HR: 1.24 (95% CI: 1.03-49) and no ACE, HR: 1.00 (reference group). CONCLUSIONS: ACE primarily due to parental psychopathology and disability contributes to increased risk of postpartum psychiatric episodes; and greater numbers of ACE increases risk for postpartum psychiatric illness with an observed dose-response effect. Future work should explore genetic and environmental factors that increase risk and/or confer resilience.

Characteristics of persons who inject drugs and who witness opioid overdoses in Vietnam: a cross-sectional analysis to inform future overdose prevention programs.

BACKGROUND: Persons who use opioids have a high risk of overdose and associated mortality. In Vietnam, little is known about the characteristics of this population and the persons who are witness to those overdoses. One approach to combatting fatal overdose has been the use of peer interventions in which a friend or injecting partner administers overdose reversal medication, but availability in Vietnam of these medications is limited to pilot programs with aims to expand in the future (Le Minh and V.F. Go, Personal Communication, 2016). The primary objective of this paper is to explore the characteristics associated with witnessing three or more overdoses in a lifetime. METHODS: This cross-sectional analysis used baseline data from a four-arm randomized control trial conducted in Thai Nguyen, Vietnam, known as the Prevention for Positives project. One thousand six hundred seventy-three PWID were included in the analysis. We conducted bivariable and multivariable logistic regression to identify characteristics associated with witnessing three or more overdoses in a lifetime. Characteristics explored included education, employment, marital status, risky drug use behaviors, locations for accessing syringes, recent overdose, history of incarceration, drug treatment, and having slept outside in the past 3 months. RESULTS: Seventy-two percent (n = 1203) of participants had witnessed at least one overdose in their lifetime, and 46% had witnessed three or more overdoses (n = 765). In the multivariable model, having less than secondary education (AOR 0.70; 95% CI 0.57, 0.86), having slept outside in the past 3 months (AOR 1.77; 95% CI 1.31, 2.40), having a history of incarceration (AOR 1.33; 95% CI 1.07, 1.65), having a history of drug treatment (AOR 1.41; 95% CI 1.12, 1.77), experiencing a recent non-fatal overdose (AOR 3.84; 95% CI 2.36, 6.25), injecting drugs daily (AOR 1.79; 95% CI 1.45, 2.20), receptive needle sharing (AOR 1.30; 95% CI 1.04, 1.63), and number of years injecting (AOR 1.04; 95% CI 1.02, 1.07) were significantly associated with witnessing three or more overdoses. CONCLUSIONS: Targeted interventions are needed to train persons witnessing an overdose to administer overdose-reversal medication. This includes targeting persons prior to release from prisons, drug treatment centers, and those accessing syringe exchange programs. Additional research should assess the burden of witnessing an overdose as well as locations for medication distribution. Assessments of the training capacity and needs for implementing these programs among drug using peers in Vietnam are of the utmost importance.

Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women.

BACKGROUND: Childbirth is a potent trigger for the onset of psychiatric illness in women including postpartum depression (PPD) and postpartum psychosis (PP). Medical complications occurring during pregnancy and/or childbirth have been linked to postpartum psychiatric illness and sociodemographic factors. We evaluated if pregnancy and obstetrical predictors have similar effects on different types of postpartum psychiatric disorders. METHOD: A population-based cohort study using Danish registers was conducted in 392 458 primiparous women with a singleton delivery between 1995 and 2012 and no previous psychiatric history. The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum. RESULTS: PPD and postpartum acute stress reactions were associated with pregnancy and obstetrical complications. For PPD, hyperemesis gravidarum [IRR 2.69, 95% confidence interval (CI) 1.93-3.73], gestational hypertension (IRR 1.84, 95% CI 1.33-2.55), pre-eclampsia (IRR 1.45, 95% CI 1.14-1.84) and Cesarean section (C-section) (IRR 1.32, 95% CI 1.13-1.53) were associated with increased risk. For postpartum acute stress, hyperemesis gravidarum (IRR 1.93, 95% CI 1.38-2.71), preterm birth (IRR 1.51, 95% CI 1.30-1.75), gestational diabetes (IRR 1.42, 95% CI 1.03-1.97) and C-section (IRR 1.36, 95% CI 1.20-1.55) were associated with increased risk. In contrast, risk of PP was not associated with pregnancy or obstetrical complications. CONCLUSIONS: Pregnancy and obstetrical complications can increase the risk for PPD and acute stress reactions but not PP. Identification of postpartum women requiring secondary care is needed to develop targeted approaches for screening and treatment. Future work should focus on understanding the contributions of psychological stressors and underlying biology on the development of postpartum psychiatric illness.

The course of fatigue after acute spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the prevalence and course of fatigue following acute spinal cord injury (SCI) during rehabilitation and after discharge. SETTING: Tertiary spinal cord rehabilitation facility. METHODS: Fifty-two patients with traumatic SCI were assessed after admission to rehabilitation and followed until 6-months post discharge into the community. Fatigue was measured using the Fatigue Severity Scale (FSS) and the Modified Fatigue Impact Scale for Spinal Cord Injury (MFIS-SCI) at admission, discharge and 6 months after discharge. Clinically significant fatigue was defined as FSS scores ⩾4 or MFIS-SCI scores ⩾24.5. RESULTS: The mean (s.d.) age of our mainly male (78.8%) sample was 46.3 (17.8) years of age. Half had cervical and 61.6% had complete injuries. Mean (s.d.) FSS scores were 3.7 (1.6) at baseline, 3.4 (1.5) at discharge and 3.7 (1.7) post discharge. Mean (s.d.) MFIS-SCI scores were 24.4 (16.1) at baseline, 23.4 (16.3) at discharge and 27.8 (17.5) post discharge. Fatigue on the FSS was present in 51.9% at baseline, 38.3% at discharge and 48.1% post discharge. Fatigue on the MFIS-SCI was present in 44.2% at baseline, 44.7% at discharge and 51.9% post discharge. There was no relationship between fatigue and injury level or completeness. CONCLUSIONS: Fatigue is common in SCI patients admitted to rehabilitation. Fatigue remained stable during rehabilitation and after discharge into the community. Clinicians should consider early screening for fatigue and interventions to reduce the consequences of fatigue in people with SCI. SPONSORSHIP: The British Columbia Medical Services Foundation funded our study.

Movement repetitions in physical and occupational therapy during spinal cord injury rehabilitation.

STUDY DESIGN: Longitudinal observational study. OBJECTIVE: To quantify the amount of upper- and lower-extremity movement repetitions (that is, voluntary movements as part of a functional task or specific motion) occurring during inpatient spinal cord injury (SCI), physical (PT) and occupational therapy (OT), and examine changes over the inpatient rehabilitation stay. SETTING: Two stand-alone inpatient SCI rehabilitation centers. METHODS: Participants: A total of 103 patients were recruited through consecutive admissions to SCI rehabilitation. INTERVENTIONS: Trained assistants observed therapy sessions and obtained clinical outcome measures in the second week following admission and in the second to last week before discharge. MAIN OUTCOME MEASURES: PT and OT time, upper- and lower-extremity repetitions and changes in these outcomes over the course of rehabilitation stay. RESULTS: We observed 561 PT and 347 OT sessions. Therapeutic time comprised two-thirds of total therapy time. Summed over PT and OT, the median upper-extremity repetitions in patients with paraplegia were 7 repetitions and in patients with tetraplegia, 42 repetitions. Lower-extremity repetitions and steps primarily occurred in ambulatory patients and amounted to 218 and 115, respectively (summed over PT and OT sessions at discharge). Wilcoxon-signed rank tests revealed that most repetition variables did not change significantly over the inpatient rehabilitation stay. In contrast, clinical outcomes for the arm and leg improved over this time period. CONCLUSIONS: Repetitions of upper- and lower-extremity movements are markedly low during PT and OT sessions. Despite improvements in clinical outcomes, there was no significant increase in movement repetitions over the course of inpatient rehabilitation stay.

Depression and Engagement in Care Among Newly Diagnosed HIV-Infected Adults in Johannesburg, South Africa.

Delayed engagement in HIV care threatens the success of HIV treatment programs in sub-Saharan Africa and may be influenced by depression. We examined the relationship between depression prior to HIV diagnosis and engagement in HIV care at a primary care clinic in Johannesburg, South Africa. We screened 1683 patients for depression prior to HIV testing using the Patient Health Questionnaire-9. Among patients who tested positive for HIV we assessed linkage to HIV care, defined as obtaining a CD4 count within 3 months. Among those who linked to care and were eligible for ART, we assessed ART initiation within 3 months. Multivariable Poisson regression with a robust variance estimator was used to assess the association between depression and linkage to care or ART initiation. The prevalence of HIV was 26 % (n = 340). Among HIV-infected participants, the prevalence of depression was 30 %. The proportion of linkage to care was 80 % among depressed patients and 73 % among patients who were not depressed (risk ratio 1.08; 95 % confidence interval 0.96, 1.23). Of the participants who linked to care, 81 % initiated ART within 3 months in both depressed and not depressed groups (risk ratio 0.99; 95 % confidence interval 0.86, 1.15). Depression was not associated with engagement in HIV care in this South African primary care setting. Our unexpected findings suggest that some depressed HIV-infected patients might be more likely to engage in care than their counterparts without depression, and highlight the complex relationship between depression and HIV infection. These findings have led us to propose a new framework relating HIV infection, depression, and the population under study.

Structure of the C-terminal domain of the prokaryotic sodium channel orthologue NsvBa.

Crystallographic and electrophysiological studies have recently provided insight into the structure, function, and drug binding of prokaryotic sodium channels. These channels exhibit significant sequence identities, especially in their transmembrane regions, with human voltage-gated sodium channels. However, rather than being single polypeptides with four homologous domains, they are tetramers of single domain polypeptides, with a C-terminal domain (CTD) composed of an inter-subunit four helix coiled coil. The structures of the CTDs differ between orthologues. In NavBh and NavMs, the C-termini form a disordered region adjacent to the final transmembrane helix, followed by a coiled-coil region, as demonstrated by synchrotron radiation circular dichroism (SRCD) and double electron-electron resonance electron paramagnetic resonance spectroscopic measurements. In contrast, in the crystal structure of the NavAe orthologue, the entire C-terminus is comprised of a helical region followed by a coiled coil. In this study, we have examined the CTD of the NsvBa from Bacillus alcalophilus, which unlike other orthologues is predicted by different methods to have different types of structures: either a disordered region adjacent to the transmembrane region, followed by a helical coiled coil, or a fully helical CTD. To discriminate between the two possible structures, we have used SRCD spectroscopy to experimentally determine the secondary structure of the C-terminus of this orthologue and used the results as the basis for modeling the open and closed conformations of the channel.

Caregiving services in spinal cord injury: a systematic review of the literature.

STUDY DESIGN: PRISMA guided systematic review. OBJECTIVES: To summarize and characterize the literature pertaining to the nature of and factors associated with caregiving services provided to individuals with spinal cord injury (SCI) and identify areas for interventional research to address the needs of care recipients. DATA SOURCES: PUBMED/Medline, CINAHL, PsycINFO, EMBASE, Social Services Abstracts and Social Work Abstracts databases. METHODS: Qualitative and quantitative peer-reviewed publications that were written in English were included if they described the nature of caregiving services in SCI, factors influencing the use of and access to caregiving services or described interventions to address caregiving needs of individuals with SCI. RESULTS: Sixteen papers were selected. The level of evidence for included studies ranged from 2 (highest) to 5 (lowest). Eleven studies described the nature of caregiving services, demographics of caregivers and recipients and factors associated with requiring care. Five studies described caregiving interventions. CONCLUSION: Caregiving services in SCI are predominantly provided by informal caregivers who are female. Quality of care from informal caregivers matches or exceeds quality of formal care. Total hours of care are dependent on the injury level and severity and care needs of the individual. Caregiver training is an important theme and has positive preliminary results on the quality of care provided. Intervention-based research is limited; further research to increase independence in activities of daily living and instrumental activities of daily living would reduce the need for caregiving hours.

The relationship between fatigue and participation in spinal cord injury.

STUDY DESIGN: Cross-sectional national survey. OBJECTIVES: To explore the association between fatigue and community participation frequency and provide an adjusted model of the relationship including important covariates. SETTING: Canada; Community. METHODS: Data were obtained from the Rick Hansen Spinal Cord Injury Registry Community Survey. We used multi-variable regression analyses with hierarchical backward elimination, including variable specification, interaction assessment and confounding assessment. Variables with statistically significant correlation with the primary-dependent variable (participation) were included for modeling. RESULTS: The crude model of association between fatigue and participation accounted for 7.2% of the variance in participation scores. The full model with all a priori selected variables accounted for 25.1% of variance in participation scores. The adjusted model, including the identified confounders (pain, depressive mood, comorbidities and level of injury), accounted for 21.1% of variance in participation scores. Depressive mood variables had the highest standardized beta coefficients, reflecting the largest contribution to this model. CONCLUSION: Fatigue has a statistically significant negative association with participation for individuals with spinal cord injury, when controlling for pain, depressive mood, comorbidities and level of injury. Multifaceted clinical interventions and research addressing fatigue, pain and depressive symptoms are warranted.

On the front line of HIV virological monitoring: barriers and facilitators from a provider perspective in resource-limited settings.

Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider perceptions of VL monitoring and indicate the importance of policies responsive to individual and environmental challenges of VL monitoring program implementation. Findings may inform scale-up by helping policy-makers identify strategies to improve feasibility and sustainability of VL monitoring.

Interventions for improving employment outcomes among individuals with spinal cord injury: a systematic review.

STUDY DESIGN: Systematic literature review. OBJECTIVE: The primary aim of this study was to evaluate interventions aimed at improving employment outcomes for individuals with spinal cord injuries (SCI). METHODS: An electronic search of Medline/PubMed, EMBASE, Cochrane database, CINAHL, PsycINFO, Social Science Abstracts and Social Work Abstract databases was performed on 31 December 2013. To be included in the review, studies needed to investigate interventions among individuals with SCI where employment was an outcome. Exclusion criteria include (i) reviews, (ii) studies not published in English and (iii) non-peer reviewed publications. RESULTS: Fourteen studies met the inclusion criteria, two were randomized controlled trials. The strongest evidence finds that supported employment can improve employment outcomes among individuals with SCI. The use of service dogs has also been shown to improve employment outcomes. The remaining 12 studies are observational and predominantly focus on vocational rehabilitation programs. CONCLUSION: There is a dearth of high-quality intervention research that targets employment outcomes in individuals with SCI. Consequently, conclusions are mostly based on evidence from observational studies. Vocational rehabilitation programs are the primary focus of this evidence, but conclusions may be confounded, as individuals may be self-selecting for these programs. Additional randomized trials on employment interventions are needed to overcome these limitations. Studies should aim to identify which components of these programs have the greatest influence on employment outcomes.

Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa.

BACKGROUND: Integration of depression screening into primary care may increase access to mental health services in sub-Saharan Africa, but this approach requires validated screening instruments. We sought to validate the Patient Health Questionnaire-9 (PHQ-9) as a depression screening tool at a high HIV-burden primary care clinic in Johannesburg, South Africa. METHODS: We conducted a validation study of an interviewer-administered PHQ-9 among 397 patients. Sensitivity and specificity of the PHQ-9 were calculated with the Mini International Neuropsychiatric Interview (MINI) as the reference standard; receiver operating characteristic (ROC) curve analyses were performed. RESULTS: The prevalence of depression was 11.8%. One-third of participants tested positive for HIV. HIV-infected patients were more likely to be depressed (15%) than uninfected patients (9%; p=0.08). Using the standard cutoff score of ≥10, the PHQ-9 had a sensitivity of 78.7% (95% CI: 64.3-89.3) and specificity of 83.4% (95% CI: 79.1-87.2). The area under the ROC curve was 0.88 (95% CI: 0.83-0.92). Test performance did not vary by HIV status or language. In sensitivity analyses, reference test bias associated with the MINI appeared unlikely. LIMITATIONS: We were unable to conduct qualitative work to adapt the PHQ-9 to this cultural context. CONCLUSION: This is the first validation study of the PHQ-9 in a primary care clinic in sub-Saharan Africa. It highlights the potential for using primary care as an access point for identifying depressive symptoms during routine HIV testing. The PHQ-9 showed reasonable accuracy in classifying cases of depression, was easily implemented by lay health workers, and is a useful screening tool in this setting.

Measurement properties of a telephone version of the Modified Fatigue Impact Scale among individuals with a traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To validate a telephone-administered version of the Modified Fatigue Impact Scale spinal cord injury scores among individuals with a traumatic SCI 6 months post discharge from rehabilitation. SETTING: GF Strong Rehabilitation Center in Vancouver, British Columbia, Canada. METHODS: Data from 42 participants who were ≥19-years-old with a confirmed American Spinal Injury Association Impairment Scale classification of A, B, C or D resulting from a traumatic SCI, and 6 months post discharge from rehabilitation were analyzed. The internal consistency was ascertained using Cronbach's alpha. Support for validity was provided by conducting correlations between the 21-item MFIS-SCI and Fatigue Severity Scale curve was constructed. Sensitivity, specificity and likelihood ratios were calculated to assess the diagnostic accuracy. RESULTS: Cronbach's alpha was 0.97. Correlations between the MFIS-SCI and FSS were in the a priori hypothesized direction and magnitude. The area under the ROC curve was 0.78 (95% confidence interval=0.65-0.92). At the optimal cutoff score of 24.5, both the sensitivity and specificity were 0.67. The positive and negative likelihood ratios were 2.03 and 0.49, respectively. CONCLUSION: There is support for the validity of the MFIS-SCI scores and it should be considered for the comprehensive measurement of the impact of fatigue in persons with a traumatic SCI.

An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify changes in subjective quality of life (QoL) as one ages with a spinal cord injury (SCI). SETTING: Vancouver, Canada. METHODS: Electronic databases were searched for studies reporting on age-related QoL changes over time. Data from relevant studies were transcribed into data extraction forms and analyzed by years post injury (YPI) and chronologic age. Each study was assigned a level of evidence based on a modified Sackett scale. RESULTS: In all, 21 studies, each with a low level of evidence, were included for review. The results indicated that regardless of chronologic age, individuals with relatively new SCI have the potential to improve their QoL. Among individuals with advanced YPI, overall QoL is consistently reported as good or excellent over time, however, with variations in different QoL domains. CONCLUSION: The QoL of individuals aging with a SCI has the potential to improve, and remain high and stable over time. As the identified studies provide low levels of evidence, more longitudinal research with greater methodological and measurement rigor is needed to corroborate the findings and conclusions of this review.

Increased prevalence of advanced tuberculosis in rural low tuberculosis caseload counties in North Carolina.

SETTING: Pulmonary tuberculosis (TB) patients reported in North Carolina (NC), USA, from 1996 to 2008 (inclusive). OBJECTIVE: To compare prevalence of cavitary TB as a surrogate marker for advanced disease in low-caseload counties with high-caseload counties. DESIGN: A multivariate log binomial regression model was used to estimate prevalence ratios (PRs) for cavitary TB. RESULTS: The proportion of TB cases in low-caseload counties vs. the total number of TB cases in NC over the study period increased from 10% in 1996 to 20% in 2008. After adjusting for human immunodeficiency virus (HIV) status, excess alcohol use and report year, patients in rural areas of low-caseload counties had greater prevalence (PR 1.40, 95%CI 1.19-1.64) of cavitary disease compared with patients from rural areas of high-caseload counties. The prevalence of cavitary TB did not differ between urban residents of high- or low-caseload counties (PR 1.00, 95%CI 0.86-1.16) after adjusting for HIV status, excess alcohol use and report year. DISCUSSION: TB patients in rural areas of low-caseload counties presented with more advanced TB disease compared with patients from urban and/or high-caseload counties. Barriers to timely recognition of TB in rural low-caseload settings must be considered in TB control programs.

Measurement properties of the wheelchair outcome measure in individuals with spinal cord injury.

STUDY DESIGN: One-week retest methodological study. OBJECTIVES: To assess the reliability and validity of the wheelchair outcome measure (WhOM) in a sample of individuals with spinal cord injury (SCI). SETTING: Vancouver, British Columbia, Canada. METHODS: The WhOM measures the impact of wheelchair interventions on a user's self-selected participation outcomes. The WhOM was administered to 50 participants on two occasions by the same rater, 1 week apart, to assess test-retest reliability. To determine inter-rater reliability, the WhOM was administered a third time approximately 72 h later by a different rater. Validity was evaluated by correlating scores from the WhOM with scores from the Assessment of Life Habits (LIFE-H). RESULTS: The test-retest intraclass correlation coefficients (ICC(2, 2)) for the WhOM satisfaction (Sat) and WhOM importance (Impt) × Sat scores were 0.83 (95% confidence interval (CI), 0.72-0.90) and 0.88 (95% CI, 0.79-0.93), respectively. The inter-rater ICC for the WhOM Sat and WhOM Impt × Sat scores were 0.91 (95% CI, 0.85-0.95) and 0.90 (95% CI, 0.83-0.94), respectively. As hypothesized, most scores on the WhOM were fair to moderate (r=0.3-0.5) and positively correlated with scores on the LIFE-H. CONCLUSION: The WhOM is a new outcome measure that demonstrates good reliability and validity among individuals with SCI. It is designed to assist wheelchair users identify and evaluate the impact of wheelchair interventions on participation level outcomes. The WhOM may be applicable for clinical- or research-oriented purposes.

Recruitment of HIV/AIDS treatment-naïve patients to clinical trials in the highly active antiretroviral therapy era: influence of gender, sexual orientation and race.

BACKGROUND: In the USA, women, racial/ethnic minorities and persons who acquire HIV infection through heterosexual intercourse represent an increasing proportion of HIV-infected persons, and yet are frequently underrepresented in clinical trials. We assessed the demographic predictors of trial participation in antiretroviral-naïve patients. METHODS: Patients were characterized as trial participants if highly active antiretroviral therapy (HAART) was initiated within a clinical trial. Prevalence ratios (PRs) were obtained using binomial regression. RESULTS: Between 1996 and 2006, 30% of 738 treatment-naïve patients initiated HAART in a clinical trial. Trial participation rates for men who have sex with men (MSM), heterosexual men, and women were respectively 36.5, 29.6 and 24.3%. After adjustment for other factors, heterosexual men appeared less likely to participate in trials compared with MSM [PR 0.79, 95% confidence interval (CI) 0.57, 1.11], while women were as likely to participate as MSM (PR 0.97, 95% CI 0.68, 1.39). The participation rate in Black patients (25.9%) was lower compared with non-Black patients (37.5%) (adjusted PR 0.80, 95% CI 0.60, 1.06). CONCLUSIONS: In our clinical setting, gender did not appear to impact participation in HIV treatment trials, but Black patients were slightly less likely to participate in these trials. Considering the substantial proportion of HIV-infected patients who are Black, future trials need to consider strategies to incorporate such underrepresented populations.