Multiple retinal detachment surgery: A functional outcome study. The Houston Vision Assessment Test-Retina (HVAT-Retina)

Retinal detachment is a common ophthalmologic procedure, and outcome is typically measured by a single factor-improvement in visual acuity. Health related functional outcome testing, which quantifies patient's self-reported perception of impairment, can be integrated with objective clinical findings. Based on the patient's self-assessed lifestyle impairment, the physician and patient together can make an informed decision on the treatment that is most likely to benefit the patient. ^ A functional outcome test (the Houston Vision Assessment Test-Retina; HVAT-Retina) was developed and validated in patients with multiple retinal detachments in the same eye. The HVAT-Retina divides an estimated total impairment into subcomponents: contribution of visual disability (potentially correctable by retinal detachment surgery) and nonvisual physical disabilities (co-morbidities not affected by retinal detachment surgery. ^ Seventy-six patients participated in this prospective multicenter study. Seven patients were excluded from the analysis because they were not certain of their answers. Cronbach's alpha coefficient was 0.91 for presurgery HVAT-Retina and 0.94 post-surgery. The item-to-total correlation ranged from 0.50 to 0.88. Visual impairment score improved by 9 points from pre-surgery (p = 0.0003). Physical impairment score also improved from pre-surgery (p = 0.0002). ^ In conclusion, the results of this study demonstrate that the instrument is reliable and valid in patients presenting with recurrent retinal detachments. The HVAT-Retina is a simple instrument and does not burden the patient or the health professional in terms of time or cost. It may be self-administrated, not requiring an interviewer. Because the HVAT-Retina was designed to demonstrate outcomes perceivable by the patient, it has the potential to guide the decision making process between patient and physician. ^

An assessment of obesity and hyperphagia in individuals with Smith-Magenis syndrome

Smith-Magenis syndrome (SMS;OMIM# 182290) is a multiple congenital anomalies and mental retardation syndrome caused by a 3.7- Mb deletion on chromosome 17p11.2 or a mutation in the RAI1 gene. Although the majority of the SMS phenotype has been well described, limited studies are available describing growth patterns in SMS. There is some evidence that individuals with SMS develop obesity. Thus, this study aims to characterize the growth and potential influence of hyperphagia in a cohort of individuals with SMS. A retrospective chart review was conducted of 78 individuals with SMS through Baylor College of Medicine (BCM) at Texas Children¡¯s Hospital (TCH.) All documented height and weight measurements were abstracted and Z-scores (SD units) for height-for-age, length-for-age and BMI-for-age were calculated. Mail-out questionnaires were provided to the corresponding parents of the cohort to assess for the presence of hyperphagia through a validated hyperphagia questionnaire (HQ). Analysis of this data demonstrates that by the age ¡Ý 20 years males with SMS have mean BMI¡¯s in the 85th-90th percentile corresponding to an overweight BMI, and females with SMS had mean BMI¡¯s in the 95th -97th percentile corresponding to an obese BMI. Parents indicated that hyperphagia is present in individuals with SMS as 76% of parent¡¯s report having to lock food away from their child. Females¡¯ age ¡Ý 20 years of age had the highest mean behavior, drive and severity scores as well as the highest BMI. Thus, this study concludes that it appears overweight and obesity, as well as hyperphagia, are present in this cohort of SMS individuals. The results of this study will hopefully enable parents and caregivers of children with SMS to take preventative measures in order to control food related behaviors present in their children as well as to prevent overweight and obesity and the associated negative health consequences.

Noninvasive assessment of diffusion hypoxia following administration of nitrous oxide-oxygen.

The phenomenon of diffusion hypoxia is commonly believed to occur unless nitrous oxide-oxygen inhalation sedation is followed by "washout" with 100% oxygen for 5 minutes upon termination of the flow of nitrous oxide. When systematically studied, however, this phenomenon generally appears to be unfounded. The present study evaluated the effect of breathing room air instead of 100% oxygen in healthy (ASA 1) human volunteers following administration of sedative concentrations of nitrous oxide. The occurrence of hypoxia was determined objectively, using pulse oximetry and a standardized psychomotor skills test (Trieger test). Diffusion hypoxia was not observed using these criteria.

The Development and Implementation of an Anthropomorphic Head Phantom for the Assessment of Proton Therapy Treatment Procedures

Proton therapy has become an increasingly more common method of radiation therapy, with the dose sparing to distal tissue making it an appealing option, particularly for treatment of brain tumors. This study sought to develop a head phantom for the Radiological Physics Center (RPC), the first to be used for credentialing of institutions wishing to participate in clinical trials involving brain tumor treatment of proton therapy. It was hypothesized that a head phantom could be created for the evaluation of proton therapy treatment procedures (treatment simulation, planning, and delivery) to assure agreement between the measured dose and calculated dose within ±5%/3mm with a reproducibility of ±3%. The relative stopping power (RSP) and Hounsfield Units (HU) were measured for potential phantom materials and a human skull was cast in tissue-equivalent Alderson material (RLSP 1.00, HU 16) with anatomical airways and a cylindrical hole for imaging and dosimetry inserts drilled into the phantom material. Two treatment plans, proton passive scattering and proton spot scanning, were created. Thermoluminescent dosimeters (TLDs) and film were loaded into the phantom dosimetry insert. Each treatment plan was delivered three separate times. Each treatment plan passed our 5%/3mm criteria, with a reproducibility of ±3%. The hypothesis was accepted and the phantom was found to be suitable for remote audits of proton therapy treatment facilities.

Assessment of interrater agreement using a binomial-based statistic: K(bin)

This project develops K(bin), a relatively simple, binomial based statistic for assessing interrater agreement in which expected agreement is calculated a priori from the number of raters involved in the study and number of categories on the rating tool. The statistic is logical in interpretation, easily calculated, stable for small sample sizes, and has application over a wide range of possible combinations from the simplest case of two raters using a binomial scale to multiple raters using a multiple level scale.^ Tables of expected agreement values and tables of critical values for K(bin) which include power to detect three levels of the population parameter K for n from 2 to 30 and observed agreement $\ge$.70 calculated at alpha =.05,.025, and.01 are included.^ An example is also included which describes the use of the tables for planning and evaluating an interrater reliability study using the statistic, K(bin). ^

Outcomes assessment of a pediatric practice guideline

Objective. This study examines the structure, processes, and data necessary to assess the outcome variables, length of stay and total cost, for a pediatric practice guideline. The guideline was developed by a group of physicians and ancillary staff members representing the services that most commonly provide treatment for asthma patients at Texas Children's Hospital, as a means of standardizing care. Outcomes have needed to be assessed to determine the practice guideline's effectiveness.^ Data sources and study design. Data for the study were collected retrospectively from multiple hospital data bases and from inpatient chart reviews. All patients in this quasi-experimental study had a diagnosis of Asthma (ICD-9-CM Code 493.91) at the time of admission.^ The study examined data for 100 patients admitted between September 15, 1995 and November 15, 1995, whose physician had elected to apply the asthma practice guideline at the time of the patient's admission. The study examined data for 66 inpatients admitted between September 15, 1995 and November 15, 1995, whose physician elected not to apply the asthma practice guideline. The principal outcome variables were identified as "Length of Stay" and "Cost".^ Principal findings. The mean length of stay for the group in which the practice guideline was applied was 2.3 days, and 3.1 days for the comparison group, who did not receive care directed by the practice guideline. The difference was statistically significant (p value = 0.008). There was not a demonstrable difference in risk factors, health status, or quality of care between the groups. Although not showing statistical significance in the univariate analysis, private insurance showed a significant difference in the logistic regression model presenting an elevated odds ratio (odds ratio = 2.2 for a hospital stay $\le$2 days to an odds ratio = 4.7 for a hospital stay $\le$3 days) showing that patients with private insurance experienced greater risk of a shorter hospital stay than the patients with public insurance in each of the logistic regression models. Public insurance included; Medicaid, Medicare, and charity cases. Private insurance included; private insurance policies whether group, individual, or managed care. The cost of an admission was significantly less for the group in which the practice guideline was applied, with a mean difference between the two groups of $1307 per patient.^ Conclusion. The implementation and utilization of a pediatric practice guideline for asthma inpatients at Texas Children's Hospital has a significant impact in terms of reducing the total cost of the hospital stay and length of the hospital stay for asthma patients admitted to Texas Children's Hospital. ^

Status epilepticus and multiple organ system dysfunction

Recent reports have suggested the possible association of status epilepticus and multiple organ system failure. The purpose of this case control study was to investigate this association and to identify factors that predispose individuals with status epilepticus (SE) or aborted status epilepticus (ASE) to develop multiple organ system failure (MOSF) or multiple organ system dysfunction (MODS).^ For the purpose of the study, definitions of SE, ASE, MOSF, and MODS were operationalized as follows: SE was defined as any seizure lasting for a duration of $\ge$30 minutes or intermittent seizures lasting for $\ge$30 minutes from which the patient does not regain consciousness. ASE was defined as any seizure lasting for a duration of $\ge$10 minutes but $<$30 minutes and which was aborted as a result of a medical intervention. MOSF was defined as the failure of $\ge$2 organ systems in the same patient; organ system failure was said to be present whenever standard MOSF criteria were met. MODS was defined as the dysfunction of $\ge$2 organ systems in the same patient; organ system dysfunction was said to be present, whenever the monitor(s) of that organ's function exceeded the normal range for the physiological or laboratory parameters.^ Medical records of 686 individuals between the age of 5 and 44 years, with history of seizures needing hospitalization at the Texas Children's Hospital or Methodist Hospital, Houston, Texas, between 1991-95 were reviewed and 100 individuals with SE/ASE were identified. Of these 100 individuals with SE/ASE, 45 developed MOSF/MODS during their hospitalization and 9 of these individuals died. Using multivariate analyses, it was found that adult individuals who had an "acute" etiology of their seizure disorder (OR = 5.23; 95%CI: 0.41, 66.24) and children who had a "remote" etiology of their seizure disorder (OR = 3.92; 95%CI: 0.53, 29.22), were more likely to develop MOSF/MODS compared with those who had other etiologies of the seizure disorder. Individuals with SE lasting more than one hour were more likely to develop MOSF/MODS compared with individuals with SE lasting less than 1 hour (OR = 6.51; 95%CI: 1.63, 25.92). Individuals who presented with the SE/ASE episode as their first seizure episode were more likely to develop MOSF/MODS compared to those with a previous history of seizure episodes (OR = 1.78; 95%CI: 0.36, 8.82).^ The major limitations of this study includes the relatively small sample size and the study being performed in only two institutions. However, this is the first study of this kind and should therefore be viewed as largely exploratory in nature. Future studies should investigate the relationship of the risk factors identified in this study using a larger number of institutions and patients. ^

THE DESIGN AND DEVELOPMENT OF A SURVEY INSTRUMENT FOR THE ASSESSMENT OF OCCUPATIONAL STRESS

Using stress and coping as a unifying theoretical concept, a series of five models was developed in order to synthesize the survey questions and to classify information. These models identified the question, listed the research study, described measurements, listed workplace data, and listed industry and national reference data.^ A set of 38 instrument questions was developed within the five coping correlate categories. In addition, a set of 22 stress symptoms was also developed. The study was conducted within two groups, police and professors, on a large university campus. The groups were selected because their occupations were diverse, but they were a part of the same macroenvironment. The premise was that police officers would be more highly stressed than professors.^ Of a total study group of 80, there were 37 respondents. The difference in the mean stress responses was observable between the two groups. Not only were the responses similar within each group, but the stress level of response was also similar within each group. While the response to the survey instrument was good, only 3 respondents answered the stress symptom survey properly. It was determined that none of the 37 respondents believed that they were ill. This perception of being well was also evidenced by the grand mean of the stress scores of 2.76 (3.0 = moderate stress). This also caused fewer independent variables to be entered in the multiple regression model.^ The survey instrument was carefully designed to be universal. Universality is the ability to transcend occupational or regional definitions as applied to stress. It is the ability to measure responses within broad categories such as physiological, emotional, behavioral, social, and cognitive functions without losing the ability to measure the detail within the individual questions, or the relationships between questions and categories.^ Replication is much easier to achieve with standardized categories, questions, and measurement procedures such as those developed for the universal survey instrument. Because the survey instrument is universal it can be used as an analytical device, an assessment device, a basic tool for planning and a follow-up instrument to measure individual response to planned reductions in occupational stress. (Abstract shortened with permission of author.) ^

The utility of rapid participatory appraisal for community assessment, diagnosis, and policy development

The selection of a model to guide the understanding and resolution of community problems is an important issue relating to the foundation of public health practice: assessment, policy development, and assurance. Many assessment models produce a diagnosis of community weaknesses, but fail to promote planning and interventions. Rapid Participatory Appraisal (RPA) is a participatory action research model which regards assessment as the first step in the problem solving process, and claims to achieve assessment and policy development within limited resources of time and money. Literature documenting the fulfillment of these claims, and thereby supporting the utility of the model, is relatively sparse and difficult to obtain. Very few articles discuss the changes resulting from RPA assessments in urban areas, and those that do describe studies conducted outside the U.S.A. ^ This study examines the utility of the RPA model and its underlying theories: systems theory, grounded theory, and principles of participatory change, as illustrated by the case study of a community assessment conducted for the Texas Diabetes Institute (TDI), San Antonio, Texas, and subsequent outcomes. Diabetes has a high prevalence and is a major issue in San Antonio. Faculty and students conducted the assessment by informal collaboration between two nursing and public health assessment courses, providing practical student experiences. The study area was large, and the flexibility of the model tested by its use in contiguous sub-regions, reanalyzing aggregated results for the study area. Official TDI reports, and a mail survey of agency employees, described policy development resulting from community diagnoses revealed by the assessment. ^ The RPA model met the criteria for utility from the perspectives of merit, worth, efficiency, and effectiveness. The RPA model best met the agencies' criteria (merit), met the data needs of TDI in this particular situation (worth), provided valid results within budget, time, and personnel constraints (efficiency), and stimulated policy development by TDI (effectiveness). ^ The RPA model appears to have utility for community assessment, diagnosis, and policy development in circumstances similar to the TDI diabetes study. ^

A full pedigree based method for the statistical assessment of genetic anticipation

Genetic anticipation is defined as a decrease in age of onset or increase in severity as the disorder is transmitted through subsequent generations. Anticipation has been noted in the literature for over a century. Recently, anticipation in several diseases including Huntington's Disease, Myotonic Dystrophy and Fragile X Syndrome were shown to be caused by expansion of triplet repeats. Anticipation effects have also been observed in numerous mental disorders (e.g. Schizophrenia, Bipolar Disorder), cancers (Li-Fraumeni Syndrome, Leukemia) and other complex diseases. ^ Several statistical methods have been applied to determine whether anticipation is a true phenomenon in a particular disorder, including standard statistical tests and newly developed affected parent/affected child pair methods. These methods have been shown to be inappropriate for assessing anticipation for a variety of reasons, including familial correlation and low power. Therefore, we have developed family-based likelihood modeling approaches to model the underlying transmission of the disease gene and penetrance function and hence detect anticipation. These methods can be applied in extended families, thus improving the power to detect anticipation compared with existing methods based only upon parents and children. The first method we have proposed is based on the regressive logistic hazard model. This approach models anticipation by a generational covariate. The second method allows alleles to mutate as they are transmitted from parents to offspring and is appropriate for modeling the known triplet repeat diseases in which the disease alleles can become more deleterious as they are transmitted across generations. ^ To evaluate the new methods, we performed extensive simulation studies for data simulated under different conditions to evaluate the effectiveness of the algorithms to detect genetic anticipation. Results from analysis by the first method yielded empirical power greater than 87% based on the 5% type I error critical value identified in each simulation depending on the method of data generation and current age criteria. Analysis by the second method was not possible due to the current formulation of the software. The application of this method to Huntington's Disease and Li-Fraumeni Syndrome data sets revealed evidence for a generation effect in both cases. ^

A qualitative assessment of multi-level nutrition strategies for reducing racial and ethnic disparities in diabetes

The purpose of this study is to examine the stages of program realization of the interventions that the Bronx Health REACH program initiated at various levels to improve nutrition as a means for reducing racial and ethnic disparities in diabetes. This study was based on secondary analyses of qualitative data collected through the Bronx Health REACH Nutrition Project, a project conducted under the auspices of the Institute on Urban Family Health, with support from the Centers for Disease Control and Prevention (CDC). Local human subjects' review and approval through the Institute on Urban Family Health was required and obtained in order to conduct the Bronx Health REACH Nutrition Project. ^ The study drew from two theoretical models—Glanz and colleagues' nutrition environments model and Shediac-Rizkallah and Bone's sustainability model. The specific study objectives were two-fold: (1) to categorize each nutrition activity to a specific dimension (i.e. consumer, organizational or community nutrition environment); and (2) to evaluate the stage at which the program has been realized (i.e. development, implementation or sustainability). ^ A case study approach was applied and a constant comparative method was used to analyze the data. Triangulation of data based was also conducted. Qualitative data from this study revealed the following principal findings: (1) communities of color are disproportionately experiencing numerous individual and environmental factors contributing to the disparities in diabetes; (2) multi-level strategies that targeted the individual, organizational and community nutrition environments can appropriately address these contributing factors; (3) the nutrition strategies greatly varied in their ability to appropriately meet criteria for the three program stages; and (4) those nutrition strategies most likely to succeed (a) conveyed consistent and culturally relevant messages, (b) had continued involvement from program staff and partners, (c) were able to adapt over time or setting, (d) had a program champion and a training component, (e) were integrated into partnering organizations, and (f) were perceived to be successful by program staff and partners in their efforts to create individual, organizational and community/policy change. As a result of the criteria-based assessment and qualitative findings, an ecological framework elaborating on Glanz and colleagues model was developed. The qualitative findings and the resulting ecological framework developed from this study will help public health professionals and community leaders to develop and implement sustainable multi-level nutrition strategies for addressing racial and ethnic disparities in diabetes. ^

Household health assessment and associated water sample analysis in the Miches watershed of the Dominican Republic

Background. Diarrhea and malnutrition are the leading causes of mortality for children age one to four in the Dominican Republic. Communities within the Miches watershed lack sanitation infrastructure and water purification systems, which increases the risk of exposure to water-borne pathogens. The purpose of this cross-sectional study was to analyze health information gathered through household interviews and to test water samples for the presence of diarrheagenic pathogens and antibiotic-resistant bacteria within the Miches watershed. Methods. Frequency counts and thematic analysis were used to investigate Human Health Survey responses and Fisher's exact test was used to determine correlation between water source and reported illness. Bacteria cultured from water samples were analyzed by Gram stain, real-time PCR, API® 20E biochemical identification, and for antibiotic resistance. Results. Community members reported concerns about water sources with respect to water quality, availability, and environmental contamination. Pathogenic strains of E. coli were present in the water samples. Drinking aquifer water was positively-correlated with reported stomach aches (p=0.04) while drinking from rivers or creeks was associated with the reported absence of “gripe” (cold or flu) (p=0.01). The lack of association between reported illnesses and water source for the majority of variables suggested that there were multiple vehicles of disease transmission. Antibiotic resistant bacteria were isolated from the water samples tested. Conclusions. The presence of pathogenic E. coli in water samples suggested that water is at least one route of transmission for diarrheagenic pathogens in the Miches watershed. The presence of antibiotic-resistant bacteria in the water samples may indicate the proliferation of resistance plasmids in the environment as a result of antibiotic overuse in human and animal populations and a lack of sanitation infrastructure. An intervention that targets areas of hygiene, sanitation, and water purification is recommended to limit human exposure to diarrheagenic pathogens and antibiotic-resistant organisms. ^

The Comal County Needs Assessment Youth Survey

A crucial link in preserving and protecting the future of our communities resides in maintaining the health and well being of our youth. While every member of the community owns an opinion regarding where to best utilize monies for prevention and intervention, the data to support such opinion is often scarce. In an effort to generate data-driven indices for community planning and action, the United Way of Comal County, Texas partnered with the University Of Texas - Houston Health Science Center, School Of Public Health to accomplish a county-specific needs assessment. A community-based participatory research emphasis utilizing the Mobilization for Action through Planning and Partnership (MAPP) format developed by the National Association of City and County Health Officials (NACCHO) was implemented to engage community members in identifying and addressing community priorities. The single greatest area of consensus and concern identified by community members was the health and well being of the youth population. Thus, a youth survey, targeting these specific areas of community concern, was designed, coordinated and administered to all 9-11th grade students in the county. 20% of the 3,698 completed surveys (72% response rate) were randomly selected for analysis. These 740 surveys were coded and scanned into an electronic survey database. Statistical analysis provided youth-reported data on the status of the multiple issues affecting the health and well being of the community's youth. These data will be reported back to the community stakeholders, as part of the larger Comal County Needs Assessment, for the purposes of community planning and action. Survey data will provide community planners with an awareness of the high risk behaviors and habit patterns amongst their youth. This knowledge will permit more effective targeting of the means for encouraging healthy behaviors and preventing the spread of disease. Further, the community-oriented, population-based nature of this effort will provide answers to questions raised by the community and will provide an effective launching pad for the development and implementation of targeted, preventive health strategies. ^

Assessment of US Air Force student pilots with intermittent monofixation syndrome on a non-stereoptic dependent flight maneuver in pilot training

The United States Air Force School of Aerospace Medicine (USAFSAM) and Aeromedical Consult Service (ACS) have developed waiver criteria for pilots with subtle substandard depth perception. This is to allow United States Air Force (USAF) pilots with mild depth perception deficiency to continue flying duties while limiting the risk to flight safety and ensuring the availability of costly human resources. From 1999 to 2005, 166 aviators were given waivers for intermittent monofixation syndrome (IMFS). Of these, 96 were student pilots who performed slightly worse at stereoptic dependent flight maneuvers than student pilots (8,907) with normal depth perception (Lowry, 2006).^ This study's purpose is to evaluate the performance of the extended-trail maneuver, a non-stereoptic dependent flying maneuver, as executed by a cohort of 12 United States Air Force student pilots with intermittent monofixation syndrome versus the cohort of 100 student pilots with normal depth perception. These subjects are extracted from the cohorts examined by Lowry (2006) and the null hypothesis predicts no statistical difference in the performance of the non-stereoptic dependant flight maneuver extended-trail between student pilots with intermittent monofixation syndrome and those without the condition. ^

A community-based assessment of the spatiotemporal distribution of influenza in a U.S.-Mexico border county during the spring 2009 novel H1N1 swine-origin influenza A pandemic

This study retrospectively evaluated the spatial and temporal disease patterns associated with influenza-like illness (ILI), positive rapid influenza antigen detection tests (RIDT), and confirmed H1N1 S-OIV cases reported to the Cameron County Department of Health and Human Services between April 26 and May 13, 2009 using the space-time permutation scan statistic software SaTScan in conjunction with geographical information system (GIS) software ArcGIS 9.3. The rate and age-adjusted relative risk of each influenza measure was calculated and a cluster analysis was conducted to determine the geographic regions with statistically higher incidence of disease. A Poisson distribution model was developed to identify the effect that socioeconomic status, population density, and certain population attributes of a census block-group had on that area's frequency of S-OIV confirmed cases over the entire outbreak. Predominant among the spatiotemporal analyses of ILI, RIDT and S-OIV cases in Cameron County is the consistent pattern of a high concentration of cases along the southern border with Mexico. These findings in conjunction with the slight northward space-time shifts of ILI and RIDT cluster centers highlight the southern border as the primary site for public health interventions. Finally, the community-based multiple regression model revealed that three factors—percentage of the population under age 15, average household size, and the number of high school graduates over age 25—were significantly associated with laboratory-confirmed S-OIV in the Lower Rio Grande Valley. Together, these findings underscore the need for community-based surveillance, improve our understanding of the distribution of the burden of influenza within the community, and have implications for vaccination and community outreach initiatives.^