Improving the Delivery of Function-Directed Care During Acute Hospitalizations: Methods to Develop and Validate the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT).

OBJECTIVE: To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans. DESIGN: This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics. SETTING: A large (2000-bed) Midwestern Medical Center. PARTICIPANTS: The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization. CONCLUSIONS: The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

Worth the risk? Terrorism-induced fear of flying / ¿Vale la pena el riesgo? Miedo inducido por el terrorismo a volar

We conducted two bi-national experiments regarding emotional and behavioral responses to a terrorist plot against commercial flights, examining both feelings and projected action. The studies employed hypothetical scenarios in which terrorists attacked airplanes with shoulder-fired missiles as they were landing or taking off from an international airport. The scenarios were built around two factorially crossed manipulated variables, each with three levels: (1) government announcements or actions (2) social norm, expressed as variation in airline ticket sales. Each respondent read a questionnaire containing only one of the nine scenarios. Experiment 1 was conducted in Spain and California (n = 360, 50% female), Experiment 2 in Israel and California (n = 504, 50% female). In both studies, fear and flight plans were not differentially affected by governmental response or social norm. Women expressed more fear than men. Experiment 1 examined the purpose of the trip. Most respondents would not change a planned flight to attend a close friend's wedding or important job interview, but a substantial number would postpone a vacation or drive to a different location. Experiment 2 featured escalating attacks. These yielded increased fear and more canceled trips. Within both studies, responses were similar across countries despite national differences in direct experience with terrorism.

Se realizaron dos experimentos bi-nacionales con respecto a las respuestas emocionales y conductuales a un plan terrorista contra vuelos comerciales, examinando ambas cosas: sentimientos y proyectos de acción. Los estudios emplearon escenarios hipotéticos en los que los terroristas atacaron los aviones con misiles disparados desde el hombro, ya que estaban aterrizando o despegando desde un aeropuerto internacional. Los escenarios fueron construidos alrededor de dos variables factoriales cruzadas, cada uno con tres niveles: (1) los anuncios o acciones del gobierno (2) norma social, expresada como la variación en la venta de billetes de avión. Cada encuestado leyó un cuestionario que contenía sólo uno de los nueve escenarios. El experimento 1 se realizó en España y California (n = 360, 50% mujeres), el experimento 2 en Israel y California (n = 504, 50% mujeres). En ambos estudios, el miedo y los planes de vuelo no fueron diferencialmente afectados por la respuesta gubernamental o la norma social. Las mujeres expresaron más miedo que los hombres. El experimento 1 examinó el propósito del viaje. La mayoría de los encuestados no cambiarían un vuelo planeado para asistir a la boda de un amigo cercano o para una importante entrevista de trabajo, pero un número considerable de participantes podrían posponer unas vacaciones o ir en coche a un lugar diferente. El experimento 2 contó con la escalada de los ataques. Estas aumentaron el temor y la cantidad de viajes cancelados. En ambos estudios, las respuestas fueron similares en todos los países a pesar de las diferencias nacionales y la experiencia directa con el terrorismo.

The computerized adaptive diagnostic test for major depressive disorder (CAD-MDD): a screening tool for depression.

OBJECTIVE: To develop a computerized adaptive diagnostic screening tool for depression that decreases patient and clinician burden and increases sensitivity and specificity for clinician-based DSM-IV diagnosis of major depressive disorder (MDD). METHOD: 656 individuals with and without minor and major depression were recruited from a psychiatric clinic and a community mental health center and through public announcements (controls without depression). The focus of the study was the development of the Computerized Adaptive Diagnostic Test for Major Depressive Disorder (CAD-MDD) diagnostic screening tool based on a decision-theoretical approach (random forests and decision trees). The item bank consisted of 88 depression scale items drawn from 73 depression measures. Sensitivity and specificity for predicting clinician-based Structured Clinical Interview for DSM-IV Axis I Disorders diagnoses of MDD were the primary outcomes. Diagnostic screening accuracy was then compared to that of the Patient Health Questionnaire-9 (PHQ-9). RESULTS: An average of 4 items per participant was required (maximum of 6 items). Overall sensitivity and specificity were 0.95 and 0.87, respectively. For the PHQ-9, sensitivity was 0.70 and specificity was 0.91. CONCLUSIONS: High sensitivity and reasonable specificity for a clinician-based DSM-IV diagnosis of depression can be obtained using an average of 4 adaptively administered self-report items in less than 1 minute. Relative to the currently used PHQ-9, the CAD-MDD dramatically increased sensitivity while maintaining similar specificity. As such, the CAD-MDD will identify more true positives (lower false-negative rate) than the PHQ-9 using half the number of items. Inexpensive (relative to clinical assessment), efficient, and accurate screening of depression in the settings of primary care, psychiatric epidemiology, molecular genetics, and global health are all direct applications of the current system.

Development of a computerized adaptive test for depression.

CONTEXT Unlike other areas of medicine, psychiatry is almost entirely dependent on patient report to assess the presence and severity of disease; therefore, it is particularly crucial that we find both more accurate and efficient means of obtaining that report. OBJECTIVE To develop a computerized adaptive test (CAT) for depression, called the Computerized Adaptive Test-Depression Inventory (CAT-DI), that decreases patient and clinician burden and increases measurement precision. DESIGN Case-control study. SETTING A psychiatric clinic and community mental health center. PARTICIPANTS A total of 1614 individuals with and without minor and major depression were recruited for study. MAIN OUTCOME MEASURES The focus of this study was the development of the CAT-DI. The 24-item Hamilton Rating Scale for Depression, Patient Health Questionnaire 9, and the Center for Epidemiologic Studies Depression Scale were used to study the convergent validity of the new measure, and the Structured Clinical Interview for DSM-IV was used to obtain diagnostic classifications of minor and major depressive disorder. RESULTS A mean of 12 items per study participant was required to achieve a 0.3 SE in the depression severity estimate and maintain a correlation of r = 0.95 with the total 389-item test score. Using empirically derived thresholds based on a mixture of normal distributions, we found a sensitivity of 0.92 and a specificity of 0.88 for the classification of major depressive disorder in a sample consisting of depressed patients and healthy controls. Correlations on the order of r = 0.8 were found with the other clinician and self-rating scale scores. The CAT-DI provided excellent discrimination throughout the entire depressive severity continuum (minor and major depression), whereas the traditional scales did so primarily at the extremes (eg, major depression). CONCLUSIONS Traditional measurement fixes the number of items administered and allows measurement uncertainty to vary. In contrast, a CAT fixes measurement uncertainty and allows the number of items to vary. The result is a significant reduction in the number of items needed to measure depression and increased precision of measurement.

Characterization of the KRN cell transfer model of rheumatoid arthritis (KRN-CTM), a chronic yet synchronized version of the K/BxN mouse.

In this study, a chronic yet synchronized version of the K/BxN mouse, the KRN-cell transfer model (KRN-CTM), was developed and extensively characterized. The transfer of purified splenic KRN T cells into T cell-deficient B6.TCR.Calpha(-/-)H-2(b/g7) mice induced anti-glucose 6-phosphate isomerase antibody-dependent chronic arthritis in 100% of the mice with uniform onset of disease 7 days after T cell transfer. Cellular infiltrations were assessed by whole-ankle transcript microarray, cytokine and chemokine levels, and microscopic and immunohistochemical analyses 7 through 42 days after T cell transfer. Transcripts identified an influx of monocytes/macrophages and neutrophils into the ankles and identified temporal progression of cartilage damage and bone resorption. In both serum and ankle tissue there was a significant elevation in interleukin-6, whereas macrophage inflammatory protein-1 alpha and monocyte chemotactic protein-1 were only elevated in tissue. Microscopic and immunohistochemical analyses revealed a time course for edema, synovial hypertrophy and hyperplasia, infiltration of F4/80-positive monocytes/macrophages and myeloperoxidase-positive neutrophils, destruction of articular cartilage, pannus invasion, bone resorption, extra-articular fibroplasia, and joint ankylosis. The KRN cell transfer model replicates many features of chronic rheumatoid arthritis in humans in a synchronized manner and lends itself to manipulation of adoptively transferred T cells and characterizing specific genes and T cell subsets responsible for rheumatoid arthritis pathogenesis and progression.

Motivation to quit as a mediator of tobacco cessation among at-risk youth.

The purpose of this study is twofold: 1) to evaluate the effects of a smoking cessation clinic (Project EX) on changing motivation to quit smoking, and 2) to assess differences in quit rates based on these changes in motivation. Student smokers in 18 continuation high schools in the Los Angeles county area were invited to participate in a tobacco cessation clinic designed to enhance motivation to quit tobacco use. The 18 schools were randomly assigned to one of three conditions. Compared to students in the control group, students who participated in the program conditions were more likely to express higher motivation to quit tobacco use. Higher motivation was also significantly related to higher quit rates. Motivation to quit as defined by constituents of the energy/direction model of motivation appears to be a plausible mediator of cessation program effects.

Analysis of natural flavonoids by microchip-micellar electrokinetic chromatography with pulsed amperometric detection.

Catechins (catechin and other derivatives) are naturally occurring flavonoids present in a number of plants and foods. They are also part of numerous nutraceutical formulations because they are believed to have antioxidant, cancer chemo-preventative, anti-inflammatory and antimicrobial properties. The determination of catechins has traditionally been performed by HPLC. However, this methodology is both time and sample intensive and generates large amounts of organic solvent waste. In the current report, an application of MEKC using a PDMS microchip is presented for the analysis of catechins. The system uses pulsed amperometric detection for direct analysis of important naturally occurring catechins. The effect of pH, surfactant concentration, detection potential and signal stability were analyzed. Linear relationships were found between the concentration and peak current, with good stability and limits of detection of 8 [micro sign]M for catechin, epigallocatechin gallate and epicatechin, and 14 [micro sign]M for epicatechin gallate. Optimum conditions were applied to the detection of selected catechins in a commercially available green tea extract nutraceutical and the results were compared to HPLC analysis. The analysis using microchip micellar electrokinetic chromatography and pulsed amperometric detection was completed in 4.5 min, 10 times faster than the HPLC analysis.

Haptic rendering of tissue cutting with scissors.

Current surgical simulations that involve cutting with scissors lack display of forces "between the fingers" of the operator. The objective of this work is to develop a fast, realistic haptic rendering technique for scissor cutting that can be easily integrated into soft tissue models commonly used in surgical simulators. A virtual environment was created for combined graphic and haptic display of cutting. Two 2-dimensional deformable mass-spring-damper models were developed: The first is a large mesh that is used to calculate translational forces. The second is a smaller, one-element-thick mesh that is used to calculate cutting (angular) forces. This technique was implemented on the haptic scissors, a haptic interface that allows motion and force feedback in translation and cutting.