Interrater Reliability of the Power Mobility Road Test in the Virtual Reality-Based Simulator-2.

OBJECTIVE: To assess interrater reliability of the Power Mobility Road Test (PMRT) when administered through the Virtual Reality-based SIMulator-version 2 (VRSIM-2). DESIGN: Within-subjects repeated-measures design. SETTING: Participants interacted with VRSIM-2 through 2 display options (desktop monitor vs immersive virtual reality screens) using 2 control interfaces (roller system vs conventional movement-sensing joystick), providing 4 different driving scenarios (driving conditions 1-4). Participants performed 3 virtual driving sessions for each of the 2 display screens and 1 session through a real-world driving course (driving condition 5). The virtual PMRT was conducted in a simulated indoor office space, and an equivalent course was charted in an open space for the real-world assessment. After every change in driving condition, participants completed a self-reported workload assessment questionnaire, the Task Load Index, developed by the National Aeronautics and Space Administration. PARTICIPANTS: A convenience sample of electric-powered wheelchair (EPW) athletes (N=21) recruited at the 31st National Veterans Wheelchair Games. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total composite PMRT score. RESULTS: The PMRT had high interrater reliability (intraclass correlation coefficient [ICC]>.75) between the 2 raters in all 5 driving conditions. Post hoc analyses revealed that the reliability analyses had >80% power to detect high ICCs in driving conditions 1 and 4. CONCLUSIONS: The PMRT has high interrater reliability in conditions 1 and 4 and could be used to assess EPW driving performance virtually in VRSIM-2. However, further psychometric assessment is necessary to assess the feasibility of administering the PMRT using the different interfaces of VRSIM-2.

Stability and Workload of the Virtual Reality-Based Simulator-2.

OBJECTIVE: To assess the stability of clinicians' and users' rating of electric-powered wheelchair (EPW) driving while using 4 different human-machine interfaces (HMIs) within the Virtual Reality-based SIMulator-version 2 (VRSIM-2) and in the real world (accounting for a total of 5 unique driving conditions). DESIGN: Within-subjects repeated-measures design. SETTING: Simulation-based assessment in a research laboratory. PARTICIPANTS: A convenience sample of EPW athletes (N=21) recruited at the 31st National Veterans Wheelchair Games. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Composite PMRT scores from the Power Mobility Road Test (PMRT); Raw Task Load Index; and the 6 subscale scores from the Task Load Index developed by the National Aeronautics and Space Administration (NASA-TLX). RESULTS: There was moderate stability (intraclass correlation coefficient between .50 and .75) in the total composite PMRT scores (P<.001) and the users' self-reported performance scores (P<.001) among the 5 driving conditions. There was a significant difference in the workload among the 5 different driving conditions as reflected by the Raw Task Load Index (P=.009). Subanalyses revealed this difference was due to the difference in the mental demand (P=.007) and frustration (P=.007) subscales. Post hoc analyses revealed that these differences in the NASA-TLX subscale scores were due to the differences between real-world and virtual driving scores, particularly attributable to the conditions (1 and 3) that lacked the rollers as a part of the simulation. CONCLUSIONS: Further design improvements in the simulator to increase immersion experienced by the EPW user, along with a standardized training program for clinicians to deliver PMRT in VRSIM-2, could improve the stability between the different HMIs and real-world driving.

Prevalence of hearing loss in Black and White elders: results of the Cardiovascular Health Study.

PURPOSE: The goal of this study was to determine the impact of age, gender, and race on the prevalence and severity of hearing loss in elder adults, aged 72-96 years, after accounting for income, education, smoking, and clinical and subclinical cardiovascular disease. Methods Air-conduction thresholds for standard and extended high-frequency pure-tones were obtained from a cohort of 548 (out of 717) elderly adults (ages 72-96 years) who were recruited during the Year 11 clinical visit (1999-2000) of the Cardiovascular Health Study (CHS) at the Pittsburgh, Pennsylvania site. Participant smoking, income, education, and cardiovascular disease histories were obtained from the CHS database and were included as factors. RESULTS: Hearing loss was more common and more severe for the participants in their 80s than for those in their 70s-the men more than the women and the White participants more than the Black participants. The inclusion of education, income, smoking, and cardiovascular disease (clinical and subclinical) histories as factors did not substantively impact the overall results. CONCLUSION: Although the data reported in this article were cross-sectional and a cohort phenomenon might have been operational, they suggested that hearing loss is more substantive in the 8th than the 7th decade of life and that race and gender influence this decline in audition. Given the high prevalence in the aging population and the differences across groups, there is a clear need to understand the nature and causes of hearing loss across various groups in order to improve prevention and develop appropriate interventions.

Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004.

BACKGROUND: Bariatric surgery has emerged as the most effective treatment for class III obesity (body mass index, >or=40). The number of operations continues to increase. We measured case fatality and death rates by time since operation, sex, age, specific causes of death, and mortality rates. DESIGN AND SETTING: Data on all bariatric operations performed on Pennsylvania residents between January 1, 1995, and December 31, 2004, were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data were obtained from the Division of Vital Records, Pennsylvania State Department of Health. OUTCOME MEASURES: Age- and sex-specific death rates after bariatric surgery. RESULTS: There were 440 deaths after 16 683 operations (2.6%). Age-specific death rates were much higher in men than in women and increased with age. Age- and sex-specific death rates after bariatric surgery were substantially higher than comparable rates for the age- and sex-matched Pennsylvania population. The 1-year case fatality rate was approximately 1% and nearly 6% at 5 years. Less than 1% of deaths occurred within the first 30 days. Fatality increased substantially with age (especially among those > 65 years), with little evidence of change over time. Coronary heart disease was the leading cause of death overall, being cited as the cause of death in 76 patients (19.2%). Therapeutic complications accounted for 38 of 150 natural deaths within the first 30 days, including pulmonary embolism in 31 (20.7%), coronary heart disease in 26 (17.3%), and sepsis in 17 (11.3%). CONCLUSIONS: There was a substantial excess of deaths owing to suicide and coronary heart disease. Careful monitoring of bariatric surgical procedures and more intense follow-up could likely reduce the long-term case fatality rate in this patient population.

Nursing home deaths which fall under the jurisdiction of the coroner: an 11-year retrospective study.

Twenty percent of deaths in the United States occur in nursing homes, yet less than 1% come to autopsy. The current study analyzed causes and manners of death in all nursing homes between 1993 and 2003, investigated by the coroner of Allegheny County, PA, which has the second highest elderly population in the United States. Two hundred eight decedents were identified, aged 19 to 91 years, 58% women and 42% men, 88% Caucasian and 22% African-American. Fifty-eight percent were accidental and 38.5% were natural manners of death, with 2 homicides, 2 suicides, and 3 undetermined cases. The manner of death was significantly different between Caucasians and African-Americans, with 92.6% of accidental deaths occurring in Caucasians and 6.6% in African-Americans (P < 0.1). Most common natural deaths were arteriosclerotic cardiovascular disease, nonarteriosclerotic cardiovascular disease, pneumonia, pulmonary thromboembolism, chronic obstructive pulmonary disease (COPD), seizure disorder, and atraumatic intracranial hemorrhage. Blunt force trauma was the single most commonly identified traumatic accidental death. Accidental deaths were more common in Caucasians than African-Americans. Homicides and suicides were rare events (<2%). Blunt force trauma is a major autopsy finding in accidental nursing home deaths, and a root-cause analysis may be helpful in developing policies and procedures to decrease the incidence of blunt force trauma.

Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation.

OBJECTIVE: To report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation. DESIGN: Retrospective chart review. SETTING: An inpatient neurosurgery unit and outpatient physical medicine and rehabilitation clinics. PARTICIPANTS: Fifty-seven patients with refractory spasticity who underwent a continuous ITB trial during the years 2006-2012. METHODS: Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. A successful trial was defined as a one-level reduction in lower limb modified Ashworth scores in key spastic lower limb muscles identified for each individual patient. Subjective improvement in function or ease of performing functional tasks also were monitored. MAIN OUTCOME MEASURES: Modified Ashworth scores, functional mobility in ambulatory patients only, and the incidence and severity of adverse events during the trial and up to 1 year after implantation. RESULTS: Spasticity significantly decreased during the trial. Average ambulation distance was unchanged, although 34% of ambulatory patients progressed to a less restrictive assistive device by trial completion. Adverse events (AEs) occurred in 26 patients. Minor AEs were seen in 18 patients, with the most common being nausea, transient urinary retention, and headache. Pumps were implanted in 86% of patients; 14% did not receive a pump because of AEs or because goals were not met. Six patients had their pump removed at 12 months for the following reasons: pump malfunctions (3), skin breakdown around the pump (1), infection (1), and expectations not met (1). CONCLUSIONS: Continuous trials via an external catheter could be an option if patients and clinicians desire a comprehensive assessment of systemic and functional effects of ITB before pump implantation. The majority of AEs were minor and resolved spontaneously, and the most effective starting intrathecal dose was determined by pump insertion.

Depressive symptoms in adults with spina bifida.

OBJECTIVE: To examine the prevalence of depressive symptoms in adults with spina bifida and identify contributing factors for depressive symptomatology. METHOD: Retrospective Cohort Study. Data collection was conducted at a regional adult spina bifida clinic. A total of 190 charts from adult patients with spina bifida were included. The main outcome measures were the Beck Depression Inventory-II (BDI-II) and the mobility domain of the Craig Handicap Assessment Reporting Technique-Short Form (CHART-SF). RESULTS: Of the 190 participants, 49 (25.8%) had BDI-II scores (14+) indicative of depressive symptomatology. Sixty-nine (36.3%) were on antidepressants to treat depressive symptoms, and 31 (63.3%) of those with clinical symptoms of depression were on antidepressants. Participants with a history of depressive symptoms may be as high as 45.7% if both participants with BDI-II scores 14+ and those with antidepressant use specifically for the purposes of depression treatment are combined. In this population, lower CHART-SF mobility score, expressing "emotional concerns" as a reason for the visit on an intake sheet, and use of antidepressant medications were significantly associated with depressive symptoms. CONCLUSIONS: Depressive symptomatology appears to be common and undertreated in this cohort of adults with spina bifida, which may warrant screening for emotional concerns in routine clinic appointments. Significant depressive symptoms are associated with fewer hours out of bed and fewer days leaving the house. Additional research is needed to assess the impact of interventions directed toward mobility on depression and in the treatment of depression in this patient population.

Relationship between circulating serum osteoprotegerin and total receptor activator of nuclear κ-B ligand levels, triglycerides, and coronary calcification in postmenopausal women.

OBJECTIVE: This study evaluates the relationship of blood osteoprotegerin (OPG) and receptor activator of nuclear κ-B ligand (RANKL) levels with coronary artery calcium (CAC) and cardiovascular risk factors in two studies of postmenopausal women. OPG, a marker of bone turnover, and its ligand, RANKL, may contribute to cardiovascular disease risk. METHODS: We tested the hypothesis that serum OPG and RANKL levels were associated with CAC and cardiovascular disease risk factors among postmenopausal women in the Women On the Move through Activity and Nutrition Study (WOMAN Study; n = 86; mean [SD], age 58 [2.9] y) and replicated our findings in the Healthy Women Study (HWS; n = 205; mean [SD] age, 61 [2.3] y). Serum OPG, total RANKL, and CAC were measured at baseline and 48 months in the WOMAN Study and on the eighth postmenopausal visit in the HWS. RESULTS: In the WOMAN Study, higher OPG was associated with higher CAC, and higher total RANKL was associated with lower CAC and triglycerides. In the HWS, higher total RANKL was also associated with lower CAC and triglycerides. In logistic regression models adjusted for body mass index and triglycerides, the odds ratios (95% CIs) for CAC per unit increase in OPG were 1.78 (1.17-2.73) for the WOMAN Study and 1.02 (0.84-1.24) for the HWS, and the odds ratios (95% CIs) for CAC per unit increase in log total RANKL were 0.86 (0.64-1.17) for the WOMAN Study and 0.83 (0.72-0.96) for the HWS. CONCLUSIONS: The inverse association of total RANKL with CAC and triglycerides is a new finding and may have important implications given the increasing use of drugs that modify total RANKL and its receptor, receptor activator of nuclear κ-B.

The Women on the Move Through Activity and Nutrition (WOMAN) study: final 48-month results.

The Women on the Move through Activity and Nutrition (WOMAN) study was designed to test whether a nonpharmacological intervention including qualitative and quantitative dietary changes to induce weight loss and increased physical activity levels would reduce blood triglyceride levels and number of low-density lipoprotein particles (LDL-P). Such decreases in lipoproteins and other risk factors could reduce or slow progression of subclinical cardiovascular disease (CVD). Study participants were randomized to either the intervention (Lifestyle Change) or assessment (Health Education) group. Most of the intervention ended at the 30-month visit. The last 48-month examination was completed in 9/2008. There was very substantial weight loss and increased exercise during the first 30 months of the trial resulting in significant decreases in CV risk factors. Most of the intervention effect was lost through 48 months. Weight loss was 3.4 kg in Lifestyle Intervention and 0.2 kg in the Health Education at 48 months (P = 0.000). There were no significant changes at 48 months in lipid levels, blood pressure (BP), glucose, insulin, or in the subclinical measures of coronary calcium, carotid intima media thickness, or plaque. There was a significant decrease in long-distance corridor walk time in the Lifestyle vs. Health Education groups. Significant lifestyle changes can be achieved that result in decreases in CV risk factors. Whether such changes reduce CV outcomes is still untested in clinical trials of weight loss or exercise. Long-term maintenance of successful lifestyle changes, weight loss and reduced risk factors is the hurdle for lifestyle interventions attempting to prevent CV and other chronic diseases.