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Context: There is a need for brief measurement instruments that do not cause burden to hospice caregivers. The Caregiver Quality of Life Index (CQLI) has been used in several studies, but assessment of its psychometric properties has been minimal. The CQLI-R (revised) instrument was found to have equivalent properties but also has had minimal testing in small samples.Objective: This study sought to evaluate the reliability and validity of the CQLI-R.Methods: Data were used from three hospice clinical trials. Reliability was assessed using test-retest and an item analysis. Construct validity was evaluated by comparing items to similar items within the same data set.Results: Test-rest and item analysis found moderate-to-good reliability. Construct validity found significance in comparison of CQLI-R items with those of similar instruments.Conclusions: The CQLI-R is an easy-to-use instrument to assess caregiver quality of life. Despite adequate reliability and construct validity, further evidence is needed to support content validity. [ABSTRACT FROM AUTHOR]

Estrogen-mimicking chemicals, such as cadmium, may be associated with increased susceptibility to hormone-dependent cancers, though supporting data are sparse, particularly for endometrial cancer. The Health and Environmental Exposure Research (HEER) study worked with the Arkansas Central Cancer Registry, Iowa Cancer Registry and Missouri Cancer Registry to obtain names of women diagnosed with endometrial cancer who were willing to be contacted for participation in our case control study. Voter registration lists from Iowa and Missouri were used to randomly select similarly aged women as represented in the case population. Participants were interviewed by telephone to obtain information on known or suspected endometrial risk factors. Urine kits were sent to participants for home collection and returned for analysis. Our case-control study consisted of 631 incident cases of endometrial cancer diagnosed from January 2010 to October 2012 and 879 age-matched population-based controls, ages 18–81 years (mean age 65 years). We quantified cadmium amounts in urine and standardized these values through creatinine adjustment. Using data from all survey completers, we developed a multivariable model for endometrial cancer. Creatinine-adjusted cadmium concentration was added to this model. Odds ratio (OR) and 95% confidence intervals (CIs) for endometrial cancer were calculated. After multivariable adjustment, higher creatinine-adjusted cadmium exposure was associated with a statistically significant increase of endometrial cancer risk (OR: 1.22; 95% CI: 1.03–1.44). Our results provide evidence that cadmium may increase the risk of endometrial cancer, possibly through estrogenic effects. [ABSTRACT FROM AUTHOR]

Context The Caregiver Pain Medicine Questionnaire is designed to measure caregiver agreement with statements regarding pain management. However, little testing has been done to determine its reliability and validity. Objectives The objective of the study was to test the factorial validity of scores from the Caregiver Pain Medicine Questionnaire as hypothesized by the original study authors. Methods Confirmatory factor analysis was conducted to assess whether the subscales postulated by the instrument authors could be replicated in external data. Results Fit statistics reveal an unsatisfactory fit between the hypothesized model and the observed data. Conclusion The theoretical model hypothesized by the original study authors was not confirmed. Results lead us to conclude that the instrument is poor and should not be used. Further research is needed to define content domains and validate the items developed to assess them. [ABSTRACT FROM AUTHOR]

Background. Weight-bearing exercise has been discouraged for people with diabetes mellitus and peripheral neuropathy (DM + PN). However, people with diabetes mellitus and insensate feet have an increased risk of falling. Lower-extremity exercise and balance training reduce fall risk in some older adults. It is unknown whether those with neuropathy experience similar benefits. Objective. As part of a study of the effects of weight-bearing exercise on foot ulceration in people with DM+PN, the effects of a lower-extremity exercise and walking intervention on balance, lower-extremity strength (force-generating capacity), and fall incidence were determined. Design. The study was an observer-masked, 12-month randomized controlled trial. Setting. Part I of the intervention took place in physical therapy offices, and part 2 took place in the community. Patients. The participants were 79 people who were mostly sedentary, who had DM + PN, and who were randomly assigned to either a control group (n = 38) or an intervention group (n = 41). Intervention. Part I included leg strengthening and balance exercises and a graduated, self-monitored walking program; part 2 included motivational telephone calls. Both groups received regular foot care, foot care education, and 8 sessions with a physical therapist. Measurements. The measurements collected were strength, balance, and participant-reported falls for the year after enrollment. Results. There were no statistically significant differences between the groups for falls during follow-up. At 12 months, there was a small increase in the amount of time that participants in the intervention group could stand on 1 leg with their eyes closed. No other strength or balance measurements differed between the groups. Limitations. The study was designed to detect differences in physical activity, not falls. The intensity of the intervention was insufficient to improve strength and balance in this population. Conclusions. The training program had a minimal effect on participants balance and lower-extremity strength. Increasing weight-bearing activity did not alter the rate of falling for participants in the intervention group relative to that for participants in the control group. People who are sedentary and who have DM + PN appear to be able to increase activity without increasing their rate of falling. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background: Maintaining data quality and integrity is important for research studies involving prospective data collection. Data must be entered, erroneous or missing data must be identified and corrected if possible, and an audit trail created. Methods: Using as an example a large prospective study, the Missouri Lower Respiratory Infection (LRI) Project, we present an approach to data management predominantly using SAS software. The Missouri LRI Project was a prospective cohort study of nursing home residents who developed an LRI. Subjects were enrolled, data collected, and follow-ups occurred for over three years. Data were collected on twenty different forms. Forms were inspected visually and sent off-site for data entry. SAS software was used to read the entered data files, check for potential errors, apply corrections to data sets, and combine batches into analytic data sets. The data management procedures are described. Results: Study data collection resulted in over 20,000 completed forms. Data management was successful, resulting in clean, internally consistent data sets for analysis. The amount of time required for data management was substantially underestimated. Conclusion: Data management for prospective studies should be planned well in advance of data collection. An ongoing process with data entered and checked as they become available allows timely recovery of errors and missing data. [ABSTRACT FROM AUTHOR]

Purpose: Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different.Methods: We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity.Results: Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality.Conclusion: Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment. [ABSTRACT FROM AUTHOR]

Addresses the hypothesis that pesticides currently used in Missouri contributed to the differences in semen quality in fertile men. Examination of the relationship between environmental pesticide exposure and semen quality in infertile and fertile men; Association of the herbicides 2,4-D(2,4-dichlorophenoxyacetic acid) and metolachor with poor semen quality.

To assess whether the term "intention to treat" (ITT) predicts Inclusion of all randomized subjects in the analysis, we reviewed 100 randomly selected reports of randomized trials that mentioned analysis by ITT. Only 42 of 100 reports included all randomized subjects in the ITT analysis. We could not determine which categories of participants were excluded from the ITT analysis in 13 trials. The most common categories of excluded subjects were patients who. after randomization, received no follow-up (16/100), received no treatment (14/100), or were found not to meet study entry criteria (12/100). We could determine the number of participants in the ITT analysis for 92 studies. Nineteen of the 92 studies excluded more than 5% of randomized participants, and 10 excluded more than 10%. There is considerable variation in how researchers define and apply the principle of intention to treat. [ABSTRACT FROM AUTHOR]

Background: Identifying individual and neighborhood-level factors associated with worsening cardiometabolic risks despite clinic-based care coordination may help identify candidates for supplementary team-based care. Methods: Secondary data analysis of data from a two-year nurse-led care coordination program cohort of Medicare, Medicaid, dual-eligible adults, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2), from ten Midwestern primary care clinics in the U.S. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed individual and neighborhood-level factors associated with changes in outcome measures from before to after completion of the LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure. In adjusted models, higher pre-intervention cardiometabolic measures were associated with worsening of all cardiometabolic measures. Women had worsening LDL-cholesterol compared with men. Women with pre-intervention HbA1c > 6.8% and systolic blood pressure > 131 mm of Hg had worse post-intervention HbA1c and systolic blood pressure compared with men. Adding individual's neighborhood-level risks did not change effect sizes significantly. Conclusions: Increased cardiometabolic risks and gender were associated with worsening cardiometabolic outcomes. Understanding unresolved gender-specific needs and preferences of patients with increased cardiometabolic risks may aid in tailoring clinic-community-linked care planning. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45% of the radiograph reports suggested pneumonia (possible = 12%; probable or definite = 33%). In 80% of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate ≥30, temperature ≥38°C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33% of subjects (score ≥3) with more than 50% probability of pneumonia and an additional 24% (score of 2) with 44% probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk for pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph. INSET: KEY POINTS FOR CLINICIANS.. [ABSTRACT FROM AUTHOR]

BACKGROUND. Lower respiratory infections (LRI) are an important cause of morbidity, mortality, and hospitalization of nursing home residents, yet treatment recommendations have primarily been based on the minority who are hospitalized. We sought to prospectively evaluate risk factors for mortality from LRI in community nursing home residents. METHODS. We studied residents of 10 central Missouri nursing homes (910 beds) from January 1994 to September 1994. Attending physicians authorized nurse evaluations of ill residents who showed symptoms of an LRI. Those residents who met the study definition of LRI received a more detailed assessment and follow ups at 30 and 90 days. RESULTS. The 231 evaluations identified 141 LRIs in 121 individuals. Sixteen (11%) residents died within 30 days of evaluation. The most important univariate predictor of 30-day mortality was severe activities of daily living (ADL) dependency (relative risk = 8.8, 95% confidence interval, 2.55 - 30.1). Several other clinical and laboratory findings were also significant predictors. In multivariable logistic regression, ADL dependency, respiratory rate, and pneumonia on chest radiograph independently predicted mortality; the model showed good discriminating ability (c=.83). CONCLUSIONS. For nursing home residents with LRI, ADL dependency is an important mortality predictor. Further research with a larger sample should lead to a useful prediction rule for outcome from nursing home-acquired LRI. [ABSTRACT FROM AUTHOR]

Context: Family caregivers play a vital role in managing the pain of hospice patients with cancer; however, caregivers' knowledge of pain management principles and experiences as pain managers vary widely. Differences in cultural values and access to resources suggest that rural and urban hospice family caregivers may differ with regard to their pain knowledge and experience, but this has not been empirically investigated.Objectives: We sought to determine if rural and urban hospice family caregivers differed in terms of their knowledge of cancer pain management principles and their experiences managing cancer pain.Methods: Our study consisted of a secondary analysis of baseline, cross-sectional data from hospice family caregivers (N = 196) participating in an ongoing cluster randomized crossover pragmatic trial. We performed multivariable regression to model associations between caregivers' demographic characteristics and their scores on the Family Pain Questionnaire (FPQ), which included subscales measuring pain knowledge and experience.Results: When controlling for other demographic variables, rural caregivers' scores on the FPQ knowledge subscale were worse (P = 0.01) than their urban counterparts. FPQ experience subscale scores and FPQ total scores were not statistically significantly different between the two groups.Conclusion: Rural hospice family caregivers report greater pain knowledge deficits than urban hospice family caregivers, although the two groups report comparable pain management experiences. Additional research is needed to better explain observed differences. [ABSTRACT FROM AUTHOR]

Context: Family caregivers play a central role in the care of those in hospice care. Little is known about the social support networks for those providing this day-to-day care without training.Objectives: The purpose of this study was to explore changes in family and friend social networks among hospice caregivers over the course of the hospice stay.Methods: Data on social support networks were collected as part of a multisite randomized controlled trial and analyzed using structural equation modeling.Results: A statistically significant decline in the caregivers' family network subscale score was found over the four week period during which they received hospice services, reflecting a possible weakening of their family networks.Conclusion: This result illustrates the potential importance of ongoing comprehensive assessment of caregiver networks and attention to interventions that may assist in capitalizing on both the quantity of support (numbers of individuals asked to help) and the quality of social support (attending to issues of support burden). [ABSTRACT FROM AUTHOR]

Context: Those caring for their loved ones in hospice experience tremendous stress, being faced with numerous decisions as they work to manage the pain experienced by their loved one. Although hospice care teams create pain management strategies, it is the role of the caregiver to implement these plans.Objectives: The purpose of this study was to further understand the hospice caregiver experience relating to pain management.Methods: Semistructured interviews with 146 caregivers provided data for the study. Responses to seven questions asking for a ranking of end-of-life pain management indicated a less than ideal experience. Available narratives from 38 caregivers were analyzed for themes related to further understanding of the concerns.Results: Five themes were identified in the data including difficulty with administration of pain medicines, concerns about side effects of medications, insecurity with pain assessment, frustrations with communication among health care team members, and memories of unrelieved pain.Conclusion: These findings should raise concern among hospice professionals, whose commitment is to the management of pain, including emotional pain, with a focus on both the patient and the family as a unit of care. These data clearly suggest that hospice providers have an opportunity to be sensitive to perceptions held by caregivers regarding pain management. Effective planning for pain control must incorporate the values and beliefs not only of each patient but also of the family caregiver. [ABSTRACT FROM AUTHOR]

Abstract: Context: Those caring for their loved ones in hospice experience tremendous stress, being faced with numerous decisions as they work to manage the pain experienced by their loved one. Although hospice care teams create pain management strategies, it is the role of the caregiver to implement these plans. Objectives: The purpose of this study was to further understand the hospice caregiver experience relating to pain management. Methods: Semistructured interviews with 146 caregivers provided data for the study. Responses to seven questions asking for a ranking of end-of-life pain management indicated a less than ideal experience. Available narratives from 38 caregivers were analyzed for themes related to further understanding of the concerns. Results: Five themes were identified in the data including difficulty with administration of pain medicines, concerns about side effects of medications, insecurity with pain assessment, frustrations with communication among health care team members, and memories of unrelieved pain. Conclusion: These findings should raise concern among hospice professionals, whose commitment is to the management of pain, including emotional pain, with a focus on both the patient and the family as a unit of care. These data clearly suggest that hospice providers have an opportunity to be sensitive to perceptions held by caregivers regarding pain management. Effective planning for pain control must incorporate the values and beliefs not only of each patient but also of the family caregiver. [Copyright &y& Elsevier]

Abstract: Context: Low oral literacy has been identified as a barrier to pain management for informal caregivers who receive verbal instructions on pain medication and pain protocols. Objectives: To examine recorded communication between hospice staff and informal caregivers and explore caregiver experiences. Methods: Using transcripts of interactions (n = 47), oral literacy features were analyzed by examining the generalized language complexity using the Flesch-Kincaid grading scale and the dialogue interactivity defined by talking turns and interaction time. Means for longitudinal follow-up measures on caregiver anxiety, quality of life, perception of pain management, knowledge and comfort providing pain medication, and satisfaction were examined to explore their relationship to oral literacy. Results: Communication between team members and caregivers averaged a fourth-grade level on the Flesch-Kincaid scale, indicating that communication was easy to understand. Reading ease was associated (r = 0.67, P < 0.05) with caregiver understanding of and comfort with pain management. Perceived barriers to caregiver pain management were lower when sessions had increased use of passive sentences (r = 0.61, P < 0.01), suggesting that passive voice was not an accurate indicator of language complexity. Caregiver understanding and comfort with administering pain medications (r = −0.82, P < 0.01) and caregiver quality of life (r = −0.49, P < 0.05) were negatively correlated with dialogue pace. Conclusion: As the grade level of talk with caregivers and hospice teams increased, associated caregiver anxiety increased. Caregivers with higher anxiety also experienced greater difficulty in understanding pain medication and its management. Specific adjustments that hospice teams can make to improve caregiver experiences are identified. [Copyright &y& Elsevier]

The article presents a study which compares the accuracy of diabetes dashboard screen and conventional approach in accessing multiple electronic health record (EHR) for high-quality diabetes care. The time, accuracy, and number of mouse clicks were measured while 10 primary care physicians searched their EHR using dashboard and conventional approach. Results show that dashboard screen is the most accurate because 100% of the data requested was identified correctly with 3 clicks in the mouse.

Prenatal phthalate exposure impairs testicular function and shortens anogenital distance (AGD) in male rodents. We present data from the first study to examine AGD and other genital measurements in relation to prenatal phthalate exposure in humans. A standardized measure of AGD was obtained in 134 boys 2–36 months of age. AGD was significantly correlated with penile volume (R = 0.27, p = 0.001) and the proportion of boys with incomplete testicular descent (R = 0.20, p = 0.02). We defined the anogenital index (AGI) as AGD divided by weight at examination [AGI = AGD/weight (mm/kg)] and calculated the age-adjusted AGI by regression analysis. We examined nine phthalate monoester metabolites, measured in prenatal urine samples, as predictors of age-adjusted AGI in regression and categorical analyses that included all participants with prenatal urine samples (n = 85). Urinary concentrations of four phthalate metabolites [monoethyl phthalate (MEP), mono-n-butyl phthalate (MBP), monobenzyl phthalate (MBzP), and monoisobutyl phthalate (MiBP)] were inversely related to AGI. After adjusting for age at examination, p-values for regression coefficients ranged from 0.007 to 0.097. Comparing boys with prenatal MBP concentration in the highest quartile with those in the lowest quartile, the odds ratio for a shorter than expected AGI was 10.2 (95% confidence interval, 2.5 to 42.2). The corresponding odds ratios for MEP, MBzP, and MiBP were 4.7, 3.8, and 9.1, respectively (all p-values < 0.05). We defined a summary phthalate score to quantify joint exposure to these four phthalate metabolites. The age-adjusted AGI decreased significantly with increasing phthalate score (p-value for slope = 0.009). The associations between male genital development and phthalate exposure seen here are consistent with the phthalate-related syndrome of incomplete virilization that has been reported in prenatally exposed rodents. The median concentrations of phthalate metabolites that are associated with short AGI and incomplete testicular descent are below those found in one-quarter of the female population of the United States, based on a nationwide sample. These data support the hypothesis that prenatal phthalate exposure at environmental levels can adversely affect male reproductive development in humans. [ABSTRACT FROM AUTHOR]

Although geographic variation in semen quality has been reported, this is the first study in the United States to compare semen quality among study centers using standardized methods and strict quality control. We evaluated semen specimens from partners of 512 pregnant women recruited through prenatal clinics in four U.S. cities during 1999-2001; 91% of men provided two specimens. Sperm concentration, semen volume, and motility were determined at the centers, and morphology was assessed at a central laboratory. Study protocols were identical across centers, and quality control was rigorously maintained. Sperm concentration was significantly lower in Columbia, Missouri, than in New York, New York; Minneapolis, Minnesota; and Los Angeles, California. Mean counts were 58.7, 102.9, 98.6, and 80.8 × 10[sup 6]/mL (medians 53.5, 88.5, 81.8, and 64.8 × 10[sup 6]/mL) in Missouri, New York, Minnesota, and California, respectively. The total number of motile sperm was also lower in Missouri than in other centers: 113, 196, 201, and 162 × 10[sup 6] in Missouri, New York, Minnesota, and California, respectively. Semen volume and the percent morphologically normal sperm did not differ appreciably among centers. These between-center differences remained significant in multivariate models that controlled for abstinence time, semen analysis time, age, race, smoking, history of sexually transmitted disease, and recent fever (all p-values < 0.01). Confounding factors and differences in study methods are unlikely to account for the lower semen quality seen in this mid-Missouri population. These data suggest that sperm concentration and motility may be reduced in semirural and agricultural areas relative to more urban and less agriculturally exposed areas. [ABSTRACT FROM AUTHOR]