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Background and Objectives: The NIH Toolbox for Neurological and Behavioral Function assessment battery contains measures in the domains of cognitive function, motor function, sensory function, and emotional health. It was designed for use in epidemiological and clinical trials health-related research., Design: This paper describes the first phase of instrument development for the stress and self-efficacy subdomain of emotional health. Based on an extensive literature review and expert consultation, 127 measures were initially considered for inclusion in this subdomain, including measures of stress, self-efficacy, emotion regulation, and coping., Results: Several measures, including emotion regulation and measures of coping strategies, did not meet criteria that were a priori established for inclusion. Psychometric properties of the remaining candidate measures were evaluated using data from five independent samples (combined N = 3175). Confirmatory and exploratory factor analyses indicated the Perceived Stress Scale and the General Self-Efficacy Scale each assessed single dimensions., Conclusions: Based on their psychometric performance, these two instruments were selected for inclusion and subsequent national norming for the NIH Toolbox.

Donation after cardiac death (DCD) has expanded in the last decade in the US; however, DCD liver utilization has flattened in recent years due to poor outcomes. We examined clinical and quality of life (QOL) outcomes of DCD recipients by conducting a retrospective and cross-sectional review of patients from 2003 to 2010. We compared clinical outcomes of DCD recipients (n = 60) to those of donation after brain death (DBD) liver recipients (n = 669) during the same time period. DCD recipients had significantly lower rates of 5-year graft survival (P < 0.001) and a trend toward lower rates of 5-year patient survival (P = 0.064) when compared to the DBD cohort. In order to examine QOL outcomes in our cohorts, we administered the Short Form Liver Disease Quality of Life questionnaire to 30 DCD and 60 DBD recipients. The DCD recipients reported lower generic and liver-specific QOL. We further stratified the DCD cohort by the presence of ischemic cholangiopathy (IC). Patients with IC reported lower QOL when compared to DBD recipients and those DCD recipients without IC (P < 0.05). While the results are consistent with clinical experience, this is the first report of QOL in DCD recipients using standardized measures. These data can be used to guide future comparative effectiveness studies.

Background: Upper limb transplantation is a life-enhancing rather than life-saving procedure. Little research has investigated how individuals with upper limb amputations perceive the benefits and risks of this complex procedure. To address this knowledge gap, the authors conducted qualitative research with individuals with upper limb amputations to understand their perspectives., Methods: Twenty-two individuals with upper limb amputations (age range, 24 to 73 years) participated in a focus group (n=5) or semistructured interview (n=17) about the benefits and risks of upper limb transplantation. Data were analyzed by means of constant comparative methods and a two-phase analysis process., Results: Participants identified enhanced functional performance and improved appearance as the greatest potential benefits. Over half of participants indicated that function was a more important consideration than appearance. Enhanced function performance was a relative concept strongly influenced by individual expectations, which varied widely. Increased sensation, psychological well-being, and social acceptability were also described as potential benefits. Identified risks included health risks and the demands of transplantation and recovery, decreased functional performance, and uncertainty over outcomes from upper limb transplantation as an experimental procedure. Participants also expressed concerns regarding the psychological impact of negative outcomes and adverse events., Conclusions: Participants had a large variation in their perceived importance of the many risks and benefits of upper limb transplantation. These findings elucidate how potential upper limb transplantation candidates evaluate the benefits and risks of the procedure. The findings can also inform important issues to address and outcomes to assess in the pretransplant and posttransplant settings.

Purpose: Due to diagnosis at advanced stages, comorbidities, and the impact of treatment, patients with hepatocellular carcinoma (HCC) may experience pain. The purpose of this study was to evaluate the psychometric properties of a brief, clinically relevant measure of pain in HCC., Methods: We conducted a secondary data analysis from four longitudinal studies of patients with HCC (total n = 304). All patients completed the FACT-Hepatobiliary (FACT-Hep) questionnaire, and 49 patients completed the Brief Pain Inventory (BPI) Interference scale. We conducted confirmatory factor analysis (CFA), Rasch modeling, and correlational analysis to assess the psychometrics of the three items on the FACT-Hep that assess HCC-relevant pain scale., Results: Patients had an average age of 63.5 (±12.2) and were mostly male (76 %). The mean three-item pain subscale score was 8.5 ± 3.0. Seventy-four (24.3 %) patients reported no pain (score = 12). Results of a one-factor CFA supported unidimensionality of the items, and all items fit the Rasch model. An item-person map demonstrated that the three items covered all patients with non-extreme scores. Pain scores were significantly associated with baseline general health-related quality of life (FACT-General, r = 0.60, p < 0.001) and pain interference (BPI, r = -0.63, p < 0.001)., Conclusions: The three FACT-Hep pain items are unidimensional, cover the range of pain experienced by most patients with HCC, and demonstrate convergent validity. This pain subscale is, if future research demonstrates its sensitivity to change, potentially useful for HCC clinical trials.

Context: Symptom cluster research expands cancer investigations beyond a focus on individual symptoms in isolation., Objectives: We conducted a prospective longitudinal study of sleep, fatigue, depression, anxiety, and perceived cognitive impairment in patients with breast cancer undergoing chemotherapy., Methods: Patient-reported outcome measures were administered prior to chemotherapy, at Cycle 4 Day 1, and six months after initiating chemotherapy. Participants were divided into four groups and assigned a symptom cluster index (SCI) score based on the number/severity of symptoms reported at enrollment., Results: Participants (N = 80) were mostly women (97.5%) with Stage II (69.0%) breast cancer, 29-71 years of age. Scores on all measures were moderately-highly correlated across all time points. There were time effects for all symptoms, except sleep quality (nonsignificant trend), with most symptoms worsening during chemotherapy, although anxiety improved. There were no significant group × time interactions; all four SCI groups showed a similar trajectory of symptoms over time. Worse performance status and quality of life were associated with higher SCI score over time., Conclusion: With the exception of anxiety, the coherence of the symptom cluster was supported by similar patterns of severity and change over time in these symptoms (trend for sleep quality). Participants with higher SCI scores prior to chemotherapy continued to experience greater symptom burden during and after chemotherapy. Early assessment and intervention addressing this symptom cluster (vs. individual symptoms) may have a greater impact on patient performance status and quality of life for patients with higher SCIs., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Purpose: We examined the health-related quality of life (HRQOL) and pain experiences of patients with hepatocellular carcinoma (HCC) and assessed content validity of existing patient-reported pain items for patients with HCC., Methods: Semi-structured interviews to elicit symptoms, side effects and concerns were conducted with ten patients with HCC. Symptom and side effect importance was ranked on a 0 to 10 scale. Patients completed pain items from the Functional Assessment of Cancer Therapy--Hepatocellular (FACT-Hep) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire--Hepatocellular-18 (EORTC QLQ-HCC18)., Results: Mean age was 58 years (range 33-77). Spontaneously reported symptoms included fatigue (n = 5), diarrhea (n = 5), skin toxicities (n = 5), and loss of appetite (n = 4). Upon questioning, nine of ten patients reported experiencing pain over the course of their treatment. Over half of the importance rankings given for pain were 8 or higher on a 0 to 10 scale. Abdomen (n = 7) and lower back (n = 3) were the most common sites of pain. Pain onset varied from 6 months pre-diagnosis to over 2 years post-diagnosis. All patients indicated that FACT-Hep and EORTC items adequately assessed their pain., Conclusions: Results support the content validity of FACT-Hep pain items for patients with HCC. The finding that patients typically did not spontaneously report pain but often ranked it as very important for their HRQOL upon questioning suggests a need for systematic, routine pain and other symptom assessment and management as an integral component of patient care in advanced HCC.

Background: One of the primary benefits of breast conserving therapy (BCT) is the potential ability to preserve the aesthetic appearance of the breast. However, current literature and clinical experience suggest that the aesthetic benefits of BCT may not be equally shared among ethnic groups. This is a pilot study that uses novel techniques to evaluate the cosmetic outcomes of African American and white women following BCT., Methods: A total of 21 participants (10 African American and 11 white) completed the study. Cosmetic outcomes following BCT were evaluated by a multidisciplinary team using both quantitative and qualitative measures, including 3-dimensional photographic analysis and a pilot questionnaire. Preliminary measures were taken to evaluate the validity of the questionnaire., Results: There were no statistically significant differences in objective measures of breast symmetry between African American patients and white patients (P > 0.05 in all cases). However, all raters reported the African American patients to have worse breast symmetry and appearance when compared with white patients. Interrater reliability was found to be fair with regard to the nipple complex questions [intraclass correlation (ICC), 0.56], good with regard to the breast mound questions (ICC, 0.66), and poor with regard to the scar appearance questions (ICC = 0.32)., Conclusions: Although generalizing the results of this study is limited by the small sample size, it seems that there is a difference in the perception of cosmetic outcomes between white and African American patients. The novel techniques of cosmetic evaluation used in this study show promise toward identifying variables that can affect cosmetic outcome following BCT.

Objective: Psychological well-being (PWB) has a significant relationship with physical and mental health. As a part of the NIH Toolbox for the Assessment of Neurological and Behavioral Function, we developed self-report item banks and short forms to assess PWB., Study Design and Setting: Expert feedback and literature review informed the selection of PWB concepts and the development of item pools for positive affect, life satisfaction, and meaning and purpose. Items were tested with a community-dwelling US Internet panel sample of adults aged 18 and above (N = 552). Classical and item response theory (IRT) approaches were used to evaluate unidimensionality, fit of items to the overall measure, and calibrations of those items, including differential item function (DIF)., Results: IRT-calibrated item banks were produced for positive affect (34 items), life satisfaction (16 items), and meaning and purpose (18 items). Their psychometric properties were supported based on the results of factor analysis, fit statistics, and DIF evaluation. All banks measured the concepts precisely (reliability ≥0.90) for more than 98% of participants., Conclusion: These adult scales and item banks for PWB provide the flexibility, efficiency, and precision necessary to promote future epidemiological, observational, and intervention research on the relationship of PWB with physical and mental health.

Objective: To translate and validate the Pittsburgh Sleep Quality Index (PSQI), a standardized self-administered questionnaire for the assessment of subjective sleep quality into the Urdu language., Study Design: Validation study., Place and Duration of Study: Mayo Hospital, Lahore, from March to April 2012., Methodology: The PSQI was translated into Urdu following standard guidelines. The final Urdu version (PSQI-U) was administered to 200 healthy volunteers comprising medical students, nursing staff and doctors. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation of component scores with global score was assessed by calculating Spearman correlation coefficient. Correlation between global PSQI-U scores at baseline with global scores for each PSQI-U and PSQI-E at 4-week interval was evaluated by calculating Spearman correlation coefficient. Moreover, scores on individual items of the scale at baseline were compared with respective scores after 4-week by t-test., Results: One hundred and eighty five (185) participants completed the PSQI-U at baseline. The Cronbach alpha for PSQI-U was 0.56. Scores on individual components of the PSQI-U and composite scores were all highly correlated with each other (all p-values < 0.01). Composite scores for PSQI-U at baseline and PSQI-E at 4-week interval were also highly correlated with each other (Spearman correlation coefficient 0.74, p-value < 0.01) indicating good linguistic interchangeability. Composite scores for PSQI-U at baseline and at 4-week interval were positively correlated with each other (Spearman correlation coefficient 0.70, p < 0.01) indicating good test-retest reliability., Conclusion: The PSQI-U is a valid and reliable instrument for the assessment of sleep quality. It shows good linguistic interchangeability and test-retest reliability in comparison to the original English version when applied to individuals who speak the Urdu language. The PSQI-U can be a tool either for clinical management or research.

Background: The aim of the present study was to examine the association of diabetes mellitus (DM) with the prevalence and severity of hepatic encephalopathy (HE) in patients with decompensated cirrhosis (DC) and determine the impact of age and gender on this relationship., Methods: West Haven criteria was used to prospectively evaluate 352 consecutive patients with DC for the presence of HE. Detailed clinicobiochemical profiling of patients was performed. Categorical data and ordered categorical variables were evaluated using the Chi-squared test for independence and trend, respectively. Continuous normal and non-parametric data were evaluated using the t-test and Mann-Whitney U-test, respectively., Results: At the time of admission, HE was present in 50.3% of patients. In all, 118 patients had DM (33.5%). Patients with DM had a significantly higher prevalence (58.5% vs 42.6%; P = 0.03) and severity of HE (P(trend) = 0.01) than patients without DM. However, there were no significant differences between the two groups in terms of Child-Pugh class, MELD scores, the presence of ascites and esophageal varices. Patients with DM had higher platelet counts than those without DM (P(trend) = 0.003). In age and gender subgroup analyses, older patients and men with DM had significantly greater evidence of HE (P = 0.02 and 0.03, respectively). Multivariate analysis showed that DM (P = 0.03) and older age (P = 0.006) were independently related to HE, whereas the association of gender was non-significant., Conclusion: Both DM and older age are independently associated with HE in patients with cirrhosis., (© 2013 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

Angiomyofibroblastoma (AMF) is a rare benign tumor of the female genital tract. Three cases of AMF-like tumors of the male genital tract have been reported in the literature. We present the first documented case of an AMF-like soft tissue tumor of the male pelvis excised with robotic assisted laparoscopic surgery.

Background: Laparoscopic cholecystectomy (LC) is the second most common general surgical operation performed in the United States, yet little has been reported on patient-centered outcomes., Methods: We prospectively followed 100 patients for 2 years as part of an institutional review board-approved study. The Surgical Outcomes Measurement System (SOMS) was used to quantify quality-of-life (QoL) values at various time points postoperatively., Results: Maximum pain was reported at 24 h (5.5 ± 2.2), and decreased to preoperative levels at 7 days (1.2 ± 2.3 vs. 2.0 ± 1.6, P = 0.096). Bowel function improved from before the operation to 3 weeks after surgery (10.7 ± 3.8 vs. 12.0 ± 3.2, P < 0.05), but then regressed to preoperative levels. Physical function worsened from before surgery (31.7 ± 6.2) to 1 week (27.5 ± 5.9, P < 0.0001), but surpassed preoperative levels at 3 weeks (33.5 ± 3.4, P < 0.01). Return to the activities of daily living occurred at 6.3 ± 4.7 days and work at 11.1 ± 9.0 days. Fatigue increased from before surgery (15.8 ± 6.2) to week 1 (20.7 ± 6.6, P < 0.0001) before improving at week 3 (14.0 ± 5.8, P < 0.01). Forty-four patients contacted the health care team 61 times before their 3 weeks appointment, most commonly for wound issues (26.2%), pain (24.6%), and gastrointestinal issues (24.6%). Seventy-two percent reported that the procedure had no negative effect on cosmesis at 6 months. Satisfaction with the procedure was high, averaging 9.52 out of 11., Conclusions: QoL is significantly affected in the 24 h after LC but returns to baseline at week 3. Cosmesis and overall satisfaction are high, and QoL improvements are maintained in the long term except for bowel function, which regresses to preoperative levels of impairment. Analysis of patient-initiated contacts after LC may provide feedback on discharge counseling to increase patient satisfaction.

Background: Our objective was to compare hospital charges and both perioperative and mid-term quality of life between single- (SILC) and multi-incision (MILC) laparoscopic cholecystectomy in a randomized controlled trial., Methods: Patients with acute or chronic biliary disease were invited to participate. Pain scores, quality of life, and perioperative outcomes were measured. Patients were followed for 1 year postoperatively in the clinic with examination to document hernia formation., Results: One hundred subjects were randomized to SILC (n = 49) or MILC (n = 51). Demographics were similar for both groups except more women underwent SILC (86% vs 67%, P = .026). Operative time was greater for SILC (63.5 ± 21.0 vs 43.8 ± 24.2 minute, P < .0001). Five SILC patients required added ports. One substantial complication occurred in SILC. Pain, the use of analgesics, and duration of hospital stay were equal between groups; however, charges were greater in the SILC group ($17,602 ± $6,089 vs $13,342 ± $8,197, P < .0001). Both groups reported similar quality of life and cosmesis. At an average follow-up of SILC (16.4 ± 12.1 months) and MILC (16.2 ± 10.5 months), no novel umbilical hernias were identified., Conclusion: SILC results in longer operative time and greater hospital charges with similar pain and quality of life scores compared with a standard laparoscopic approach., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background & Aims: Quality of life (QoL) is an important aspect of any palliative treatment. However, few data are available from studies comparing how embolotherapy affects QoL for patients with hepatocellular carcinoma (HCC). We performed a health-related QoL study in patients with HCC treated by transarterial chemoembolization (TACE) or (90)Y radioembolization., Methods: We performed a prospective study of patients undergoing (90)Y radioembolization (n = 29) or TACE (n = 27) for HCC. We assessed patients before treatment and 2 and 4 weeks after treatment using the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) survey. We compared differences in health-related QoL between the treatment groups using linear regression repeated-measures analysis., Results: At baseline, the groups had comparable baseline Child-Pugh class and performance statuses, although patients undergoing TACE had lower tumor burdens (P = .018) and less-advanced disease, based on United Network for Organ Sharing and Barcelona stage (P = .03 and P = .02, respectively), permitting injections at segmental arteries (P < .0001). There were no significant differences between groups in overall FACT-Hep health-related QoL scores (P = .055, effect size [ES], .54), owing to a limited sample size. Despite the more advanced disease of patients who received (90)Y radioembolization, they had a significantly better QoL, based on social well being (P = .019; ES, .65), functional well-being (P = .031; ES, .60), and embolotherapy-specific scores (P = .018; ES, .67). They also had a trend toward better overall QoL (P = .055; ES, .54) and higher Trial Outcome Index (P = .05; ES, .56) and FACT-Hep scores (P = .071; ES, .52)., Conclusions: In a prospective study, although (90)Y radioembolization was used to treat patients with more advanced disease, those who received this treatment had significant increases in several features of QoL, whereas patients who received TACE had decreases in QoL scores. However, because of the limited sample size, there was no significant difference in overall FACT-Hep health-related QoL scores. The increase was greatest in the embolotherapy-specific score. ClinicalTrials.gov, number NCT00739167., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Purpose: An essential aspect of patient-centered outcomes research (PCOR) and comparative effectiveness research (CER) is the integration of patient perspectives and experiences with clinical data to evaluate interventions. Thus, PCOR and CER require capturing patient-reported outcome (PRO) data appropriately to inform research, healthcare delivery, and policy. This initiative's goal was to identify minimum standards for the design and selection of a PRO measure for use in PCOR and CER., Methods: We performed a literature review to find existing guidelines for the selection of PRO measures. We also conducted an online survey of the International Society for Quality of Life Research (ISOQOL) membership to solicit input on PRO standards. A standard was designated as "recommended" when >50 % respondents endorsed it as "required as a minimum standard.", Results: The literature review identified 387 articles. Survey response rate was 120 of 506 ISOQOL members. The respondents had an average of 15 years experience in PRO research, and 89 % felt competent or very competent providing feedback. Final recommendations for PRO measure standards included: documentation of the conceptual and measurement model; evidence for reliability, validity (content validity, construct validity, responsiveness); interpretability of scores; quality translation, and acceptable patient and investigator burden., Conclusion: The development of these minimum measurement standards is intended to promote the appropriate use of PRO measures to inform PCOR and CER, which in turn can improve the effectiveness and efficiency of healthcare delivery. A next step is to expand these minimum standards to identify best practices for selecting decision-relevant PRO measures.

The current review examines the relationship between depression and the inflammatory immune response. Mood disorders are a significant cause of morbidity and the etiology of depression is still not clearly understood. Many studies have shown links between inflammatory cytokines and mood disorders, including elevated level of cytokines like tumour necrosis factor-alpha (TNF alpha), Interleukins (IL-1,IL-6) and others. Raised levels of cytokines have been shown to increase depressive behaviour in animal models, while many anti-depressants reverse this behaviour alongside reducing the Central Nervous System (CNS) inflammatory response and reduction in the amounts of inflammatory cytokines. Cytokines reduce neurogenesis, Brain Derived Neurotrophic Factor (BDNF) and neuronal plasticity in the CNS, while many anti-depressants have been shown to reverse these processes. The considerations of anti-depressants as anti-inflammatory agents, and implication of other anti-inflammatory therapeutics for the treatment of depression are pointed out.

Purpose: Evaluate reliability and validity of the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) questionnaire and its derivative FACT Hepatobiliary Symptom Indexes (FHSI-18 and FHSI-8) in people with metastatic pancreatic cancer., Methods: Self-reported questionnaire data from a randomized controlled Phase II study evaluating the efficacy and safety of conatumumab (AMG 655), ganitumab (AMG 479) or placebo combined with gemcitabine were evaluated. The following were assessed: internal consistency, using Cronbach's α; discriminant validity, comparing baseline patient-reported outcomes (PRO) scores across Eastern Cooperative Oncology Group (ECOG) performance status (PS) levels; and ability to detect change, comparing change from baseline PRO score at each cycle across PS and tumour response groups., Results: The analysis included 96 patients. All scale scores demonstrated good internal consistency (Cronbach's α > 0.7) and discriminant validity. Baseline scores were significantly poorer among patients with PS = 1 versus patients with PS = 0 (e.g. difference in FACT-Hep total score -17.27; p < 0.001). Ability to detect change was established for Cycles 2/3 versus baseline; PRO scores reduced in the PS-worsened group versus the PS-stable group (e.g. difference in FACT-Hep total score -24.29; p < 0.001). All PRO scale scores showed significant decline for progressive disease versus stable disease (e.g. difference in FACT-Hep total score -12.58; p = 0.004). Changes on the FHSI-18 and FHSI-8 scales were similar in magnitude whether ECOG improved or worsened., Conclusions: FACT-Hep detects change and is a reliable and valid instrument for measuring health-related quality of life in patients with metastatic pancreatic cancer.

Health researchers and policy-makers increasingly urge both patient and clinician engagement in shared decision making (SDM) to promote patient-centered care. Although SDM has been examined in numerous clinical settings, it has received little attention in solid organ transplantation. This paper describes the application of SDM to the kidney transplantation context. Several distinctive features of kidney transplantation present challenges to SDM including fragmented patient-provider relationships, the time-sensitive and unpredictable nature of deceased organ offers, decision-making processes by transplant providers serving as both organ guardians (given the organ scarcity) versus advocates for specific patients seeking transplantation, variable clinical practices and policies among transplant centers, and patients' potentially compromised cognitive status and literacy levels. We describe potential barriers to and opportunities for SDM, and posit that SDM is feasible, warranting encouragement in kidney transplantation. We propose strategies to promote and overcome obstacles to SDM in kidney transplantation. We contend that engagement in SDM can be facilitated by re-organization of clinical care, communication and education of providers and patients., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objective: To examine the prevalence and magnitude of gender discrimination experienced by undergraduate medical students, and its repercussions on their academic performance and emotional health., Methodology: A cross sectional study of 500 medical and dental students studying at a private medical college in Lahore, Pakistan., Results: Majority (78%) of students reported being victims of gender discrimination. Females were the main perpetrators (70.8%).Most common forms were denied opportunities (63%), followed by neglecting students' needs (44.3%), and unethical talk (43.6%). Most common places of gender discrimination were teachers' offices (43.7%) and lecture halls (37.2%). Most of the perpetrators were clerical staff (48%) and professors (43%).Gender discrimination did not affect the academic performance of most victims (62.6%). The most common emotional responses were anger (57.6%), frustration (46.7%) and helplessness (40.3%). 52.4% of students said that gender discrimination still continues and the majority (83.3%) did not report the problem to college authorities., Conclusions: RESULTS demonstrate that gender discrimination is widely prevalent in undergraduate medical education. Females are both the main victims as well as the main perpetrators. In most cases gender discrimination does not affect academic performance but does cause emotional distress.

Purpose: Cross-sectional data suggest that many individuals with breast cancer experience significant sleep disturbance across the continuum of care. Understanding the longitudinal trajectory of sleep disturbance may help identify factors associated with its onset, severity, or influence on health-related quality of life (HRQL). Study objectives were to observe sleep quality in breast cancer patients prior to, during, and after completion of adjuvant chemotherapy, evaluate its relationship with HRQL and explore correlates over time., Methods: Participants were administered patient-reported outcome measures including the Pittsburgh Sleep Quality Index (PSQI) and the Functional Assessment of Cancer Therapy--General (FACT-G), which assesses HRQL. Data were collected prospectively 3-14 days prior to beginning chemotherapy, cycle 4 day 1 of chemotherapy, and 6 months following initiation of chemotherapy., Results: Participants (n = 80) were primarily women (97.5 %) with stage II (69.0 %) breast cancer. Total FACT-G scores were negatively correlated with global PSQI scores at each time point (rho = -0.46, -0.41, -0.45; all p < 0.001). Poor sleep quality (PSQI ≥ 5) was prevalent at all time points (48.5-65.8 %); however, there were no significant changes within participants over time. Correlates with sleep quality varied across time points. Participants with poor sleep quality reported worse overall HRQL, fatigue, depression, and vasomotor/endocrine symptoms., Conclusions: These findings suggest that early identification of sleep disturbance and ongoing assessment and treatment of contributing factors over the course of care may minimize symptom burden associated with chemotherapy and prevent chronic insomnia in survivorship.

We report on the selection of self-report measures for inclusion in the NIH Toolbox that are suitable for assessing the full range of negative affect including sadness, fear, and anger. The Toolbox is intended to serve as a "core battery" of assessment tools for cognition, sensation, motor function, and emotional health that will help to overcome the lack of consistency in measures used across epidemiological, observational, and intervention studies. A secondary goal of the NIH Toolbox is the identification of measures that are flexible, efficient, and precise, an agenda best fulfilled by the use of item banks calibrated with models from item response theory (IRT) and suitable for adaptive testing. Results from a sample of 1763 respondents supported use of the adult and pediatric item banks for emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) as a starting point for capturing the full range of negative affect in healthy individuals. Content coverage for the adult Toolbox was also enhanced by the development of a scale for somatic arousal using items from the Mood and Anxiety Symptom Questionnaire (MASQ) and scales for hostility and physical aggression using items from the Buss-Perry Aggression Questionnaire (BPAQ)., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

One of the goals of the NIH Toolbox for Assessment of Neurological and Behavioral Function was to identify or develop brief measures of emotion for use in prospective epidemiologic and clinical research. Emotional health has significant links to physical health and exerts a powerful effect on perceptions of life quality. Based on an extensive literature review and expert input, the Emotion team identified 4 central subdomains: Negative Affect, Psychological Well-Being, Stress and Self-Efficacy, and Social Relationships. A subsequent psychometric review identified several existing self-report and proxy measures of these subdomains with measurement characteristics that met the NIH Toolbox criteria. In cases where adequate measures did not exist, robust item banks were developed to assess concepts of interest. A population-weighted sample was recruited by an online survey panel to provide initial item calibration and measure validation data. Participants aged 8 to 85 years completed self-report measures whereas parents/guardians responded for children aged 3 to 12 years. Data were analyzed using a combination of classic test theory and item response theory methods, yielding efficient measures of emotional health concepts. An overview of the development of the NIH Toolbox Emotion battery is presented along with preliminary results. Norming activities led to further refinement of the battery, thus enhancing the robustness of emotional health measurement for researchers using the NIH Toolbox.

Objective: The quality of our daily social interactions-including perceptions of support, feelings of loneliness, and distress stemming from negative social exchanges-influence physical health and well-being. Despite the importance of social relationships, brief yet precise unidimensional scales that assess key aspects of social relationship quality are lacking. As part of the National Institute of Health (NIH) Toolbox for the Assessment of Neurological and Behavioral Function, we developed brief self-report scales designed to assess aspects of social support, companionship, and social distress across age cohorts. This article details the development and psychometric testing of the adult NIH Toolbox Social Relationship scales., Methods: Social relationship concepts were selected, and item sets were developed and revised based on expert feedback and literature review. Items were then tested across a community-dwelling U.S. Internet panel sample of adults aged 18 and above (N = 692) using traditional (classic) psychometric methods and item response theory approaches to identify items for inclusion in 5-8 item unidimensional scales. Finally, concurrent validity of the newly developed scales was evaluated with respect to their interrelationships with classic social relationship validation instruments., Results: Results provide support for the internal reliability and concurrent validity of resulting self-report scales assessing Emotional Support, Instrumental Support, Friendship, Loneliness, Perceived Rejection, and Perceived Hostility., Conclusion: These brief social relationship scales provide the pragmatic utility and enhanced precision needed to promote future epidemiological and social neuroscience research on the impact of social relationships on physical and emotional health outcomes., (PsycINFO Database Record (c) 2013 APA, all rights reserved.)

Background: Metastatic renal cell cancer is associated with poor long-term survival and has no cure. Traditional clinical endpoints are best supplemented by patient-reported outcomes designed to assess symptoms and function. Normative data was obtained on the National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Kidney Symptom Index (NFKSI) to aid in score interpretation and planning of future trials., Methods: General population data were obtained from 2000 respondents, who completed the 19-item NFKSI-19, as well the SF-36 (Short Form 36-item instrument) and the PROMIS-29 (29-item Patient Reported Outcomes Measurement Information System), both general health status measures. Basic demographic and self-reported comorbidity data were also collected., Results: The sample was 50% female, 85.7% caucasian, with an equal distribution across age bands from 18 years to 75 years and older. Most respondents (62.8%) had more than a high school education and reported an Eastern Cooperative Oncology Group performance status of normal activity without symptoms (63.4%). Score distributions on the NFKSI-19, its subscales, and individual items are summarized., Conclusions: The NFKSI-19 and its subscales now have scores for the general US population, allowing comparability to generic questionnaires such as the SF-36 and PROMIS-29. These data can be used to guide treatment expectations and plan future comparative effectiveness research using the scales., (Copyright © 2012 American Cancer Society.)

Objective: Given the importance of fatigue in cancer, stroke and HIV, we sought to assess the measurement properties of a single, well-described fatigue scale in these populations. We hypothesized that the psychometric properties of the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) subscale would be favorable and that the scale could serve as a useful indicator of fatigue in these populations., Methods: Patients were eligible for the study if they were outpatients, aged 18 or older, with a diagnosis of cancer (n=297), stroke (n=51), or HIV/AIDS (n=51). All participants were able to understand and speak English. Patients answered study-related questions, including the FACIT-F using a touch-screen laptop, assisted by the research assistant as necessary. Clinical information was abstracted from patients' medical records., Results: Item-level statistics on the FACIT-F were similar across the groups and internal consistency reliability was uniformly high (α>0.91). Correlations with performance status ratings were statistically significant across the groups (range r=-0.28 to -0.80). Fatigue scores were moderately to highly correlated with general quality of life (range r=0.66-0.80) in patients with cancer, stroke, and HIV. Divergent validity was supported in low correlations with variables not expected to correlate with fatigue., Conclusions: Originally developed to assess cancer-related fatigue, the FACIT-F has utility as a measure of fatigue in other populations, such as stroke and HIV. Ongoing research will soon allow for comparison of FACIT-F scores to those obtained using the fatigue measures from the Patient-Reported Outcomes Measurement Information System (PROMIS®; www.nihpromis.org) initiative., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The 45-item Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) questionnaire assesses health-related quality of life in patients with liver, bile duct, and pancreatic cancers. Although the FACT-Hep was initially derived from patient input, this study's researchers sought to verify adequate coverage of items by soliciting open-ended input from patients with advanced disease., Methods: As part of a larger study in collaboration with the National Comprehensive Cancer Network (NCCN), 50 people (60% male, 80% caucasian, average age 60.4 years) with stage 3 or 4 hepatobiliary or pancreatic cancer were recruited. Participants generated and ranked up to 10 important symptoms and concerns that physicians should monitor when assessing the value of chemotherapy. Patients were also able to provide open-ended, qualitative information that was evaluated systematically. Ten expert physicians also provided input on priority symptoms., Results: The resulting 18-item NCCN-FACT Hepatobiliary-Pancreatic Symptom Index (NFHSI-18) demonstrated high internal consistency (α = .89) and moderate to strong correlations with measures of physical well-being (ρ = .76), emotional well-being (ρ = 0.52), and functional well-being (ρ = 0.57). Scores on the NFHSI-18 were also highly correlated with the original hepatobiliary scale of the FACT-Hep (ρ = .82; all P < .001). Compared with patients with better performance status, patients with poor performance status had worse NFHSI-18 symptom scores, F(3,47) = 9.74; P = .0003., Conclusions: The NFHSI-18 assesses symptoms of importance to patients with hepatobiliary and pancreatic cancers and demonstrates promising measurement properties. The scale is a good candidate for brief symptom assessment in clinical trials., (Copyright © 2012 American Cancer Society.)

Noting a lack of such a resource, the authors developed a primer summarizing key concepts for career development and promotion for psychologists working in an academic health center. The present article presents a brief summary of the primer; however, the full version is available as an APAHC membership benefit (or for a small fee for non-members) by visiting http://www.div12.org/section8/index.html and is a supplement to the December issue of Volume 19 of the Journal of Clinical Psychology in Medical Settings (Supplementary material 1). The primer complements other APAHC membership benefits, which may be helpful for early career or more seasoned psychologists planning for career transitions.

The field of solid organ transplantation has historically concentrated research efforts on basic science and translational studies. However, there has been increasing interest in health services and outcomes research. The aim was to build an effective and sustainable, inter- and transdisciplinary health services and outcomes research team (NUTORC), that leveraged institutional strengths in social science, engineering, and management disciplines, coupled with an international recognized transplant program. In 2008, leading methodological experts across the university were identified and intramural funding was obtained for the NUTORC initiative. Inter- and transdisciplinary collaborative teams were created across departments and schools within the university. Within 3 years, NUTORC became fiscally sustainable, yielding more than tenfold return of the initial investment. Academic productivity included funding for 39 grants, publication of 60 manuscripts, and 166 national presentations. Sustainable educational opportunities for students were created. Inter- and transdisciplinary health services and outcomes research in transplant can be innovative and sustainable.

Background: Since the development of single-incision surgery, several retrospective studies have demonstrated its feasibility; however, randomized prospective trials are still lacking. We report a prospective randomized single-blinded trial with a cost analysis of single-incision (SI) to multi-incision (MI) laparoscopic cholecystectomy., Study Design: After obtaining IRB approval, patients with chronic cholecystitis, acute cholecystitis, or biliary dyskinesia were offered participation in this multihospital, multisurgeon trial. Consenting patients were computer randomized into either a transumbilical SI or standard MI group; patient data were then entered into a prospective database., Results: We report 79 patients that were prospectively enrolled and analyzed. Total hospital charges were found to be significantly different between SI and MI groups (MI $15,717 ± $14,231 vs SI $17,817 ± $5,358; p < 0.0001). Broken down further, the following subcharges were found to also be significant: operating room charges (MI $4,445 ± $1,078 vs SI $5,358 ± 893; p < 0.0001); medical/surgical supplies (MI $3,312 ± $6,526 vs SI $5,102 ± $1,529; p < 0.0001); and anesthesia costs (MI $579 ± $7,616 vs SI $820 ± $23,957; p < 0.0001). A validated survey (ie, Surgical Outcomes Measurement System) was used to evaluate various patient quality-of-life parameters at set visits after surgery; scores were statistically equivalent for fatigue, physical function, and satisfaction with results. No difference was found between visual analogue scale scores or inpatient and outpatient pain-medication use., Conclusions: We show SI surgery to have higher costs than MI surgery with equivalent quality-of-life scores, pain analogue scores, and pain-medication use., (Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: As reconstructive transplantation emerges as an increasingly viable option for upper limb amputees, a better understanding of quality of life (QOL) outcomes is needed to evaluate the benefits and risks of the procedure from the patient perspective., Methods: To address this need, we searched PubMed (1998-2011) to characterize QOL outcomes among upper limb transplant recipients. We identified 27 articles reporting on QOL outcomes in hand transplantation. Common instruments to assess domains of QOL in hand transplantation include the Disabilities of the Arm, Shoulder, and Hand questionnaire, the Medical Outcomes Study Short Form-36, and the International Registry on Hand and Composite Tissue Transplantation's Hand Transplantation Score System., Results: Preliminary reports using standardized measures indicate that most hand transplant recipients described improved QOL. Several studies also qualitatively reported that recipients expressed satisfaction with cosmetic, sensory, functional, and social outcomes after transplantation. However, our review suggests that the measurement of QOL in hand transplantation is limited, although it is largely driven by QOL considerations., Conclusions: This review highlights the need for improved measurement of QOL in hand transplantation. The preliminary QOL findings across published hand transplantation articles will aid in improving the future assessment of QOL in hand transplantation., Type of Study/level of Evidence: Therapeutic III., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

AML-M6 has a peak incidence in the seventh decade with slight male preponderance, and can also present at a younger age. The usual features are anaemia, thrombocytopenia, malaise, fatigue, easy bruising, epistaxis and petechiae. Splenomegaly may occur in 20-40 % of the cases but massive splenomegaly is rare presentation and have been only reported once in humans and once in animals. A 22 year Asian female, presented with fatigue, pallor, mild jaundice, exertional dyspnoea, epigastric pain, tender right hypochondrium and massive splenomegaly. Investigations revealed anaemia and thrombocytopenia, tear drop cells, basophilic stippling, piokilocytosis and anisochromia; increased uric acid and LDH. Abdominal ultrasound showed enlarged liver (22cm) and spleen (20cm). Bone marrow aspiration revealed 51% erythroid and 24% non-erythroid precursors, depressed leukopoeisis and megakarypoeisis. Erythroblasts were PAS and CD71 positive and also reacted to Antihaemoglobin-Antibody. This report highlights characteristic features and diagnostic criteria of erythroleukaemia, differential diagnosis of massive splenomegaly and their rare association.

Purpose of Review: In this review, we briefly summarize three fruitful, emerging areas in liver transplantation research, quality of life; risk assessment; and patient safety. Our goal is to highlight recent findings in these areas, with a call for increased integration of social scientists and transplant clinicians to address how best to shape policy and improve outcomes., Recent Findings: After liver transplantation, recipients generally experience clinically significant, sustained improvement in their physical, social and emotional well being. However, a sizeable minority of patients do experience excess morbidity that may benefit from ongoing surveillance and/or intervention. There is growing body of research that describes risks associated with liver transplantation, which can be useful aids to better inform decision making by patients, clinicians, payers, and policy makers. In contrast, there has been a relative lack of empirical data on transplant patient safety vulnerabilities, placing the field of surgery in stark contrast to other high-risk industries, wherein such assessments inform continuous process improvement., Summary: Health services and outcomes research has grown in importance in the liver transplantation literature, but several important questions remain unanswered that merit programmatic, interdisciplinary research.

We conducted a cross-sectional study of patients who underwent pediatric liver transplant (LT) between 1988 and 1992 to evaluate long-term health status. Survivors completed socio-demographic, medical and Health-Related Quality of Life (HRQOL) surveys by mail including the SF-36v2, PedsQL™4.0 Generic Core Scale, PedsQL™ Cognitive Functioning Scale and PedsQL™3.0 Transplant Module. SF-36 scores were converted to SF6D-based utilities and risk factors for lower outcomes were assessed. Eighty-five of 171 patients had survived. Fifty-six were contacted with a response rate of 66%. Median age at LT was 0.86 years (IQR 0.58-3.0) and 64.3% had biliary atresia. Mean age at survey was 23.0 ± 4.4 years: 62% attended college, 68% lived with parents and 80% of those over 23 were employed. Patient health utilities were lower than norms (0.75 ± 0.12 vs. 0.82 ± 0.18, p < 0.01) and correlated with unemployment (p < 0.042), hospitalizations (p < 0.005) and lower education level (p < 0.016). Lower PedsQL™3.0 Transplant Module and PedsQL™ 4.0 Generic Core Scale scores correlated with unemployment (p = 0.006, p = 0.009) and hospitalizations (p = 0.006, p = 0.02). Pediatric transplant recipients who survive to adulthood have lower physical HRQOL, measurable transplant-related disability and lower health utility. Transplantation is life saving; however, physical and psychological sequelae continue to affect health status up to two decades later., (© Copyright 2012 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objective: To evaluate the difference between pre- and post-menopausal breast cancer regarding menstrual and reproductive risk factors, Methods: The case-control study was conducted in Mayo Hospital, Lahore, between October 2008 and April 2009. Cases were breast cancer patients admitted in the surgical and oncology floors of the hospital. Controls were hospital patients without breast cancer. The study enrolled 150 cases and 300 controls. Menstrual and reproductive history was taken from both the cases and the controls. For every risk factor age-adjusted odds ratio (OR) and 95% confidence interval (CI) was calculated by logistic regression analysis, separate for pre- and post-menopausal women., Results: Among the breast cancer patients, 42.7% were pre-menopausal and 57.3% were post-menopausal. Age at menarche had no association with breast cancer for both pre- and post-menopausal women. Nulliparity was a risk factor for both pre-menopausal (OR 4.1, 95% CI 1.4-12.6) and post-menopausal breast cancer (OR 8.2, 95% CI 1.7-40.4). Among parous women only post-menopausal females having < 3 children were at increased risk for breast cancer (OR 4.5, 95% CI 1.8-11.5) compared with females having > or = 3 children. Younger age at first live birth decreased breast cancer risk in both pre- and post-menopausal women. Breastfeeding was not associated with both pre- and post-menopausal breast cancer., Conclusions: Majority of risk factors for pre-menopausal breast cancer are also associated with postmenopausal breast cancer except less parity, which increased the risk for post-menopausal breast cancer only.

Objective: To study the prevalence of anxiety and depression symptoms in patients with dengue and to examine their correlation with symptom severity., Methods: In this cross sectional study, 531 consecutive patients who met the World Health Organization criteria for dengue fever admitted to Mayo Hospital, Lahore between September and November 2011 were administered the Hospital Anxiety and Depression Scale (HADS). In addition to the HADS, the severity of their symptoms, like headache, myalgias/arthralgias, fever, and retro/periorbital pain, was assessed on a 3-point scale (mild, moderate, and severe)., Results: About 60% of the patients in our study met the criteria for anxiety and 62.2% of the patients met criteria for depression. Severity of fever, headache, myalgias and arthralgias, and retro/periorbital pain was positively correlated with both anxiety (Correlation coefficients: 0.148, 0.247, 0.184, 0.184 respectively and P < 0.01 for all) and depression scores (Correlation coefficients: 0.098, 0.154, 0.131, 0.125 respectively and P value < 0.01 for all). The strongest correlation was found between severity of headache and scores for both anxiety and depression. Both mean anxiety and depression scores were significantly higher in patients with platelet count below median (30,000/mm3) than in patients with platelet count above median (9.1 +/- 4.7 vs 8.2 +/- 4.7, P < 0.03, and 9.5 +/- 4.5 vs 8.5 +/- 4.5, P < 0.01, respectively)., Conclusion: A majority of patients with dengue have anxiety and depression symptoms. Psychiatric evaluation should be done in all Dengue patients so timely treatment can be initiated.

Objective: The purpose of this study is to report the reliability, validity, and clinical utility of a parent-report perceived cognitive function (pedsPCF) item bank., Methods: From the U.S. general population, 1,409 parents of children aged 7-17 years completed 45 pedsPCF items. Their psychometric properties were evaluated using Item Response Theory (IRT) approaches. Receiver operating characteristic (ROC) curves and discriminant function analysis were used to predict clinical problems on child behavior checklist (CBCL) scales. A computerized adaptive testing (CAT) simulation was used to evaluate clinical utility., Results: The final 43-item pedsPCF item bank demonstrates no item bias, has acceptable IRT parameters, and provides good prediction of related clinical problems. CAT simulation resulted in correlations of 0.98 between CAT and the full-length pedsPCF., Conclusions: The pedsPCF has sound psychometric properties, U.S. general population norms, and a brief-yet-precise CAT version is available. Future work will evaluate pedsPCF in other clinical populations in which cognitive function is important.

Purposes: This paper reports the development and evaluation of a perceived cognitive function (pedsPCF) item bank reported by parents of the pediatric US general population., Methods: Based on feedback from clinicians, parents, and children, we developed a scale sampling concerns related to children's cognitive functioning. We administered the scale to 1,409 parents of children aged 7-17 years; of them, 319 had a neurological diagnosis. Dimensionality of the pedsPCF was evaluated via factor analyses and its clinical utility studied by comparing parent ratings in patient groups and symptom cluster defined by the Child Behavior Checklist (CBCL)., Results: Forty-four of 45 items met criteria for unidimensionality. The pedsPCF significantly differentiated samples defined by medication use, repeated grades, special education status, neurologic diagnosis, and relevant symptom clusters with large effect sizes (>0.8). It can predicted children symptoms with the correction rates ranging 79-89%., Conclusions: We have provided empirical support for the unidimensionality of the pedsPCF item bank and evidence for its potential clinical utility. The pedsPCF is a promising measurement tool to screen children for further comprehensive cognitive tests.

Purpose: A phase III, randomized, double-blind, placebo-controlled trial was conducted in patients with metastatic renal cell carcinoma. The focus of this paper is to evaluate the patient-reported outcomes., Methods: Patients were randomly assigned (2:1) to receive oral everolimus 10 mg once daily or placebo. The Functional Assessment of Cancer Therapy Kidney Symptom Index-Disease-Related Symptoms (FKSI-DRS) and European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30 were administered before randomization and on day 1 of each cycle. The FKSI-DRS and the EORTC QLQ-C30 Physical Functioning and Global Quality of Life scores were the primary endpoints examined. Longitudinal models were used to compare treatment arms. Sensitivity analyses were conducted to explore the impact of missing data assumptions., Results: Longitudinal trends for FKSI-DRS scores did not differ by treatment arm. Taking nonignorable missing data into account, there were significant differences between treatment arms in the trend over time for physical functioning and global quality of life, with the everolimus arm exhibiting greater decreases. All three of these measures of health-related quality of life were significantly related to progression-free survival., Conclusions: There was no evidence of a difference between everolimus and placebo in longitudinal patterns of disease-related symptoms, and little difference between the arms in physical functioning or global quality of life trends. This supports the conclusion that delay in tumor progression demonstrated by everolimus is associated with minimal impact on symptoms, physical functioning, or quality of life, as reported by patients.

Living donor liver transplantation (LDLT) decreases the shortage of liver grafts for patients in need of a liver transplant, but it involves 2 patients: a recipient and a living donor. Despite the magnitude of the procedure for LDLT donors, only a few studies have investigated the effect of LDLT on the quality of life (QOL) of donors. We performed a systematic search of the MEDLINE database to identify peer-reviewed articles assessing QOL in adults after LDLT donation. Nineteen studies describing 768 unique donors met our inclusion criteria for this review. The median number of donors enrolled in each study was 30 (range = 10-143), and the median follow-up period was 10.4 months (range = 3-51.3 months). Before donation, donor QOL was significantly better than that in control adult populations across all measured QOL domains. Within the first 3 months after donation, the physical domains of QOL were significantly worse than the predonation levels, but they returned to baseline levels within 6 months for the majority of patients (80%-93%). Mental domains of QOL remained unchanged throughout the donation process. Common donor concerns after LDLT included bloating, loss of muscle tone, poor body image, and fatigue. In conclusion, according to our review of the existing literature, most LDLT donors return to their baseline QOL within 6 months. However, there is a lack of long-term data on donor QOL after LDLT, and few standardized assessments include measures of common patient concerns. Additional studies are necessary to develop a comprehensive risk profile for LDLT that includes a rigorous assessment of donor QOL., (© 2010 AASLD.)

Objective: To determine the accuracy of pallor of conjunctiva, nailbed, and palm in detecting mild and severe anaemia., Methods: Three hundred and five consecutive patients admitted in the medical and surgical wards of Mayo Hospital, Lahore were enrolled in the study. Conjunctiva, nailbed, and palm of patients were assessed. Mild anaemia was defined as Hb < 11.5 g/dl for females and Hb <13 g/dl for males. Severe anaemia was defined as Hb <7 g/dl. Likelihood ratios (LR) and their 95% confidence intervals (CI) for both presence and absence of pallor at each site were calculated. To compare the accuracy of different pallor sites in diagnosing severe anaemia, their areas under receiver operating characteristics curves (AUC) were compared., Results: Mild anaemia was present in 64.3% patients while severe anaemia was present in 7% patients. Presence of nailbed pallor had moderate accuracy for diagnosing mild anaemia (LR 5.6, 95% CI 4.7-6.7) while absence of pallor at nailbed, conjunctiva, and palm (LR 0.6 for all) did not rule out mild anaemia. All sites had modest accuracy for detecting severe anaemia (LR 2.5-3.0). Absence of pallor at conjunctiva (LR 0.1, 95% CI 0.03-0.5) and palm (LR 0.1, 95% CI 0.03-0.5) convincingly ruled out severe anaemia. Comparison of the AUC for different pallor sites showed that all sites were equally useful for detecting severe anaemia., Conclusion: Pallor is not an accurate sign for mild anaemia. Pallor of conjunctiva, palm, and nailbed has modest accuracy in detecting severe anaemia. Absence of pallor at conjunctiva and palm convincingly rules out severe anaemia.

Objective: To evaluate the reliability and validity of Neurologic Quality of Life (NeuroQOL) item banks that assess quality-of-life (QOL) domains not typically included in poststroke measures., Design: Secondary analysis of item responses to selected NeuroQOL domains., Setting: Community., Participants: Community-dwelling stroke survivors (n=111) who were at least 12 months poststroke., Interventions: Not applicable., Main Outcome Measures: Five measures developed for 3 NeuroQoL domains: ability to participate in social activities, satisfaction with participation in social activities, and positive psychologic function., Results: A single bank was developed for the positive psychologic function domain, but 2 banks each were developed for the ability-to-participate and satisfaction-with-participation domains. The resulting item banks showed good psychometric properties and external construct validity with correlations with the legacy instruments, ranging from .53 to .71. Using these measures, stroke survivors in this sample reported an overall high level of QOL., Conclusions: The NeuroQoL-derived measures are promising and valid methods for assessing aspects of QOL not typically measured in this population.

Objectives: In recent years ultrasound guided foam sclerotherapy (UGFS) has become an increasingly popular treatment for varicose veins. Although many published series detail the results of UGFS, little is known about the factors which are associated with outcomes and complications. The aim of this study was to identify these factors., Design: A review of a prospectively collected database of UGFS which commenced in July 2007., Methods: A successful outcome was defined as complete occlusion of the target vein on duplex scanning at follow-up. Eight factors were assessed to determine whether they were associated with outcomes and complications. These factors were age, gender, compliance with post-procedure compression hosiery, previous varicose vein surgery, single or multiple sites of injection, concentration of sclerosant, volume of sclerosant and pre-procedure severity score., Results: Between July 2007 and July 2009, a total of 126 patients (60 men, 66 women) attended follow-up visits and had a post-procedure duplex scan. Targets for UGFS included the great saphenous vein (n = 75), small saphenous vein (n = 13) and anterior accessory great saphenous vein (n = 8). The remainder of procedures involved other veins or more than a single target vein. The median timing of follow-up was 3 months (range 1.5-14 months) with duplex scans revealing complete occlusion of the target vein in 79% of patients. The only factor associated with a successful outcome was compliance with post-procedure compression hosiery (p < 0.05). The most frequently encountered complications following UGFS were skin staining (28%), superficial thrombophlebitis (18%) and pain (14%). The only factor associated with post-UGFS complications was female gender (p < 0.05). When complications were analysed in isolation female gender was also significantly associated with skin staining (p < 0.05), but no other complication., Conclusions: These data suggest that compliance with post-procedure compression hosiery and gender are important factors associated with a successful outcome and reported complications following UGFS, respectively., (Copyright 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the role of risk factors, which promote cholelithasis in Hepatic Cirrhosis (HC)., Methods: A prospective study was conducted on indoor cases with advanced HC. Outpatients with compensated Chronic Liver Disease were used as control. The subjects with history of cholecystectomy and diabetes mellitus were excluded from the study. Conventional ultrasound was used for the detection of gallstones, ascites and portal hypertension. Sonography also furnished pertinent information about the portal vein diameter, size of the spleen, gallbladder wall thickness and echogenecity of the liver., Results: The number of registered cases was 206: (age: 30-85 years): 121 (58.7%) males and 85 (41.3%) females. Hepatitis C (HCV) was the cause of HC in 187 (90.88%) cases. Of 50 (24.30%) patients with detectable gallstones, 27(54.00%) were males. We observed correlation of several risk factors with cholelithasis in our patients (n = 50): advanced age: mean 57.3 +/- 9.7 years (100%); prolonged duration of HC: 3.5 years (100%); Child-Pughs' class C: 34 (68%); increased thickness of gallbladder wall: 45 (90%); gross ascites: 39 (78%); splenic enlargement: 17.3 cm (100%); increased portal vein diameter: 13.4mm (100%). The results were statistically significant when compared with the control group (p = < 0.001)., Conclusion: Gallstones tend to occur more frequently in patients with decompensated CLD due to interaction of several risk factors in these patients.

Context: There has been some suggestion that the fatigue experienced by older cancer patients is more severe than that of younger cohorts; however, there is little empirical evidence to support this claim., Objectives: The goal of the present study was to determine the differential impact of age and cancer diagnosis on ratings of fatigue using a validated self-report instrument., Methods: The Functional Assessment of Chronic Illness Therapy-Fatigue subscale consists of 13 items measuring fatigue experience and its impact on daily life, with scores ranging from 0 (severe fatigue) to 52 (no fatigue). Fatigue data were available from the U.S. general population (n=1075; 51.3% female, 45.9+/-16.5 years) and a sample of mixed-diagnosis cancer patients (n=738; 64.3% female, 58.7+/-13.6 years). General population participants were recruited using an Internet-based survey panel; patients with cancer were recruited from Chicago-area oncology clinics., Results: On average, the cancer patient group reported more severe fatigue than the general population group (36.9 vs. 46.6; F[1,1797]=271.95, P<0.001). There was evidence for increased fatigue with age (F[6,719]=2.56, P<0.02) among patients with cancer, but not in the general population (P=0.06). Furthermore, the group x age interaction was not significant (P=0.44). Hemoglobin (Hgb) was treated as a covariate for 430 patients with available data; there was no main effect for age in this analysis., Conclusion: Older adults, whether they had a cancer diagnosis, reported more fatigue than younger adults. These differences may be explained, in part, by Hgb level. Future research would be helpful to explore longitudinal changes in fatigue in the general population and guide fatigue management for the older cancer patient., (Copyright (c) 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Hepatitis C virus (HCV) infection is increasingly recognized as a major health care problem, and is found frequently in Pakistani settings. In this article we reviewed published and unpublished data related to the seroepidemiology of HCV infection in Pakistan. For this article, data from 132 published studies and three unpublished data sets published/ presented between the period 1992-2008 were utilized. Data of 1,183,329 individuals were gathered. Blood donors (982,481) and the general population (178,322) constituted the majority of these subjects. The frequency of HCV infection in blood donors and in the general population was 3.0 % (95% CI: 3.0- 3.1) and 4.7 (95% CI: 4.6 -4.8), respectively. The frequency among 6,148 pregnant females was 7.3% (95% CI = 6.7 - 8.0). The frequency in healthy children ranged from 0.4 to 4.1% (95% CI = 1.4 - 2.3). Pakistani HCV serofrequency figures are significantly higher (P < 0.0001) compared to those of the corresponding populations in surrounding countries like India, Nepal, Myanmar, Iran and Afghanistan.