7-point Ordinal Scale Research Articles

New Bispectral Index Monitoring (BIS) Algorithm Significantly Improves Detection of Deep Sedation During Elective Endoscopy with Meperidine/Midazolam

New Bispectral Index Monitoring (BIS) Algorithm Significantly Improves Detection of Deep Sedation During Elective Endoscopy with Meperidine/Midazolam John Vargo, Gregory Zuccaro, Sandeep Patel, John Dumot, Darwin Conwell, Patricia Trolli Background: Deep sedation during endoscopy theoretically increases the risk of cardiopulmonary complications. According to the American Society for Anesthesiology (ASA) guidelines endorsed by the ASGE, deep sedation requires the presence of personnel dedicated to the continuous and uninterrupted monitoring of the patient’s physiologic parameters. BIS, an objective measure of frontal cortex activity, is currently used for monitoring levels of sedation during surgical procedures. Recently, a novel version (v) of the BIS-XP algorithm (v 4.1 Aspect Medical Systems, Newton, MA) has been developed to improve the measurement of sedation. Aims: To compare the performance of the newest BIS-XP algorithm with its predecessor (v 4.1 and v 4.0) in their ability to measure deep sedation with meperidine and midazolam (M/M) during elective endoscopy. Methods: Healthy (ASA Class I and II) patients undergoing elective outpatient EGD, EUS, ERCP, and colonoscopy were enrolled. The BIS index (v 4.0 and v 4.1) and the Modified Observer’s Assessment Alertness Sedation Scale (MOAAS) were simultaneously recorded q 3 minutes throughout the procedure. The BIS index is a 100 point scale (100 Z awake, 0 Z isoelectric) and the MOAAS is a 5 point ordinal scale (5 Z awake, 1 Z no response to mild physical stimulation). The ability to correctly measure episodes of deep sedation (MOAAS % 2) were compared using an ROC analysis. The C statistic (C) was used to determine the area under the curve (AUC) for both algorithms. Results: 73 patients (21 EGD, 13 EUS, 19 ERCP, 20 colonoscopy) were analyzed. No significant differences in gender or age were noted among the four groups. Both BIS algorithms were significant predictors of deep sedation (MOASS 1 and 2). However, the AUC for BIS v 4.1 (C Z 0.74, 95% CI: 0.70 – 0.780), was significantly higher than BIS v 4.0 (C Z 0.68, 95% CI: 0.63 – 0.73). Conclusion: The newer BIS (v 4.1) is superior to its BIS-XP predecessor in the measurement of deep sedation. BIS (v 4.1) has the promise of providing a real-time, continuous assessment of deeper levels of sedation when using meperidine and a midazolam.

Initial use of a novel instrument to measure professionalism in surgical residents

Background No universally accepted method to measure professionalism exists. We developed an instrument to measure specific aspects of professionalism in surgical residents. Methods Professionalism was deconstructed into 15 domains. Behavioral descriptors were determined for extreme and selected intermediate anchors. It became evident that residents could “go too far” in some professional behaviors. Therefore, although a 7-point continuous ordinal scale forms the framework, a score of 7 does not necessarily indicate the ideal. This characteristic minimizes the problem of inflated ratings. Results The instrument was utilized by attending faculty to evaluate residents and also by residents as a self-evaluation. Calculated from ordinal values, mean (SD) of the ratings across domains for faculty evaluations of residents was 4.95 (0.38) while mean for self-evaluations was 4.95 (0.39). Reliability was high (coefficient alpha 0.85). Conclusions This instrument provides a means to measure professional behaviors during surgical residency. Repeated use will be required to thoroughly establish validity and reliability.

Interobserver reliability of the "Functional Independence Measure" (FIM) in patients with craniocerebral injuries

This study was conducted to examine the inter-rater reliability of the "Functional Independence Measure" (FIM). The FIM is an assessment to determine the functional independence of patients with disabilities. It consists of eighteen items to assess activities of daily living. The degree of independence is measured by a seven point ordinal scale. The inter-rater reliability was examined by a convenience sample of 128 assessments with the FIM. Fifteen nurses assessed thirty patients with brain injuries in a centre for rehabilitation. The design was correlational. The degree of agreement between the assessments was calculated by Cohen's Kappa coefficients. The Kappa coefficients of the assessments were between kappa = 0.56 and kappa = 0.78; the median of the Kappa coefficients is kappa = 0.65. This indicates a moderate to high inter-rater reliability of the FIM when used by nurses for the assessment of patients with head injuries.

Acute partial paralysis alters perceptions of air hunger, work and effort at constant P CO 2 and [formula omitted

Breathing sensations of AIR HUNGER, WORK and EFFORT may depend on projections of central motor discharge (corollary discharge) to the forebrain. Source of motor drive (brainstem or cortex) may determine what is perceived. To test the effect of changing motor discharge at constant ventilation, we induced partial neuromuscular blockade during hypercapnic hyperpnea (31±9 L min −1; PET CO 2 =49±2 Torr) and during matched volitional hyperpnea (34±5 L min −1; PET CO 2 =41±1 Torr). Decline of vital capacity was similar between conditions (39%). Ventilation was unchanged with paralysis, indicating increased respiratory motor drive to maintain hyperpnea. Sensations were rated on a seven point ordinal scale. Median EFFORT and WORK increased 3–3.5 points with paralysis during both forms of hyperpnea ( P<0.02, Wilcoxon signed rank). Median AIR HUNGER increased 2.5 points with paralysis during hypercapnic ( P<0.02) but not during volitional hyperpnea. Data suggests that EFFORT and WORK arise from motor cortex activity (subjects reported engaging volitional control when paralyzed even during hypercapnia) and suggests that AIR HUNGER arises from medullary motor activity.

Active compression-decompression cardiopulmonary resuscitation: a population-based, prospective randomised clinical trial in out-of-hospital cardiac arrest

Different mechanical devices have been developed to improve cardiopulmonary resuscitation (CPR). The aim of this study was to evaluate active compression-decompression (ACD) CPR applied by Emergency Medical Service (EMS) in a defined population. The Trondheim region EMS (population 154 000) employs simultaneous paramedic and physician response. Upon decision to treat, patients with cardiac arrest of presumed cardiac origin were allocated to ACD CPR (CardioPump®) or standard CPR by drawing a random number tag. Outcome in each patient was determined on a 5 point ordinal scale (no clinical improvement=1, survival to discharge=5). In 4 years, CPR was attempted in a total of 431 cardiac arrests, 54 patients (13%) survived to discharge; 302 patients with similar baseline characteristics were randomised. The prevalence of bystander CPR was 57% and the median call-arrival interval 9 min. By intention to treat, the mean score in the standard CPR group was 2.51 and 17/145 patients (12%) survived. The mean score in the ACD CPR group was 2.53 ( P=0.9) and 20/157 patients (13%) survived. Cerebral outcome was similar in the two groups. Among the 145 ACD patients, the technique was successfully applied in 110, found inapplicable in 35 and in seven patients chest compressions were unnecessary. This is the largest, single-centre, randomised, population based study of ACD CPR in out-of-hospital cardiac arrest to date. Even when considering a wider outcome spectrum than crude survival, we found no evidence of clinical benefit. In a quarter of cases ACD CPR was inapplicable, further limiting its potential usefulness.

Effects of oral diazepam on intravenous access in same day surgery patients

Study Objective: To determine the effects of 5 mg oral diazepam on vein quality, patient anxiety, and intravenous (IV) access. Design: Prospective, randomized, double-blind, placebo controlled study. Setting: Preoperative holding area of a large university hospital. Patients: 202 adult ASA physical status I, II, and III patients scheduled for elective outpatient surgery. Interventions: Patients were randomized to receive either 5 mg oral diazepam or placebo, 30 minutes prior to IV access. Measurements and Main Results: Vein quality and patient anxiety were assessed prior to, and 30 minutes following, premedication (just prior to venipuncture) using a 5 point ordinal scale and 10 cm visual analog scale, respectively. The number of attempts at venous access and the gauge of the catheter used were also recorded. Baseline patient anxiety was similar between the two groups and both showed a significant improvement in patient anxiety at 30 minutes following drug administration. The diazepam group, however, had a significantly greater reduction in anxiety scores ( p < 0.05). There were no differences in baseline vein quality between the two groups; however, the quality of the vein was subjectively improved following diazepam administration. The mean number of attempts at IV access between the diazepam group (1.26 ± 0.56) and the placebo group (1.32 ± 0.65) was not significantly different. However, the ability to place larger gauge catheters was significantly enhanced in the diazepam group. Conclusions: The administration of 5 mg oral diazepam prior to the establishment of IV access improved vein quality and decreased patient anxiety. This technique may be a useful method for IV catheter placement, particularly when large gauge catheters are required, or when difficult IV access is anticipated.

Increased proliferative activity due to necroses induced by pre-operative embolization in benign meningiomas.

The proliferative behaviour of 35 benign intracranial meningiomas was investigated which were embolized for devascularization 3 to 268 hours prior to surgical exstirpation. The nuclear proliferation antigen Ki-67 was visualized by means of the monoclonal antibody MIB1 on formalin fixed and paraffin embedded tissue. Tumor cells and inflammatory reactions were recognized by means of conventional staining procedures and by immunohistochemical detection of HAM56, LCA, HLA-DR, CD15-epitope and vimentin. Extravasation and proliferation of granulocytes, macrophages, lymphocytes and the degree of expression of MHCII antigens was estimated according to a 7-point ordinal scale. Confirming preliminary observations of others the proliferation index within the perinecrotic tumor rim (PIperinec) exceeded that of intact tissue highly significantly. PIperinec peaked at the third to fourth day after embolization and kept this level until the seventh day. The time course of PIperinec was paralleled by that of macrophages, whereas--expectedly--granulocytes occured earlier and lymphocytes and HLA-DR-positivity somewhat later. The timely relationships suggested that the perinecrotic increase in tumor cell proliferation was mainly due to macrophage-born mitogens. Perinecrotic proliferative activity in embolized meningiomas does not reflect genuine tumor proliferation and should not be used for assessment of the presence or degree of malignancy in a given tumor.

Primary reservoirs of Streptococcus mutans and their relationship to caries experience in adults with good oral hygiene

Primary reservoirs of Streptococcus mutans were identified in a group of 21 adults with intact dentitions and good oral hygiene by obtaining multiple plaque samples from all available tooth surfaces. Routine cultural methods and a rapid plate scoring method employing a 7-point ordinal scale were used to assess S. mutans levels. Oral hygiene status (DI-S) and caries experience (DMFT and DMFS) were determined clinically. Primary S. mutans reservoirs (high scores) were restricted essentially to the posterior interproximal areas and occasionally in the occlusal pits and fissures of partially erupted mandibular third molars. An anterior to posterior gradient of increasing S. mutans scores was observed for interproximal sites. Oral hygiene scores correlated poorly with DMFT, DMFS and the S. mutans scores obtained for different anatomic locations.

Development of a Semantic Differential to Assess the Attitude of Secondary School and College Students

The inquiry sought to develop a semantic differential (SD) for use in assessing attitude and attitude change among secondary school and college students. It included thirty-five bipolar adjectives, each using a 7-point ordinal scale, for student rating purposes. Three concepts were used in the study: teacher, learning, and student. A Likert type scoring was accomplished with part scores for each of the separate concepts, and with the total score being the sum of the three part scores. A comparison between pre- and post-college course attitudes was made involving 237 students, which showed significant change only for the concept “student” (Me as a student). Internal reliability indexes were obtained usingthe Kuder -Richardson(K-R) Formula 20 for part scores ranging from r = .421 to .610; and for the total score ranging from r = .928 to .960. Inter correlations of part scores for pretest ranged from r = .530 to .584; and for posttest r = .620 to .707. There is evidence of greater homogeneity for post-course...