Cross-sectional Validation Research Articles

Development and Validation of the Short Form (JAEN-10) of the Joint Assessment of Equilibrium and Neuromotor Status Scale (JAEN-20)

Objectives: The objective of this study was to develop and validate the short version of The Joint Assessment of Equilibrium and Neuromotor Status Scale (JAEN scale) for use in women with Fibromyalgia Syndrome (FMS) to make the balance disorder measurement process more efficient. Methods: A cross-sectional observational validation study was conducted. Fifty-six women with FMS and forty-four healthy controls were included. Certain items from the original tool were selected with the aim of (1) improving internal consistency by reducing item redundancy and (2) obtaining a diagnostic capacity with an area under the ROC curve (AUC) greater than 0.70 for discriminating FMS patients and fallers. The internal consistency, factorial validity, concurrent validity and diagnostic capacity of the new tool were analyzed. Results: Factorial analysis showed a two-factor structure that explained 72% of the variance. Cronbach alpha coefficients of 0.904 were obtained for the total score of the JAEN-10 items. Concurrent validity analysis showed strong correlations of the JAEN-10 with other instruments that measured quality of life, postural balance or disability related to dizziness. The score of the JAEN-10 items showed an AUC of 0.858 with a sensitivity of 64.29 and a specificity of 95.45 for discriminating between FMS and healthy controls, and an AUC of 0.835 with a sensitivity of 90.48 and a specificity of 67.24 for discriminating between fallers and non-fallers. Conclusions: The 10-item JAEN scale is a valid instrument for discriminating between subjects with or without FMS and between fallers and non-fallers. Its psychometric properties are good and are similar to those of the original 20-item scale. Moreover, it is quicker to complete, which may be relevant for subjects with a tendency to experience fatigue.

Comparison of Upper Lip Bite Test and Thyromental Distance with Other Airway (Malampatti and Inter Incisor Distance) Assessment Tests for Predicting Difficult Endotracheal Intubation

Objective: To study the ability of upper lip bite test and thyromental distance to predict difficult endotracheal intubation when compared to standard assessment tests such as Mallampati and inter incisor distance. Study Design: Cross-sectional validation study. Place and Duration of Study: Department of Anesthesiology, Pak-Emirates Military Hospital, Rawalpindi, Pakistan, Sep 2020 to Mar 2021. Methodology: We studied a total of 50 patients who reported for the administration of general anesthesia. All patients underwent evaluation with modified Mallampati test, upper lip bite test and thyromental distance test. All participants underwent subsequent intubation according to a standard protocol. The researcher documented difficult intubations. Results: We found the upper lip bite test to have a sensitivity of 75.7%, a specificity of 84.2%, and a diagnostic accuracy of 78.6%. Thyromental distance had a sensitivity, specificity, and diagnostic accuracy of 51.4%, 78.9% and 60.7%, respectively while the modified Mallampati had a sensitivity of 64.9%, 89.5%, specificity and a diagnostic accuracy of 73.2%. Conclusion: Upper lip bite test is a useful bedside assessment tool with which to predict the probability of a difficult endotracheal intubation. Height to thyromental distance ratio test is also acceptable for rapid assessment.

Validity and reliability of a physical literacy knowledge, attitudes, self-efficacy and behaviors questionnaire for early childhood educators (PLKASB-ECE): An exploratory factor analysis.

Nurturing physical literacy in young children offers a unique opportunity to address global physical inactivity trend. Early childhood education and care (ECEC) environments, with their extensive reach into this age group, and early childhood educators, through their daily interactions with children, are strategically positioned to influence children's physical literacy development. However, enhancing educators' ability to foster physical literacy requires valid and reliable assessment tools to measure holistic physical literacy constructs (i.e., cognitive, affective, behavioral) to assess the impact of physical literacy educational interventions. The purpose of this study was to develop a holistic digital tool to measure physical literacy knowledge, attitudes, self-efficacy, and behaviors of early childhood educators (PLKASB-ECE) for both their professional teaching context as well as the educator's own personal physical literacy behaviours. This study was conducted in two phases. Phase 1 involved item generation and content validation. Phase 2 employed a cross-sectional validation study design to assess the psychometric properties of the PLKASB-ECE tool. Based on a literature review an initial 19-item instrument was developed that subsequently underwent three rounds of expert content validation. Six additional items were added, resulting in a final 25-item self-report measure with a readability score equivalent to an 8th grade reading level (Flesch-Kincaid Grade Level: 8.7). This included 1 global rating item, 2 qualitative response items, 7 knowledge items, and 15 items addressing physical literacy attitudes, self-efficacy and behaviors using a 7-point Likert response scale. The PLKASB-ECE tool was administered to 470 educators in Alberta, Canada between 2019 to 2022. The 15 items were subjected to exploratory factor analysis and resulted in a five-factor scale with one item not loading. The five-factor scale held with the final 14 items with loadings ranging from 0.481 to 0.886, Cronbach's alpha ranging from 0.70 to 0.82, with ordinal omega ranging from 0.72 to 0.82. Usability, as assessed by completion time, was 8.15 minutes. These findings demonstrate good indices of reliability and validity for the PLKASB-ECE tool. This tool will be valuable as a research outcome measure for assessing educational interventions aimed at enhancing educators' understanding, confidence, and strategies for fostering holistic concepts of physical literacy in young children within ECECs.

Validity of self-reported number of pregnancies and maternal age at first birth among females attending organized mammographic screening.

Reproductive history conveys information about potential health risks later in adulthood. This study aimed to examine the validity of self-reported number of pregnancies and maternal age at first birth (AFB) among females attending BreastScreen Norway. Participants were identified through the Janus Serum Bank cohort in Norway and were eligible for this cross-sectional validation study if they participated in a health survey issued by BreastScreen Norway between 2006 and 2015. Retrospective self-reported survey information on number of pregnancies and AFB in years was validated against prospectively collected information from the Medical Birth Registry of Norway (MBRN) using the Spearman rank (rs) and intraclass correlation coefficients (ICC) with 95% confidence intervals (CI). After exclusions, 51,598 subjects were included in the analysis on number of pregnancies and 46,919 in the analysis on AFB. On average, study subjects were 59-60 years old when completing the health survey and had become first-time mothers roughly 36 years earlier. Survey-based information about number of pregnancies was highly correlated and demonstrated high agreement with the registry data (rs=0.967, 95% CI 0.964-0.969; ICC=0.884, 95% CI 0.882-0.885). Survey-based information about AFB demonstrated even higher correlation and very high agreement with the registry data (rs=0.975, 95% CI 0.973-0.976; ICC=0.974, 95% CI 0.974-0.975). Retrospectively recalled survey-based information about number of pregnancies and AFB was highly accurate when validated against prospectively collected information in the MBRN. These survey-based data are valuable for future epidemiological research, and linkage to the MBRN may not be required when these data are available.

AI technology for developing Bitcoin investment strategies based on altcoin trends

The objective of this study is to analyse the correlation between Bitcoin and altcoins in the post-covid world and take advantage of this possible relationship to design investment strategies on Bitcoin based on the evolution of altcoins using Artificial Intelligence (AI) models.The sample of daily observations covers from January 2020 to February 2023, and the regressions performed between altcoins and Bitcoin are positive and 99 % significant, except for Dogecoin, which has a correlation with Bitcoin.If we add a lag, the estimated parameters are still 95 % significant, except for Dogecoin, so we can assume that the return of altcoins anticipates the evolution of Bitcoin.We train an artificial intelligence model in which the predictors are the observed daily return in altcoins and the target to predict is next day trend of Bitcoin (up or down). We use decision tree algorithms (J48), random forest and naive bayes, but in a retrospective cross-sectional validation with 10 sample partitions we obtain a poor predictive capacity of only a 51 % success rate in the best of cases.Therefore, despite the evident correlation between predictors and the objective variable, we should not implement this investment strategy.

Development of the Japanese version of the Mobile Device Proficiency Questionnaire: A cross-sectional validation study.

In response to the growing popularity of mobile devices among older adults in Japan, this study aimed to establish a reliable and valid measure of mobile device proficiency by developing a Japanese version of the Mobile Device Proficiency Questionnaire (MDPQ-J) for the Japanese population. To evaluate the reliability and validity of the MDPQ-J, we administered the questionnaire to 100 young or middle-aged participants (37.78 ± 13.90 years, 57.00% women), and 62 older participants (75.90 ± 6.01 years; 59.68% women). The MDPQ-J showed a high degree of internal consistency (Cronbach's α = 0.98). Moreover, MDPQ-J scores in older participants tended to be lower than those in young or middle-aged participants. In terms of validity, the MDPQ-J score of older participants was significantly associated with age (ρ = -0.31), the amount of time using a mobile device per day (ρ = 0.64), and the system usability scale (ρ = 0.39). Additionally, the MDPQ-J scores were significantly positively associated with the importance (ρ = 0.37), performance (ρ = 0.57), and satisfaction (ρ = 0.29) associated with daily mobile device use in older participants. The high reliability and validity of the MDPQ-J in the Japanese population highlight its utility in adapting mobile devices for older adults, which is crucial in an increasingly digital society. Further research should explore the mediating role of mobile device proficiency in various health-related outcomes. Geriatr Gerontol Int 2024; ••: ••-••.

The McMaster Cough Severity Questionnaire (MCSQ): a cough severity instrument for patients with refractory chronic cough.

Cough severity represents an important endpoint to assess the impact of therapies for patients with refractory chronic cough (RCC). To develop a new patient-reported outcome measure addressing cough severity in patients with RCC. Phase 1 (item generation): A systematic survey, focus groups, and expert consultation generated 51 items. Phase 2 (item reduction): From a list of 51 items, 100 patients identified those they had experienced in the previous year and rated their importance on a 5-point scale. The MCSQ included items reported to occur most frequently and that had the highest importance scores. Patient feedback on the MCSQ led to elimination of redundant items. Another 100 patients completed the MCSQ, from which we performed an exploratory factor analysis and a Rasch analysis to further refine items on the MCSQ. Phase 2 led to selection of 15 items from the initial 51. Patient feedback on the 15 items led to elimination of 5 redundant items. An exploratory factor analysis of the 10-item MCSQ led to selection of two domains, elimination of one item that demonstrated cross-loading, and another that had high inter-item correlations. A Rasch analysis of the 8-item MCSQ confirmed that the response options functioned in a logically progressive manner and that no items exhibited differential item functioning. The final 8-item MCSQ has a one-week recall period and includes two domains (intensity and frequency). The 8-item MCSQ had high internal consistency (Cronbach's alpha, 0.89), proved able to distinguish different levels of cough severity (Pearson separation index, 0.89), and demonstrated high cross-sectional convergent validity (Pearson's correlation, 0.76 [95% CI 0.66 to 0.83]) with the 100-mm cough severity visual analogue scale. Initial evidence supports the validity of the MCSQ, an 8-item instrument measuring cough severity in patients with RCC. Future studies should evaluate its properties in measuring change over time.

Reliability and Validity Evidences of Tej Emotional and Behavioral Problem Checklist (TEJ-CL) for Child Mental Health Assessment in Nepal

Introduction: The Tej Emotional and Behavioral Problem Checklist (TEJ-CL) was developed in Nepalese context to aid assessment of childhood emotional and problems of children. This study aimed to evaluate TEJ-CL's factor structure, reliability, and validity evidences as an add-on and symptom monitoring test.Methods: This cross-sectional validation study included guardians of 320 children (age 5 – 17 years) from tertiary mental health centers in Kathmandu as referred group, along with 601 children from two schools (private and community) in Kathmandu as non-referred group.Study was conducted after obtaining ethical approval (ref: 183 (6-11-E)2/073/074 and ref: 776). TEJ-CL, an 89-item parent-reported questionnaire, served as the index test, while referral status acted as the reference standard. Factor structure, internal consistency, test-retest/ cross-informant correlations and criterion validity evidence was assessed using principal component analysis, coefficient alpha, spearman's rank correlation and linear regression models, respectively.Results: Analysis was done using 179 referred and 412 non-referred individuals based on non-missing data. Principal component analysis in referred sample reduced the number of items of questionnaire to 65 from 89 and indicated six factors: externalizing behavioral issues, anxiety/worries, upset/sadness, somatic concern, miscellaneous syndrome, and severe issues with coefficient alpha ranging from .62 to .95. As criterion validity evidence, referred children showed significantly higher scores than non-referred children across composite and factor scores, except for anxiety/worries factor. Similarly, regression analyses within the referred group demonstrated significant associations between factor scores and specific diagnoses.Conclusions: Reliability and validity estimate of questionnaire is comparable to similar empirically based scales. Future research should focus on assessing the tool's generalizability and improving discriminatory indexes.

Validation of Administrative Data and Timing of Point Prevalence Surveys for Antibiotic Monitoring

Point prevalence surveys (PPSs) are used globally to collect data on antibiotic prescriptions. However, the optimal frequency for data collection to ensure comprehensive understanding of antibiotic use and to target and monitor stewardship interventions remains unknown. To identify the optimal frequency for collecting data on antibiotic use among the pediatric population through PPSs leveraging administrative data. This prognostic study used a cross-sectional validation approach and was conducted in pediatric outpatient and inpatient settings in the Veneto region of Italy. Antibiotics were classified according to the World Health Organization Access, Watch and Reserve criteria. Prescribing rates of access antibiotics were analyzed for pediatric inpatients with records dated between October 1, 2014, and December 31, 2022, and outpatients with records dated between January 1, 2010, and December 31, 2022. The study included children younger than 15 years with an antibiotic prescription who were admitted to the pediatric acute care unit or evaluated by a primary care pediatrician. Data analysis was performed from October 2023 to January 2024. An algorithm was developed to identify optimal time frames for conducting PPSs. This approach sought to minimize the discrepancy between quarterly and yearly PPS results, aiming to accurately estimate annual antibiotic prescribing rates in both inpatient and outpatient settings (primary outcome). External validity of the optimal PPS time frames derived from outpatient data when applied to the inpatient setting was also investigated. Validation involved assessing the effectiveness of administrative data in identifying strategic PPS periods for capturing inpatient antibiotic use patterns (secondary outcome). This analysis included 106 309 children: 3124 were inpatients (1773 males [56.8%]) and 103 185 were outpatients (53 651 males [52.0%]). A total of 5099 and 474 867 antibiotic prescriptions from inpatients and outpatients were analyzed, respectively. Outpatients tended to be older than inpatients, with a median age of 3.2 (IQR, 1.3-6.3) years vs 2.6 (IQR, 0.6-6.6) years, respectively, and with a lower burden of clinical comorbidities (≥1 comorbidity: 6618 [6.4%] vs 1141 [36.5%], respectively). The algorithm successfully identified distinct time frames within the calendar year from inpatient and outpatient records optimized for PPS data collection. Rates obtained from the quarterly PPS during these identified periods exhibited greater agreement with annual antibiotic prescribing rates (inpatient: r = 0.17, P < .001; and outpatient: r = 0.42, P < .001) than those derived from the yearly PPS (inpatient: r = 0.04, P = .58; and outpatient: r = 0.05, P = .34), with a Δ reduction of up to 89.8% (where Δ represents the percentage point change in antibiotic prescribing rates). Furthermore, the optimal PPS time frames gleaned from the outpatient data demonstrated robust applicability to the inpatient setting, yielding comparable results in both scenarios. This study evaluated the potential of administrative data in determining the optimal timing of PPS implementation. The quarterly PPS balanced precision and sustainability, especially when implemented during strategically selected periods across different seasons. Further studies are needed to validate the algorithm used in this study, especially in post-COVID-19 pandemic years and different settings.

Work–family enrichment among parent nurses: a cross-sectional scale development and validation study

BackgroundWork-family enrichment refers to the extent to which experiences in one role improve the quality of life in another role, and the bidirectionality indicates that benefits derived from work can be applied to family and vice versa. Parent nurses, that is, female nurses who are raising preschool children, play a major role at work and in the family. Thus, work-family enrichment is significant for them. The Work-Family Enrichment Scale cannot be generalized to parent nurses. This study was aimed at developing and psychometrically validating a draft Work-Family Enrichment Scale for Parent Nurses.MethodsA questionnaire survey was conducted among 1,090 parent nurses who were randomly sampled from hospitals with more than 200 beds in Japan. The survey evaluated (1) a draft Work-Family Enrichment Scale for Parent Nurses, (2) the Japanese version of the Work-Family Enrichment Scale, and (3) the Positive Spillover Scale. The scales were psychometrically evaluated for internal consistency, construct validity, and criterion-related validity.ResultsData from 503 participants (age, mean ± standard deviation [range] 35.5 ± 4.96 [23–47] years) were analyzed. Results of exploratory factor analysis, the work to family enrichment direction yielded five factors for 23 items: “emotional fulfillment,” “efficiency,” “ability to lead,” “displaying industriousness,” and “self-growth.” Cronbach’s alpha coefficients ranged from 0.862 to 0.914. In the family-to-work enrichment direction, there were five factors for 28 items: “help-seeking,” “receptiveness,” “expansion of one’s horizon,” “efficiency,” and “emotional fulfillment.” Cronbach’s alpha coefficients ranged from 0.790 to 0.907. Additionally, the correlation coefficients reporting criterion-related validity were 0.685 and 0.619 with regard to the Japanese version of the Work-Family Enrichment Scale and 0.596 and 0.534 with the Positive Spillover Scale for the Work-to-Family Enrichment Scale and the Family-to-Work Enrichment Scale for Parent Nurses, respectively.ConclusionsThe Work-Family Enrichment Scale for Parent Nurses has adequate reliability and validity and can be used as an effective measure to assess the positive aspects of work and family roles among female parent nurses.

Comprehensive needs assessment tool for informal cancer caregivers (CNAT-ICs): Instrument development and cross-sectional validation study

BackgroundGrowing cancer incidence and its subsequent burden is a worldwide concern. Needs assessment for caregivers has recently received growing attention, as it identifies specific unmet needs. The remaining tools have been established within the healthcare context of Western countries and have been studied only in some Asian populations; it seems appropriate to develop needs assessment tools that apply to a wider ethnic and socio-cultural context. ObjectiveThis study planned to adapt and examine the psychometric properties of the CNAT-C for the Sri Lankan informal caregivers for wider applicability. DesignAn instrument development and cross-sectional validation study was conducted. SettingApeksha Hospital Maharagama, Sri Lanka (National Cancer Institute). ParticipantsA sample of 226 informal caregivers (ICs) providing palliative care for patients with advanced cancer was selected. MethodsA CNAT-C (41 items; seven factors) was incorporated and used after a cross-cultural adaptation following WHO guidelines after the permission and pilot test. ICs completed the socio-demographic and clinical details along with the validated Centre for Epidemiological Studies-Depression (CES-D), and the World Health Organization-Quality of Life-Brief (WHOQOL-BREF). Internal consistency and test-retest were used to check the reliability. Convergent and divergent validity of the Sinhala version of CNAT (S-CNAT) was confirmed using the CES-D scale and WHOQOL-BREF. Construct validity was evaluated using the exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). ResultsMost of the participants were female (60 %) and married (72 %), and the mean age was 41.78 (SD+14.54). Face and content validity were established during the cross-cultural adaptation. Cronbach's alpha was 0.903 for the overall S-CNAT and the test-retest reliability was 0.965. The S-CNAT was associated positively with the CES-D while negatively with the WHOQOL-BREF. Both EFA and CFA discovered a structure contained seven factors (35 items); domain named as healthcare staff/nurses’ support and information, physical/practical needs, medical officers’ support, psychological needs, social/family support, spiritual/religious support, and hospital facilities/service. ConclusionsThe Sinhala version of CNAT is shown to have adequate validity and reliability in assessing the comprehensive and multidimensional/unmet needs of informal caregivers of patients with advanced cancer (S-CNAT-ICs). It would be a helpful tool to determine the unmet needs of ICs and guide future interventions to meet those needs and enhance or maintain the quality of life for patients and their informal caregivers.

Clinical Validation of the Nursing Diagnosis 'Inadequate Health Self-Efficacy' in People With Hypertension.

To test the clinical validity of clinical indicators and causal relationships of aetiological factors of the new nursing diagnosis of inadequate health self-efficacy in people with hypertension. The diagnosis of inadequate health self-efficacy has both theoretical and content validity. However, a clinical validation study is needed to establish an appropriate framework for distinguishing individuals who manifest this unique human response. The study adopts a cross-sectional clinical validation approach, adhering strictly to the STROBE guidelines throughout its design and implementation. Naturalistic sampling was used to identify 302 adults diagnosed with hypertension. Their data were subjected to latent class analysis, which facilitated the identification of a comprehensive set of clinical indicators that demonstrated better diagnostic accuracy and established posterior probabilities to guide the inference of inadequate health self-efficacy. In addition, logistic regression analysis was used to assess the magnitude of the impact of aetiological factors. The prevalence of inadequate health self-efficacy was 76.61%. Among the 13 indicators examined, seven demonstrated notable sensitivity: 'risk-prone health behaviour', 'failure to take action that prevents health problems', 'inadequate self-control', 'avoidance behaviours', 'negative health self-perception', 'inadequate health-related quality of life' and 'difficulty feeling good about adopting a healthy lifestyle'. Additionally, two indicators showed high specificity: 'difficulty feeling good about adopting a healthy lifestyle' and 'inadequate adherence to treatment regimen'. Notably, 15 aetiological factors were identified as significantly associated with an increased risk of inadequate health self-efficacy. A clinical framework consisting of eight clinical indicators and 15 aetiological factors was developed to characterise inadequate health self-efficacy in individuals with hypertension. Clinical validation provides insight into the precision of clinical indicators and the magnitude of the effect of putative causal elements, thereby facilitating identification and tailored intervention for individuals with hypertension and inadequate health self-efficacy.

European Portuguese version of the Mini-BESTest: a cross-cultural adaptation and psychometric measurements in individuals with sensorimotor impairments

Purpose This study aimed to translate and cross-culturally adapt the Mini-BESTest into European Portuguese and to evaluate its psychometric properties in individuals with sensorimotor impairments. Material and Methods A cross-sectional cross-cultural adaptation and validation study was conducted according to the COSMIN guidelines and the STROBE statement. The study included 100 participants with sensorimotor impairments who were able to walk 6 m. Cronbach’s alpha and item-total correlations were used to assess internal consistency. Interpretability was assessed by examining floor and ceiling effects and skewness. To investigate construct validity, Spearman correlation coefficients and Bland-Altman analysis were performed to compare the Berg Balance Scale and the Mini-BESTest Inter- and intra-rater reliability were assessed by calculating the ICC, SEM and MDC based on video recordings of the participants during the Mini-BESTest assessments. Results The European Portuguese Mini-BESTest showed good internal consistency (Cronbach’s α = 0.892) and no significant floor or ceiling effects. Excellent inter- and intra-rater reliability (ICC = 0.97) were also demonstrated, with MDC of 2.58 and 2.57, respectively. Furthermore, this instrument showed a significant correlation with the BBS (r = 0.902). Bland-Altman analysis showed small absolute differences. Conclusion The European Portuguese Mini-BESTest is comparable to the original English version in terms of validity and reliability and is therefore highly recommended for use by Portuguese-speaking professionals to assess postural control.

NANDA-I and NOC Linkages for Six Psychosocial Nursing Diagnoses: A Validation Study

The aim of this study was to validate the diagnostic content and the NANDA-I and NOC linkages for six psychosocial nursing diagnoses. This multicentre, descriptive, cross-sectional validation study followed Fehring’s model. Expert nurses in nursing methodology and standardised nursing languages in Spain participated, with expertise criteria based on academic level and clinical, teaching, and research experience in the fields of nursing methodology and standardised nursing languages. This study adhered to the STROBE guidelines for cross-sectional studies. Eighty-seven professionals participated in the diagnostic content validation phase, and 57 in the NANDA-I and NOC linkages validation phase. The content validity indices of the six diagnoses ranged from 0.74 to 0.84, all considered valid. All 84 proposed defining characteristics were valid, with 42 scoring ≥0.8. Thirty-two linkages between diagnoses and NOC outcomes were proposed, all valid, with mean scores between 0.73 and 0.98. Each diagnosis was linked to 5–6 NOC outcomes, comprising 26 main outcomes and 6 supplementary outcomes. Overall coverage rates for each diagnosis ranged from 68.42% to 100%. All linkages between defining characteristics and NOC outcome indicators were validated. The six selected psychosocial diagnoses, their defining characteristics, and the proposed linkages between diagnoses and outcomes have been validated. The validation of linkages between NOC indicators and nearly all major defining characteristics of these six psychosocial diagnoses will make it possible to enhance diagnostic accuracy and enable continuous assessment of the effects of nursing interventions on the clinical progression of these diagnoses.

External validation of the Hong Kong Chinese non-laboratory risk models and scoring algorithm for case finding of prediabetes and diabetes mellitus in primary care.

Two Hong Kong Chinese non-laboratory-based prediabetes/diabetes mellitus (pre-DM/DM) risk models were developed using logistic regression (LR) and machine learning, respectively. We aimed to evaluate the models' validity in case finding of pre-DM/DM in a Chinese primary care (PC) population. We also evaluated the validity of a risk-scoring algorithm derived from the LR model. This was a cross-sectional external validation study on Chinese adults, without a prior DM diagnosis, who were recruited from public/private PC clinics in Hong Kong. A total of 1,237 participants completed a questionnaire on the models' predictors. Of that, 919 underwent blood glucose testing. The primary outcome was the models' and the algorithm's sensitivity in finding pre-DM/DM cases. The secondary outcomes were the models' and the algorithm's specificity, positive/negative predictive values, discrimination and calibration. The models' sensitivity were 0.70 (machine learning) and 0.72 (LR). Both showed good external discrimination (area under the receiver operating characteristic curve: machine learning 0.744, LR 0.739). The risks estimated by the models were lower than the observed incidence, indicating poor calibration. Both models were more effective among participants with lower pretest probabilities; that is, age 18-44 years. The algorithm's sensitivity was 0.77 at the cut-off score of ≥16 out of 41. This study showed the validity of the models and the algorithm for finding pre-DM/DM cases in a Chinese PC population in Hong Kong. They can facilitate more cost-effective identification of high-risk individuals for blood testing to diagnose pre-DM/DM in PC. Further studies should recalibrate the models for more precise risk estimation in PC populations.

Simplified Chinese Trauma Advanced Practice Nurses' Core Competency Scale: A development and psychometric validation study

BackgroundThe core competency of trauma advanced practice nurses (APNs) is directly related to the quality of trauma nursing work. ObjectivesTo develop an instrument to measure trauma APNs' core competency and examine its psychometric properties. DesignA cross-sectional psychometric validation study. ParticipantsA total of 762 trauma nurses recruited from several tertiary hospitals in 14 different provinces of China between June 2023 and May 2024 provided valid data for analysis. MethodsThe Simplified Chinese Trauma Advanced Practice Nurses' Core Competency Scale (TAPNCCS-SC) was developed through five steps. Step 1) Creation of the operational definition: Based on the onion model, an operational definition of core competencies for trauma nurses is proposed. Step 2) Item generation: Based on the theoretical model, literature review, semi-structured interviews, and Delphi consultation, a preliminary scale was developed. Step 3) Item content validation: 6 experts reviewed items for content validity; Step 4) Pilot study: 21 nurses were selected to test the readability of the preliminary scale; and Step 5) Psychometric evaluation: Item analysis, content validity, exploratory and confirmatory factor analyses, convergent validity, internal consistency reliability, and half-reliability were conducted. ResultsThe TAPNCCS-SC consists of 34 items and three dimensions (knowledge and skills, professional competencies, and occupational qualities). The explained variance of the 3-factor was 81.86 %. The CFA showed an acceptable-fitting 3-factor model (χ2/df = 3.653, RMSEA = 0.088, SRMR = 0.402, CFI = 0.920, IFI = 0.920, and TLI = 0.914). For convergent validity, AVE was 0.784–0.804 and CR was 0.974–0.980. The internal consistency and split-half reliability for the total scale were 0.991 and 0.945, respectively. The I-CVI ranged from 0.83 to 1. ConclusionsThe proposed scale exhibits high reliability and validity and is suitable for assessing the core competency of trauma APNs, which can help nursing managers plan relevant training and enhance trauma care competency.

Correlation of Liver Enzymes and Serum Ferritin in Patients With β-Thalassaemia Major

Background: β-Thalassemia major is a hereditary hematological disorder that necessitates regular blood transfusions, leading to iron overload and subsequent liver injury. Elevated serum liver enzymes and ferritin are commonly used to monitor liver function in these patients; however, their reliability in predicting true hepatic dysfunction remains unclear. Objective: To determine the sensitivity, specificity, and diagnostic accuracy of serum liver enzymes and ferritin in predicting liver dysfunction, with hypoalbuminemia as the gold standard, in pediatric patients with β-thalassemia major. Methods: This cross-sectional validation study was conducted at the Department of Paediatrics, Combined Military Hospital, Rawalpindi, from July 2022 to February 2024. A total of 75 pediatric patients with β-thalassemia major were included using consecutive non-probability sampling. Patients with concurrent liver diseases, metabolic disorders, or conditions that could alter liver enzyme levels were excluded. Blood samples were collected to measure serum Alanine Transaminase (ALT), Aspartate Transaminase (AST), γ-Glutamyltransferase (γ-GT), ferritin, and albumin levels. Hypoalbuminemia was defined as a serum albumin level &lt;3.5 g/L. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ALT, AST, γ-GT, and ferritin in predicting hypoalbuminemia were calculated using 2×2 contingency tables. Data were analyzed using SPSS version 25. Results: Among the 75 patients, 18 (24.0%) exhibited hypoalbuminemia. The sensitivity, specificity, and diagnostic accuracy of ALT in detecting hypoalbuminemia were 83.33%, 31.58%, and 44.00%, respectively. For AST, these values were 50.00%, 29.82%, and 34.67%, respectively. γ-GT showed a sensitivity of 83.33%, specificity of 14.04%, and diagnostic accuracy of 30.67%. Ferritin had a sensitivity of 83.33%, specificity of 19.30%, and diagnostic accuracy of 34.67%. None of the markers showed satisfactory predictive value for hypoalbuminemia. There was a partial correlation between hyperferritinemia and elevated liver enzymes, with γ-GT showing the highest sensitivity (91.80%) and diagnostic accuracy (82.67%). Conclusion: Serum liver enzymes and ferritin are not reliable markers for predicting liver dysfunction as indicated by hypoalbuminemia in pediatric patients with β-thalassemia major. These findings suggest that additional clinical assessments and more specific biomarkers are necessary for accurate evaluation of liver health in this population.

Frequency of Hypoalbuminaemia in Preterm Neonates With Sepsis and Its Relation With Mortality

Background: Neonatal sepsis is a leading cause of morbidity and mortality in preterm infants, who are particularly vulnerable due to their immature immune systems. Hypoalbuminemia, a common biochemical abnormality in these neonates, may reflect the severity of infection and the systemic inflammatory response, potentially serving as a prognostic marker for mortality. Objective: This study aimed to determine the frequency of hypoalbuminemia in preterm neonates with sepsis and to evaluate its sensitivity, specificity, and diagnostic accuracy in predicting mortality within the neonatal period. Methods: A cross-sectional validation study was conducted at the Department of Paediatrics, Combined Military Hospital, Rawalpindi, from January 2023 to April 2024. A total of 140 preterm neonates with sepsis were included. Neonates with primary liver conditions, significant congenital anomalies, or nephrotic syndrome were excluded. Serum albumin levels were measured upon study enrollment, with hypoalbuminemia defined as a serum albumin level &lt;2.5 g/L. Mortality was monitored for up to 28 days of life. Data were analyzed using SPSS version 25. Quantitative variables were expressed as means/medians, while qualitative variables were presented as frequencies and percentages. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated, and a receiver operating characteristic (ROC) curve was plotted to determine the optimal cut-off value. Results: Hypoalbuminemia was observed in 57 (40.7%) of the neonates. Mortality occurred in 36 (25.7%) cases. Hypoalbuminemia was significantly associated with mortality (p&lt;0.001). The sensitivity, specificity, and diagnostic accuracy of hypoalbuminemia in predicting mortality were 77.78%, 72.12%, and 73.57%, respectively. The optimal serum albumin cut-off value for predicting mortality was 2.45 g/L, with a sensitivity of 73.1% and a specificity of 77.8%. Conclusion: Hypoalbuminemia is a significant predictor of mortality in preterm neonates with sepsis, demonstrating reasonable diagnostic accuracy. Monitoring serum albumin levels may be valuable in risk stratification and early identification of high-risk neonates. Further studies are recommended to validate these findings in larger cohorts and to explore potential therapeutic interventions.

Product market competition and audit fees: new evidence

PurposeThe purpose of this study is to examine the relation between product market competition and audit fees by using firm-level product market competition measures and mitigating the endogeneity issues.Design/methodology/approachThis study uses 12,136 US firms from 2004 and 2019. To ensure the robustness of the main findings, this study uses three firm-level product market competition measures and import trade tariff rate reductions of the USA as a quasi-natural experiment. This study also performs three cross-sectional tests and validation tests.FindingsThis study demonstrates that there is a negative relation between product market competition and audit fees and establishes a causal relation. Moreover, it reveals that the findings become more pronounced when auditors possess industry-specific expertise, when client firms are younger, and when operating within more homogeneous industries. Additionally, a validation analysis supports the findings.Practical implicationsThis study offers significant insights for regulators by highlighting how product market competition plays a constructive role in overseeing firm management.Originality/valueThe authors contribute to the existing literature by showing that there is a negative association between product market competition and audit fees after controlling external monitoring mechanisms. The authors also find the causal relation. These findings indicate that competitive pressures originating from product markets exert a significant influence on disciplining a client firm’s management.

Contactless and Calibration-Free Blood Pressure and Pulse Rate Monitor for Screening and Monitoring of Hypertension: Cross-Sectional Validation Study.

The key to reducing the immense morbidity and mortality burdens of cardiovascular diseases is to help people keep their blood pressure (BP) at safe levels. This requires that more people with hypertension be identified, diagnosed, and given tools to lower their BP. BP monitors are critical to hypertension diagnosis and management. However, there are characteristics of conventional BP monitors (oscillometric cuff sphygmomanometers) that hinder rapid and effective hypertension diagnosis and management. Calibration-free, software-only BP monitors that operate on ubiquitous mobile devices can enable on-demand BP monitoring, overcoming the hardware barriers of conventional BP monitors. This study aims to investigate the accuracy of a contactless BP monitor software app for classifying the full range of clinically relevant BPs as hypertensive or nonhypertensive and to evaluate its accuracy for measuring the pulse rate (PR) and BP of people with BPs relevant to stage-1 hypertension. The software app, known commercially as Lifelight, was investigated following the data collection and data analysis methodology outlined in International Organization for Standardization (ISO) 81060-2:2018/AMD 1:2020 "Non-invasive Sphygmomanometers-Part 2: Clinical investigation of automated measurement type." This validation study was conducted by the independent laboratory Element Materials Technology Boulder (formerly Clinimark). The study generated data from 85 people aged 18-85 years with a wide-ranging distribution of BPs specified in ISO 81060-2:2018/AMD 1:2020. At least 20% were required to have Fitzpatrick scale skin tones of 5 or 6 (ie, dark skin tones). The accuracy of the app's BP measurements was assessed by comparing its BP measurements with measurements made by dual-observer manual auscultation using the same-arm sequential method specified in ISO 81060-2:2018/AMD 1:2020. The accuracy of the app's PR measurements was assessed by comparing its measurements with concurrent electroencephalography-derived heart rate values. The app measured PR with an accuracy root-mean-square of 1.3 beats per minute and mean absolute error of 1.1 (SD 0.8) beats per minute. The sensitivity and specificity with which it determined that BPs exceeded the in-clinic systolic threshold for hypertension diagnosis were 70.1% and 71.7%, respectively. These rates are consistent with those reported for conventional BP monitors in a literature review by The National Institute for Health and Care Excellence. The app's mean error for measuring BP in the range of normotension and stage-1 hypertension (ie, 65/85, 76% of participants) was 6.5 (SD 12.9) mm Hg for systolic BP and 0.4 (SD 10.6) mm Hg for diastolic BP. Mean absolute error was 11.3 (SD 10.0) mm Hg and 8.6 (SD 6.8) mm Hg, respectively. A calibration-free, software-only medical device was independently tested against ISO 81060-2:2018/AMD 1:2020. The safety and performance demonstrated in this study suggest that this technique could be a potential solution for rapid and scalable screening and management of hypertension.