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Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Introduction: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. To-date, study of sex-based concussion differences in general adult populations have been limited. This study examined sex-based differences in concussion outcomes. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score 13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls at 30 and 90 days post ED discharge captured extent of PCS using the Rivermead Post-Concussion questionnaire (RPQ), effect on daily living activities measured by the Rivermead Head Injury Questionnaire (RHIQ), and overall health-related quality of life using the 12-item Short Form Health Survey (SF-12). Dichotomous and categorical variables were compared using Fishers exact test; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Results: Overall, 130/250 enrolled patients were female. The median age was 35 years; men trended towards being younger (median=32 years; IQR: 23, 45) than women (median=40 years; IQR: 22, 52). Compared to women, more men were single (56% vs 38% (p=0.007) and employed (82% vs 71% (p=0.055). Men and women experienced different injury mechanisms (p=0.007) with more women reporting injury due to a fall (44% vs 26%), while more men were injured at work (16% vs 7%) or due to an assault (11% vs. 3%). Men had a higher return to ED rate (13% vs. 5%; p=0.015). Women had higher RPQ scores at baseline (p<0.001) and 30-day follow-up (p=0.001); this difference was not significant by 90 days (p=0.099). While women reported on the RHIQ at 30 days that their injury affected their usual activities significantly more than men (Median=5, IQR: 0, 11 vs. median=0.5, IQR: 0.5, 7; p=0.004), both groups had similar scores on the SF-12 physical composite and mental composite scales at all three measurement points. Conclusion: In a general ED concussion population, demographic differences exist between men and women. Based on self-reported and objective outcomes, womens usual activities may be more affected by concussion and PCS than men. Further analysis of these differences is required in order to identify different treatment options and ensure adequate care and treatment of injury.
Despite lessons learned from the recent Ebola epidemic, attempts to survey and determine non-health care worker, industry-specific needs to address highly infectious diseases have been minimal. The aircraft rescue and fire fighting (ARFF) industry is often overlooked in highly infectious disease training and education, even though it is critical to their field due to elevated occupational exposure risk during their operations.
Supervisors perceived Frontline respondents to be more willing and comfortable to encounter potential highly infectious disease scenarios than the Frontline indicated. More than one-third of respondents incorrectly marked transmission routes of viral hemorrhagic fevers. There were discrepancies in self-reports on the existence of highly infectious disease orientation and skills demonstration, employee resources, and personal protective equipment policies, with a range of 7.5%-24.0% more Supervisors than Frontline respondents marking activities as conducted.
There are deficits in highly infectious disease knowledge, skills, and abilities among ARFF members that must be addressed to enhance member safety, health, and well-being. (Disaster Med Public Health Preparedness. 2018;12:675-679)
Introduction: Patients with mild traumatic brain injury (mTBI) frequently present to the emergency department (ED); however, wide variation in diagnosis and management has been demonstrated in this setting. Sub-optimal mTBI management can contribute to post-concussion syndrome (PCS), affecting vocational outcomes like return to work. This study documented the work-related events, ED management, discharge advice, and outcomes for employed patients presenting to the ED with mTBI. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score ≥13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls ascertained outcomes, including symptoms and their severity, advice received in the ED, and adherence to discharge instructions, at 30 and 90 days after ED discharge. Dichotomous variables were analyzed using chi-square testing; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Work-related injury and return to work outcomes were modelled using logistic or linear regression, as appropriate. Results: Overall, 250 patents were enrolled; 172 (69%) were employed at the time of their injury and completed at least one follow-up. The median age was 37 years (interquartile range [IQR]: 24, 49.5), both sexes were equally represented (48% male), and work-related concussions were uncommon (16%). Work-related concussion was related to manual labor jobs and self-reported history of attention deficit disorder. Patients often received advice to avoid sports (81%) and/or work (71%); however, the duration of recommended time off varied. Most employed patients (80%) missed at least one day of work (median=7 days; IQR: 3, 14); 91% of employees returned to work by 90 days, despite 41% reporting persistent symptoms. Increased days of missed work were linked to divorce, history of sleep disorder, and physician’s advice to avoid work. Conclusion: While work-related concussions are uncommon, most employees who sustain a mTBI at any time miss some work. Many patients experience mTBI symptoms past 90 days, which has serious implications for workers’ abilities to fulfill their work duties and risk of subsequent injury. Workers, employers, and the workers compensation system should take the necessary precautions to ensure that workers return to work safely and successfully following a concussion.
Introduction: Patients with mild traumatic brain injury (mTBI) often present to the emergency department (ED). Incorrect diagnosis may delay appropriate treatment and recommendations for these patients, prolonging recovery. Notable proportions of missed mTBI diagnosis have been documented in children and athletes, while diagnosis of mTBI has not been examined in the general adult population. Methods: A prospective cohort study was conducted in one academic (site 1) and two non-academic (sites 2 and 3) EDs in Edmonton, Canada. On-site research assistants enrolled adult (>17 years) patients presenting within 72 hours of the injury event with clinical signs of mTBI and Glasgow comma scale score ≥13. Patient demographics, injury characteristics, and ED flow information were collected by chart review. Physician-administered questionnaires and patient interviews documented the recommendations given by emergency physicians at discharge. Bi-variable comparisons are reported using Pearson’s chi-square tests, Student’s t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, 130/250 enrolled patients were female, and the median age was 35. Proportions of successfully diagnosed mTBI varied significantly across study sites (Site 1: 89%; Site 2: 73%, Site 3: 53%; p>0.001). Patients without a diagnosis were less likely to receive a recommendation to follow-up with their family physician (OR=0.08; 95% CI: 0.03, 0.21) or advice about return to work (OR=0.17; 95% CI: 0.08, 0.04) or physical activity (OR=0.08; 95% CI: 0.04, 0.17). Patients with missed diagnoses had longer ED stays (median=5.0 hours; IQR: 3.8, 7.0) compared with diagnosed mTBI patients (median=3.9 hours; IQR: 3.0, 5.3). In the adjusted model, patients presenting to non-academic centers had reduced likelihood of mTBI diagnosis (Site 2: OR=0.21; 95% CI: 0.08, 0.58; Site 3: OR=0.07; 95% CI: 0.02, 0.24). Conclusion: The diagnostic accuracy of physicians assessing patients presenting with symptoms of mTBIs to these three EDs is suboptimal. The rates of missed diagnosis vary among EDs and were associated with length of ED stay. Closer examination of institutional factors, including diagnosis processes and personnel factors such as physician training, is needed to identify effective strategies to heighten the awareness of mTBI presentations.
Sweetpotato breeding requires at least 5 years to obtain an advanced breeding clone for further testing with the goal of cultivar release. An accelerated breeding scheme (ABS) can be feasible if the genotype × year interaction is low. The objectives of the present study were to describe an ABS for sweetpotato and to investigate the efficiency of this breeding scheme for selecting high-yielding and well-adapted orange-fleshed sweetpotato (OFSP) cultivars with high β-carotene (BC) content. More than 198 500 seeds from two crossing blocks were germinated and rapidly multiplied for evaluation in observation trials at four breeding locations in Mozambique. Breeding clones with storage root yields above 10 t/ha were advanced to preliminary and advanced yield trials across four sites and for 3 years. As a result, 64 high-yielding OFSP breeding clones were selected and evaluated in four mega-environments following a randomized complete block design with three replicates at Angónia, Chókwè, Gurúè and Umbelúzi. Data from multi-environment trials were subjected to single site and combined analysis of variance as well as to stability analysis. The genotype × environment interaction was highly significant for storage root and vine yields, dry matter (DM) and BC content. Storage root yield and DM content for 15 OFSP breeding clones ranged from 14·9 to 27·1 t/ha and from 24·8 to 32·8%, respectively. BC content, iron and zinc ranged from 5·9 to 38·4, 1·6 to 2·1 and 1·1 to 1·5 mg/100 g dry weight, respectively. The OFSP breeding clones also met the culinary tastes required by local consumers in Mozambique. The proposed ABS seems to be an attractive scheme for genetic enhancement of sweetpotato.
New insights from the recent literature are summarized and new data presented concerning the formation, structure and morphology of halloysite. Halloysite formation by weathering always requires the presence of water. Where substantial drying occurs, kaolinite is formed instead. Halloysite formation is favoured by a low pH. The octahedral sheet is positively charged at pH < ∼8, whereas the tetrahedral sheet is negatively charged at pH > ∼2. The opposing sheet charge would facilitate interlayer uptake of H2O molecules. When halloysite intercalates certain polar organic molecules, additional (hkl) reflections appear in the X-ray diffraction pattern, suggesting layer re-arrangement which, however, is dissimilar to that in kaolinite. Associated oxides and oxyhydroxides of Fe and Mn may limit the growth of halloysite particles as does incorporation of Fe into the structure. Particles of different shape and Fe content may occur within a given sample of halloysite.
Hydrated halloysite was discovered in books, a morphology previously associated exclusively with kaolinite. From ∼1.5 to ∼1500 μm in length, the books showed significantly greater mean Fe contents (Fe2O3 = 5.2 wt.%) than tubes (Fe2O3 = 3.2 wt.%), and expanded rapidly with formamide. They occurred, along with halloysite tubes, spheroids and plates, in highly porous yet poorly permeable, silt-dominated, Si-rich, pumiceous rhyolitic tephra deposits aged ∼0.93 Ma (Te Puna tephra) and ∼0.27 Ma (Te Ranga tephra) at three sites ∼10–20 m stratigraphically below the modern landsurface in the Tauranga area, eastern North Island, New Zealand. The book-bearing tephras were at or near saturation, but have experienced intermittent partial drying, favouring the proposed changes: solubilized volcanic glass + plagioclase→halloysite spheroids→halloysite tubes→halloysite plates→ halloysite books. Unlike parallel studies elsewhere involving both halloysite and kaolinite, kaolinite has not formed in Tauranga presumably because the low permeability ensures that the sites largely remain locally wet so that the halloysite books are metastable. An implication of the discovery is that some halloysite books in similar settings may have been misidentified previously as kaolinite.
Background: Ataluren is the first drug to treat the underlying cause of nmDMD. Methods: Phase 2 and 3 studies of ataluren in nmDMD were reviewed, with efficacy and safety/tolerability findings summarized. Results: Ataluren nmDMD trials include: a Phase 2a proof-of-concept study (N=38); a Phase 2b randomized controlled trial (RCT) (N=174); an ongoing US-based open-label safety extension study (N=108); an ongoing non-US-based open-label safety/efficacy extension study (N=94); and a Phase 3 RCT, ACT DMD (N=228), whose primary endpoint was change in six-minute walk distance (6MWD) over 48 weeks. The proof-of-concept study demonstrated increased dystrophin production in post-treatment muscle biopsies from ataluren-treated patients with nmDMD. The Phase 2b results demonstrated an ataluren treatment effect in 6MWD, timed function tests, and other measures of physical functioning, The Phase 3 ACT DMD results demonstrated an ataluren treatment effect in patients with nmDMD in both primary and secondary endpoints, particularly in those with a baseline 6MWD of 300-400m. Ataluren was consistently well-tolerated in all three trials, as well as in the ongoing extension studies. Trial findings will be presented in detail. Conclusions: The totality of the results demonstrates that ataluren enables nonsense mutation readthrough in the dystrophin mRNA, producing functional dystrophin and slowing disease progression.
To assess the performance of two pediatric length-based tapes (Broselow and Handtevy) in predicting actual weights of US children.
In this descriptive study, weights and lengths of children (newborn through 13 years of age) were extracted from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Using the measured length ranges for each tape and the NHANES-extracted length data, every case from the study sample was coded into Broselow and Handtevy zones. Mean weights were calculated for each zone and compared to the predicted Broselow and Handtevy weights using measures of bias, precision, and accuracy. A sub-sample was examined that excluded cases with body mass index (BMI)≥95th percentile. Weights of children longer than each tape also were examined.
A total of 3,018 cases from the NHANES database met criteria. Although both tapes underestimated children’s weight, the Broselow tape outperformed the Handtevy tape across most length ranges in measures of bias, precision, and accuracy of predicted weights relative to actual weights. Accuracy was higher in the Broselow tape for shorter children and in the Handtevy tape for taller children. Among the sub-sample with cases of BMI≥95th percentile removed, performance of the Handtevy tape improved, yet the Broselow tape still performed better. When assessing the weights of children who were longer than either tape, the actual mean weights did not approximate adult weights; although, those exceeding the Handtevy tape were closer.
For pediatric weight estimation, the Broselow tape performed better overall than the Handtevy tape and more closely approximated actual weight.
LoweCG, CampwalaRT, ZivN, WangVJ. The Broselow and Handtevy Resuscitation Tapes: A Comparison of the Performance of Pediatric Weight Prediction. Prehosp Disaster Med. 2016;31(4):364–375.
The Darwin region in northern Australia has experienced rapid population growth in recent years, and with it, an increased incidence of melioidosis. Previous studies in Darwin have associated the environmental presence of Burkholderia pseudomallei, the causative agent of melioidosis, with anthropogenic land usage and proximity to animals. In our study, we estimated the occurrence of B. pseudomallei and Burkholderia spp. relatives in faecal matter of wildlife, livestock and domestic animals in the Darwin region. A total of 357 faecal samples were collected and bacteria isolated through culture and direct DNA extraction after enrichment in selective media. Identification of B. pseudomallei, B. ubonensis, and other Burkholderia spp. was carried out using TTS1, Bu550, and recA BUR3–BUR4 quantitative PCR assays, respectively. B. pseudomallei was detected in seven faecal samples from wallabies and a chicken. B. cepacia complex spp. and Pandoraea spp. were cultured from wallaby faecal samples, and B. cenocepacia and B. cepacia were also isolated from livestock animals. Various bacteria isolated in this study represent opportunistic human pathogens, raising the possibility that faecal shedding contributes to the expanding geographical distribution of not just B. pseudomallei but other Burkholderiaceae that can cause human disease.
To describe current Ebola treatment center (ETC) locations, their capacity to care for Ebola virus disease patients, and infection control infrastructure features.
A 19-question survey was distributed electronically in April 2015. Responses were collected via email by June 2015 and analyzed in an electronic spreadsheet.
The survey was sent to and completed by site representatives of each ETC.
The survey was sent to all 55 ETCs; 47 (85%) responded.
Of the 47 responding ETCs, there are 84 isolation beds available for adults and 91 for children; of these pediatric beds, 35 (38%) are in children’s hospitals. In total, the simultaneous capacity of the 47 reporting ETCs is 121 beds. On the basis of the current US census, there are 0.38 beds per million population. Most ETCs have negative pressure isolation rooms, anterooms, and a process for category A waste sterilization, although only 11 facilities (23%) have the capability to sterilize infectious waste on site.
Facilities developed ETCs on the basis of Centers for Disease Control and Prevention guidance, but specific capabilities are not mandated at this present time. Owing to the complex and costly nature of Ebola virus disease treatment and variability in capabilities from facility to facility, in conjunction with the lack of regulations, nationwide capacity in specialized facilities is limited. Further assessments should determine whether ETCs can adapt to safely manage other highly infectious disease threats.
Infect. Control Hosp. Epidemiol. 2016;37(3):313–318
Elevated levels of interleukin-6 (IL-6) have been associated with the development of common mental disorders, such as depression, but its role in symptom resolution is unclear.
We examined the association between IL-6 and symptom resolution in a non-clinical sample of participants with psychological distress.
Relative to high IL-6 levels, low levels at baseline were associated with symptom resolution at follow-up [age- and sex-adjusted risk ratio (RR) = 1.15, 95% confidence interval (CI) 1.06–1.25]. Further adjustment for covariates had little effect on the association. Symptomatic participants with repeated low IL-6 were more likely to be symptom-free at follow-up compared with those with repeated high IL-6 (RR = 1.21, 95% CI 1.03–1.41). Among the symptomatic participants with elevated IL-6 at baseline, IL-6 decreased along with symptom resolution.
IL-6 is potentially related to the mechanisms underlying recovery from symptoms of mental ill health. Further studies are needed to examine these mechanisms and to confirm the findings in relation to clinical depression.
This paper brings together the work of the GI Solvency II Technical Provisions working party. The working party was formed in 2009 for the primary purpose of raising awareness of Solvency II and the impact it would have on the work that reserving actuaries do. Over the years, the working party’s focus has shifted to exploring and promoting discussion of the many practical issues raised by the requirements and to promoting best practice. To this end, we have developed, presented and discussed many of the ideas contained in this paper at events and forums. However, the size of the subject means that at no one event have we managed to cover all of the areas that the reserving actuary needs to be aware of. This paper brings together our thinking in one place for the first time. We hope experienced practitioners will find it thought provoking, and a useful reference tool. For new practitioners, we hope it helps to get you up-to-speed quickly. Good luck!