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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.
In this cohort of Escherichia coli and Klebsiella spp hospital-onset bacteremia, isolated fluoroquinolone resistance had a larger relative impact on mortality than other phenotypic resistance patterns. This finding may support stewardship efforts targeting unnecessary fluoroquinolone use and increased attention from infection prevention and control departments.
In this single-center study, the standardized antimicrobial administration ratio (SAAR) for total antimicrobial use decreased in response to a stewardship intervention. Antimicrobial prescribing and clinical outcomes were stable or improved during the period of lower SAARs. Our findings suggest that SAAR values of ~0.8 can be safely achieved.
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.
The optimal approach to auditing outpatient antimicrobial prescribing has not been established. We assessed how different types of electronic data—including prescriptions, patient-visits, and International Classification of Disease, Tenth Revision (ICD-10) codes—could inform automated antimicrobial audits.
Outpatient visits during 2016 were retrospectively reviewed, including chart abstraction, if an antimicrobial was prescribed (cohort 1) or if the visit was associated with an infection-related ICD-10 code (cohort 2). Findings from cohorts 1 and 2 were compared.
Primary care clinics and the emergency department (ED) at the Iowa City Veterans Affairs Medical Center.
In cohort 1, we reviewed 2,353 antimicrobial prescriptions across 52 providers. ICD-10 codes had limited sensitivity and positive predictive value (PPV) for validated cases of cystitis and pneumonia (sensitivity, 65.8%, 56.3%, respectively; PPV, 74.4%, 52.5%, respectively). The volume-adjusted antimicrobial prescribing rate was 13.6 per 100 ED visits and 7.5 per 100 primary care visits. In cohort 2, antimicrobials were not indicated in 474 of 851 visits (55.7%). The antimicrobial overtreatment rate was 48.8% for the ED and 59.7% for primary care. At the level of the individual prescriber, there was a positive correlation between a provider’s volume-adjusted antimicrobial prescribing rate and the individualized rates of overtreatment in both the ED (r=0.72; P<.01) and the primary care setting (r=0.82; P=0.03).
In this single-center study, ICD-10 codes had limited sensitivity and PPV for 2 infections that typically require antimicrobials. Electronically extracted data on a provider’s rate of volume-adjusted antimicrobial prescribing correlated with the frequency at which unnecessary antimicrobials were prescribed, but this may have been driven by outlier prescribers.
The nucleation and growth of Al on 7 × 7 and
$\sqrt 3 \times \sqrt 3$
R30 Al reconstructed Si(111) that result in strain-free Al overgrown films grown with an atomically abrupt metamorphic interface are compared. The reconstructed surfaces and abrupt strain relaxations are verified using reflection high-energy electron diffraction. The topography of evolution is examined with atomic force microscopy. The growth of Al on both the surfaces exhibits 3D island growth, but the island evolution of growth is dramatically different. On the 7 × 7 surface, mounds formed are uniformly distributed across the substrate, and growth appears to proceed uniformly. Alternatively, on the
$\sqrt 3 \times \sqrt 3$
R30 surface, Al atoms exhibit a clear preference to form mounds near the step edges. During Al growth, mounds increase in size and number, expanding out from step edges until they cover the whole substrate. Consistent expression of a mounded nucleation and growth mode imparts a physical limitation to the achievable surface roughness that may impact the ultimate performance of layered devices such as Josephson junctions that are critical components of superconducting quantum circuits.
Our objective is to map dynamic provinces and investigate dynamic changes in Jakobshavn Isbræ, Greenland. We use an approach that combines structural glaciology and remote-sensing data analysis, facilitated by mathematical characterization of generalized spatial surface roughness that provides parameters related to ice dynamics, deformation and interaction of the ice with bed topography. The approach is applied to derive time series of elevation and roughness changes and to attribute changes during rapid retreat. Different dynamic types of fast- and slow-moving ice can be mapped from ICESat Geoscience Laser Altimeter System data (2003–09) and Airborne Topographic Mapper data, using spatial roughness characterization, validated with ASTER and bed-topographic data. Results of comparative analysis of elevation changes and roughness changes of Jakobshavn south ice stream indicate (1) surface lowering of 10–15 m a-1 between 2004 and 2009 and (2) no change in surface roughness and dynamic types. These findings are consistent with a front retreat as part of a fjord-glacier cycle or following warming of fjord water and with climatic warming, but not with an internal dynamic acceleration as a cause of the observed changes during rapid retreat. Relationships to changes in basal water pressure are discussed. All glaciodynamic changes appear to have initiated near the front and propagated up-glacier.
We investigated the frequency and determinants of guideline-discordant antibiotic prescribing in outpatients with respiratory infections or cystitis. Antibiotic prescribing was guideline discordant in 60% of patients. The most common reason for discordance was prescribing an antibiotic when not indicated. In a multivariate analysis, physicians in training had the highest likelihood of guideline-concordant antibiotic prescribing.
Objectives: The aim of this study was to determine the aspects of expert advice that decision makers find most useful in the development of evidence-based guidance and to identify the characteristics of experts providing the most useful advice.
Methods: First, semi-structured interviews were conducted with seventeen members of the Interventional Procedures Advisory Committee of the UK's National Institute of Health and Care Excellence. Interviews examined the usefulness of expert advice during guidance development. Transcripts were analyzed inductively to identify themes. Second, data were extracted from 211 experts’ questionnaires for forty-one consecutive procedures. Usefulness of advice was scored using an index developed through the qualitative work. Associations between usefulness score and characteristics of the expert advisor were investigated using univariate and multivariate analyses.
Results: Expert opinion was seen as a valued complement to empirical evidence, providing context and tacit knowledge unavailable in published literature, but helpful for interpreting it. Interviewees also valued advice on the training and experience required to perform a procedure, on patient selection criteria and the place of a procedure within a clinical management pathway. Limitations of bias in expert opinion were widely acknowledged and skepticism expressed regarding the anecdotal nature of advice on safety or efficacy outcomes. Quantitative analysis demonstrated that the most useful advice was given by clinical experts with direct personal experience of the procedure, particularly research experience.
Conclusions: Evidence-based guidance production is often characterized as a rational, pipeline process. This ignores the valuable role that expert opinion plays in guidance development, complementing and supporting the interpretation of empirical data.
To identify important risk factors for recurrent methicillin-resistant Staphylococcus aureus (MRSA) to assist clinicians in identifying high-risk patients for continued surveillance and follow-up.
In this retrospective cohort study, we examined patients with MRSA bacteremia at 122 Veterans Affairs medical facilities from January 1, 2003, through December 31, 2010. Recurrent MRSA bacteremia was identified by a positive blood culture result from 2 to 180 days after index hospitalization discharge. Subset analyses were performed to evaluate risk factors for early-onset (2–60 days after discharge) and late-onset (61–180 days after discharge) recurrence. Risk factors were evaluated using Cox proportional hazards regression.
Of 18,425 patients, 1,159 (6.3%) had recurrent MRSA bacteremia. The median time to recurrence was 63 days. Longer duration of index bacteremia, increased severity of illness, receipt of only vancomycin, community-acquired infection, and several comorbidities were risk factors for recurrence. Congestive heart failure, hypertension, and rheumatoid arthritis/collagen disease were risk factors for early-onset but not late-onset recurrence. Geographic region and cardiac arrhythmias were risk factors for late-onset but not early-onset recurrence.
Risk factors for recurrent MRSA bacteremia included comorbidities, severity of illness, duration of bacteremia, and receipt of only vancomycin. Awareness of risk factors may be important at patient discharge for implementation of quality improvement initiatives including surveillance, follow-up, and education for high-risk patients.
Chapter 6 has argued that workers responded to changes in real wage rates by adapting how hard they worked so as to maintain their earnings. Household incomes therefore tracked GDP per head rather than real wage rates and progressively improved over time, doubling between the early fourteenth and late seventeenth centuries and doubling again over the course of the industrial revolution. Higher incomes translated into changing patterns of consumption and the forms these consumption choices took are the subjects of this chapter. Section 7.2 reconstructs the kilocalorie value and composition of diets based on the agricultural-output estimates presented in Chapter 3, augmented by information on imported foodstuffs. Given that populations require an average daily food intake per head of 2,000 kilocalories (Livi-Bacci, 1991: 27) to provide sufficient nourishment for both economic and biological reproduction, these calculations also provide a useful cross-check on the consistency of the agricultural-output and population estimates. Section 7.3 then considers non-food consumption drawing upon early modern evidence of material culture as revealed by probate inventories. Again, these trends need to be consistent with those of industrial output reconstructed in Chapter 4.
Price, habit, fashion and status all shaped the budgetary decisions taken by households. Demand for food was inelastic up to the point where basic subsistence needs had been met, but as incomes rose there were clear trade-offs to be obtained between increasing consumption of cheap sources of kilocalories such as pottage, potatoes and salted herrings on the one hand, or indulging in more expensive refined bread, quality ale and beer, dairy produce and meat, plus the imported luxuries of wine, sugar, tea, cocoa and tobacco, on the other. In effect, higher incomes allowed more households to trade up to a respectability basket of foodstuffs providing a more varied and processed diet but not necessarily more kilocalories. The changing relative prices of arable, livestock and luxury products influenced these consumption decisions, while the relative cheapness or dearness of food determined how much disposable income could be devoted to the increasingly varied and tempting array of non-food consumer goods (Figure 5.02).
Income distribution in England between 1270 and 1870, as elsewhere in Western Europe, was profoundly unequal due to entrenched inequalities in access to the land, capital, education and political power upon which personal wealth depended. Gender, rank and servility and their differential legal rights were determined at birth. Privilege, patronage and position ensured that rent-seeking was rife, while warfare created opportunities for ransom and plunder to the enrichment of those in command and impoverishment of the vanquished. Everywhere, as a result, there were rich men in their castles and poor men at their gates. Moreover, as van Zanden (1995) and Milanovic and others (2007) have demonstrated, the effect of economic growth was to magnify rather than mitigate these inequalities and widen the income gap between those at the top and bottom of the social pyramid.
The rich became richer as average wealth grew because the more wealth there was the greater the opportunities for those with power and privilege to enrich themselves at the expense of the weak and disadvantaged majority. In Holland one legacy of the prosperity achieved during the Dutch Golden Age was a greatly increased inequality of incomes, which was more marked in towns than rural villages and greatest of all in major cities (van Zanden, 1995). In England, similarly, Milanovic and others (2007) claim that inequality rose with average incomes between 1688 and 1801/03, thereby confirming Kuznets’ (1955) observation that income inequality typically increased during the early stages of economic growth and only declined relatively late in the modernisation process. Prior to 1870, therefore, increasing inequality can be treated, like urbanisation, as a characteristic and unavoidable manifestation of economic growth.