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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.
Introduction: Quality improvement and patient safety (QIPS) are increasingly recognized as integral to the provision and advancement of emergency medicine (EM) care. In 2015, QIPS were added to the Canadian Medical Education Directives for Specialists (CanMEDS) framework. However, the level of QIPS education and support that Canadian EM residents receive is unknown. In order to better plan national QIPS efforts aimed at enabling EM residents to improve their local care settings, we sought to assess the current state of QIPS education and support in Canadian EM residency programs. Methods: This was a descriptive, cross-sectional electronic survey that was disseminated to all current Canadian EM residents from both Royal College (RC) and Family Medicine - EM training streams. Residents were recruited either directly or through their program's administrative assistant. The survey consisted of multiple-choice, Likert and free-text entry questions. Themes included a) familiarity with QIPS; b) local opportunities for QIPS projects and mentorship; and c) desire for further QIPS education and involvement. The survey was open for a five-week period, with formal reminders after the first and third weeks. Descriptive statistics are reported. Results: 189 (35%) of 535 current EM residents completed the survey, representing all 17 medical schools. 77% of respondents were from the RC stream. 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS. 47.2% of respondents reported “not knowing” or “not having readily available” QIPS projects to participate in their local environment, and 51.5% had equivalent responses with respect to QIPS mentorship opportunities. Only 17.5% of respondents reported that QIPS methodologies were already formally taught in their residency program, and 66.9% indicated a desire for increased QIPS teaching. The majority of respondents were “slightly” (35.9%), “moderately” (23.2%) or “very” (11.3%) interested in becoming involved with QIPS training and initiatives. Conclusion: Responding Canadian EM residents are interested in obtaining greater QIPS education as well as project and mentorship opportunities, but many perceive that they do not have adequate access to these at the current time. As the importance of QIPS increases in the EM community, supporting residents with more robust educational infrastructures may be necessary. Future efforts may include the standardizing of QIPS postgraduate curricula and improving access to QIPS opportunities across the country.
Shiga-toxin producing Escherichia coli (STEC) is a pathogen that can cause bloody diarrhoea and severe complications. Cases occur sporadically but outbreaks are also common. Understanding the incubation period distribution and factors influencing it will help in the investigation of exposures and consequent disease control. We extracted individual patient data for STEC cases associated with outbreaks with a known source of exposure in England and Wales. The incubation period was derived and cases were described according to patient and outbreak characteristics. We tested for heterogeneity in reported incubation period between outbreaks and described the pattern of heterogeneity. We employed a multi-level regression model to examine the relationship between patient characteristics such as age, gender and reported symptoms; and outbreak characteristics such as mode of transmission with the incubation period. A total of 205 cases from 41 outbreaks were included in the study, of which 64 cases (31%) were from a single outbreak. The median incubation period was 4 days. Cases reporting bloody diarrhoea reported shorter incubation periods compared with cases without bloody diarrhoea, and likewise, cases aged between 40 and 59 years reported shorter incubation period compared with other age groups. It is recommended that public health officials consider the characteristics of cases involved in an outbreak in order to inform the outbreak investigation and the period of exposure to be investigated.
The back reflection x-ray divergent beam technique is examined as a tool for studying elastic strains. In particular, a method of calculating interplanar spacings using a least squares fit of experimental "conic" coordinates to Newman's general equation for back reflection (J. Appl. Cryst. 3 (1970) 191) is described. Using this technique, interplanar spacings can be obtained from partial conies. To determine the precision of this method an unstrained silicon single crystal is studied, and the errors associated with determining its interplanar spacings are discussed. The technique is then applied to elastically strained silicon and the results compared to theoretical predictions. It is shown that strains down to 2 × 10−5 are readily measured on high angle planes in silicon.
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.
This paper reports on: (1) an evaluation of a common elements treatment approach (CETA) developed for comorbid presentations of depression, anxiety, traumatic stress, and/or externalizing symptoms among children in three Somali refugee camps on the Ethiopian/Somali border, and (2) an evaluation of implementation factors from the perspective of staff, lay providers, and families who engaged in the intervention.
This project was conducted in three refugee camps and utilized locally validated mental health instruments for internalizing, externalizing, and posttraumatic stress (PTS) symptoms. Participants were recruited from either a validity study or from referrals from social workers within International Rescue Committee Programs. Lay providers delivered CETA to youth (CETA-Youth) and families, and symptoms were re-assessed post-treatment. Providers and families responded to a semi-structured interview to assess implementation factors.
Children who participated in the CETA-Youth open trial reported significant decreases in symptoms of internalizing (d = 1.37), externalizing (d = 0.85), and posttraumatic stress (d = 1.71), and improvements in well-being (d = 0.75). Caregivers also reported significant decreases in child symptoms. Qualitative results were positive toward the acceptability and appropriateness of treatment, and its feasibility.
This project is the first to examine a common elements approach (CETA: defined as flexible delivery of elements, order, and dosing) with children and caregivers in a low-resource setting with delivery by lay providers. CETA-Youth may offer an effective treatment that is easier to implement and scale-up versus multiple focal interventions. A fullscale randomized clinical trial is warranted.
Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.
This paper summarises developments in understanding sea level change during the Quaternary in Scotland since the publication of the Quaternary of Scotland Geological Conservation Review volume in 1993. We present a review of progress in methodology, particularly in the study of sediments in isolation basins and estuaries as well as in techniques in the field and laboratory, which have together disclosed greater detail in the record of relative sea level (RSL) change than was available in 1993. However, progress in determining the record of RSL change varies in different areas. Studies of sediments and stratigraphy offshore on the continental shelf have increased greatly, but the record of RSL change there remains patchy. Studies onshore have resulted in improvements in the knowledge of rock shorelines, including the processes by which they are formed, but much remains to be understood. Studies of Late Devensian and Holocene RSLs around present coasts have improved knowledge of both the extent and age range of the evidence. The record of RSL change on the W and NW coasts has disclosed a much longer dated RSL record than was available before 1993, possibly with evidence of Meltwater Pulse 1A, while studies in estuaries on the E and SW coasts have disclosed widespread and consistent fluctuations in Holocene RSLs. Evidence for the meltwater pulse associated with the Early Holocene discharge of Lakes Agassiz–Ojibway in N America has been found on both E and W coasts. The effects of the impact of storminess, in particular in cliff-top storm deposits, have been widely identified. Further information on the Holocene Storegga Slide tsunami has enabled a better understanding of the event, but evidence for other tsunami events on Scottish coasts remains uncertain. Methodological developments have led to new reconstructions of RSL change for the last 2000 years, utilising state-of-the-art GIA models and alongside coastal biostratigraphy to determine trends to compare with modern tide gauge and documentary evidence. Developments in GIA modelling have provided valuable information on patterns of land uplift during and following deglaciation. The studies undertaken raise a number of research questions which will require addressing in future work.
A range of endophenotypes characterise psychosis, however there has been limited work understanding if and how they are inter-related.
This multi-centre study includes 8754 participants: 2212 people with a psychotic disorder, 1487 unaffected relatives of probands, and 5055 healthy controls. We investigated cognition [digit span (N = 3127), block design (N = 5491), and the Rey Auditory Verbal Learning Test (N = 3543)], electrophysiology [P300 amplitude and latency (N = 1102)], and neuroanatomy [lateral ventricular volume (N = 1721)]. We used linear regression to assess the interrelationships between endophenotypes.
The P300 amplitude and latency were not associated (regression coef. −0.06, 95% CI −0.12 to 0.01, p = 0.060), and P300 amplitude was positively associated with block design (coef. 0.19, 95% CI 0.10–0.28, p < 0.001). There was no evidence of associations between lateral ventricular volume and the other measures (all p > 0.38). All the cognitive endophenotypes were associated with each other in the expected directions (all p < 0.001). Lastly, the relationships between pairs of endophenotypes were consistent in all three participant groups, differing for some of the cognitive pairings only in the strengths of the relationships.
The P300 amplitude and latency are independent endophenotypes; the former indexing spatial visualisation and working memory, and the latter is hypothesised to index basic processing speed. Individuals with psychotic illnesses, their unaffected relatives, and healthy controls all show similar patterns of associations between endophenotypes, endorsing the theory of a continuum of psychosis liability across the population.
Schizophrenia is a highly heritable disorder, linked to several structural abnormalities of the brain. More specifically, previous findings have suggested that increased gyrification in frontal and temporal regions are implicated in the pathogenesis of schizophrenia.
The current study included participants at high familial risk of schizophrenia who remained well (n = 31), who developed sub-diagnostic symptoms (n = 28) and who developed schizophrenia (n = 9) as well as healthy controls (HC) (n = 16). We first tested whether individuals at high familial risk of schizophrenia carried an increased burden of trait-associated alleles using polygenic risk score analysis. We then assessed the extent to which polygenic risk was associated with gyral folding in the frontal and temporal lobes.
We found that individuals at high familial risk of schizophrenia who developed schizophrenia carried a significantly greater burden of risk-conferring variants for the disorder compared to those at high risk (HR) who developed sub-diagnostic symptoms or remained well and HC. Furthermore, within the HR cohort, there was a significant and positive association between schizophrenia polygenic risk score and bilateral frontal gyrification.
These results suggest that polygenic risk for schizophrenia impacts upon early neurodevelopment to confer greater gyral folding in adulthood and an increased risk of developing the disorder.
The Arctic marine environment is undergoing a transition from thick multi-year to first-year sea-ice cover with coincident lengthening of the melt season. Such changes are evident in the Baffin Bay-Davis Strait-Labrador Sea (BDL) region where melt onset has occurred ~8 days decade−1 earlier from 1979 to 2015. A series of anomalously early events has occurred since the mid-1990s, overlapping a period of increased upper-air ridging across Greenland and the northwestern North Atlantic. We investigate an extreme early melt event observed in spring 2013. (~6σ below the 1981–2010 melt climatology), with respect to preceding sub-seasonal mid-tropospheric circulation conditions as described by a daily Greenland Blocking Index (GBI). The 40-days prior to the 2013 BDL melt onset are characterized by a persistent, strong 500 hPa anticyclone over the region (GBI >+1 on >75% of days). This circulation pattern advected warm air from northeastern Canada and the northwestern Atlantic poleward onto the thin, first-year sea ice and caused melt ~50 days earlier than normal. The episodic increase in the ridging atmospheric pattern near western Greenland as in 2013, exemplified by large positive GBI values, is an important recent process impacting the atmospheric circulation over a North Atlantic cryosphere undergoing accelerated regional climate change.
There are several hemispheric-scale satellite-derived snow-cover maps available, but none has been fully validated. For the period 23 October–25 December 2000, we compare snow maps of North America derived from the Moderate Resolution Imaging Spectroradiometer (MODIS) and operational snow maps from the U.S. National Oceanic and Atmospheric Administration (NOAA) National Operational Hydrologic Remote Sensing Center (NOHRSC), both of which rely on satellite data from the visible and near-infrared parts of the spectrum; we also compare MODIS maps with Defense Meteorological Satellite Program (DMSP) Special Sensor Microwave/Imager (SSM/I) passive-microwave snow maps for the same period. The maps derived from visible and near-infrared data are more accurate for mapping snow cover than are the passive-microwave-derived maps, but discrepancies exist as to the location and extent of the snow cover even between operational snow maps. The MODIS snow-cover maps show more snow in each of the 8 day periods than do the NOHRSC maps, in part because MODIS maps the effects of fleeting snowstorms due to its frequent coverage. The large (~30 km) footprint of the SSM/I pixel, and the difficulty in distinguishing wet and shallow snow from wet or snow-free ground, reveal differences up to 5.33 x 106 km2 in the amount of snow mapped using MODIS vs SSM/I data. Algorithms that utilize both visible and passive-microwave data, which would take advantage of the all-weather mapping capability of the passive-microwave data, will be refined following the launch of the Advanced Microwave Scanning Radiometer (AMSR) in the fall of 2001.
Unusual speleothems, associated with hyperalkaline (pH > 12) groundwaters
have formed within a shallow, abandoned railway tunnel at Peak Dale,
Derbyshire, UK. The hyperalkaline groundwaters are produced by the leaching
of a thin layer (<2 m) of old lime-kiln waste on the soil-bedrock surface
above the tunnel by rainwater. This results in a different reaction and
chemical process to that more commonly associated with the formation of
calcium carbonate speleothems from Ca-HCO3-type groundwaters and
degassing of CO2. Stalagmites within the Peak Daletunnel have
grown rapidly (averaging 33 mm y–1), following the closure of the
tunnel 70 years ago. They have an unusual morphology comprising a central
sub-horizontally-laminated column of micro- to nano-crystalline calcium
carbonate encompassed by an outer sub-vertical assymetricripple-laminated
layer. The stalagmites are composed largely of secondary calcite forming
pseudomorphs (<1 mm) that we believe to be predominantly after the 'cold
climate' calcium carbonate polymorph, ikaite (calcium carbonate hexahydrate:
CaCO3·6H2O), withminor volumes of small (<5 μm)
pseudomorphs after vaterite. The tunnel has a near constant temperature of
8–9°C, which is slightly above the previously published crystallization
temperatures for ikaite (<6°C). Analysis of a stalagmite actively growing
at the time ofsampling, and preserved immediately within a dry nitrogen
cryogenic vessel, indicates that following crystallization of ikaite,
decomposition to calcite occurs rapidly, if not instantaneously. We believe
this is the first occurrence of this calcium carbonate polymorph observed
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
Previous neuroimaging studies indicate abnormalities in cortico-limbic circuitry in mood disorder. Here we employ prospective longitudinal voxel-based morphometry to examine the trajectory of these abnormalities during early stages of illness development.
Unaffected individuals (16–25 years) at high and low familial risk of mood disorder underwent structural brain imaging on two occasions 2 years apart. Further clinical assessment was conducted 2 years after the second scan (time 3). Clinical outcome data at time 3 was used to categorize individuals: (i) healthy controls (‘low risk’, n = 48); (ii) high-risk individuals who remained well (HR well, n = 53); and (iii) high-risk individuals who developed a major depressive disorder (HR MDD, n = 30). Groups were compared using longitudinal voxel-based morphometry. We also examined whether progress to illness was associated with changes in other potential risk markers (personality traits, symptoms scores and baseline measures of childhood trauma), and whether any changes in brain structure could be indexed using these measures.
Significant decreases in right amygdala grey matter were found in HR MDD v. controls (p = 0.001) and v. HR well (p = 0.005). This structural change was not related to measures of childhood trauma, symptom severity or measures of sub-diagnostic anxiety, neuroticism or extraversion, although cross-sectionally these measures significantly differentiated the groups at baseline.
These longitudinal findings implicate structural amygdala changes in the neurobiology of mood disorder. They also provide a potential biomarker for risk stratification capturing additional information beyond clinically ascertained measures.
The radial density gradient (Gr) of Galactic cosmic rays in the ecliptic plane points outward from the Sun. This indicates an increasing density of cosmic ray particles beyond the Earth’s orbit. Due to this gradient and the direction of the Sun’s interplanetary magnetic field (IMF) above and below the IMF wavy neutral sheet, there exists an anisotropic flow of cosmic ray particles approximately perpendicular to the ecliptic plane (i.e. in the direction parallel to BIMF × Gr). This effect is called the north–south anisotropy (ξNS) and manifests as a diurnal variation in sidereal time in the particle intensity recorded by a cosmic ray detector. By analysing the yearly averaged sidereal diurnal variation recorded by five neutron monitors and six muon telescopes from 1957 to 1990, we have deduced probable values of the average rigidity spectrum and magnitude of ξNS. Furthermore, we have used determined yearly amplitudes of ξNS to infer the magnitude of Gr for particles with rigidities in excess of 10 GV.
We have deduced the yearly averaged value of the solar diurnal variation as observed by a surface muon telescope and three underground muon telescopes over the years 1957 to 1985. This has allowed us to examine the temporal variation in both the latitudinal gradient Gz and the product of the parallel mean free path and the radial gradient of galactic cosmic rays during three consecutive solar cycles. The median rigidities of the primary particles being detected by the telescopes are 50 GV in the case of the surface muon telescope and greater than 150 GV in the case of the underground muon telescopes. We have compared our results with those of a similar study made from observations of the solar diurnal variation by neutron monitors and an ion chamber, which have median rigidities of response between 17 and 70 GV (Bieber and Chen 1991a). The product has a solar magnetic cycle dependence and our values are lower than those observed by neutron monitors, in agreement with the Bieber and Chen observation that reverses after a solar magnetic field reversal, in accordance with drift theories.