Comparing Screening Instruments to Predict Posttraumatic Stress Disorder

Background

Following traumatic exposure, a proportion of trauma victims develops posttraumatic stress disorder (PTSD). Early PTSD risk screening requires sensitive instruments to identify everyone at risk for developing PTSD in need of diagnostic follow-up.

Aims

This study compares the accuracy of the 4-item SPAN, 10-item Trauma Screening Questionnaire (TSQ) and 22-item Impact of Event Scale-Revised (IES-R) in predicting chronic PTSD at a minimum sensitivity of 80%.

Method

Injury patients admitted to a level-I trauma centre (N = 311) completed the instruments at a median of 23 days and were clinically assessed for PTSD at 6 months. Areas under the curve and specificities at 80% sensitivity were compared between instruments.

Results

Areas under the curve in all instruments were adequate (SPAN: 0.83; TSQ: 0.82; IES-R: 0.83) with no significant differences. At 80% sensitivity, specificities were 64% for SPAN, 59% for TSQ and 72% for IES-R.

Conclusion

The SPAN, TSQ and IES-R show similar accuracy in early detection of individuals at risk for PTSD, despite differences in number of items. The modest specificities and low positive predictive values found for all instruments could lead to relatively many false positive cases, when applied in clinical practice.     

Assessment of Diagnostic Skills in Specialist Examinations Should Include Lessons Learnt From Misdiagnosis

Background

Poor authenticity in high stake clinical exams adversely effects validity. We propose including known misleading diagnostic factors and contextual biases in the assessment of diagnostic skills amongst advanced specialty trainees. We hypothesise that this strategy offers a more realistic and critical assessment of diagnostic skill than strategies in which candidates are presented with directive, bias free information, allowing for assumptions which cannot be made in real life.

Methods

Eleven patient based practice clinical exam stations were presented to nine advanced ophthalmology trainees. Four patients had a history of misdiagnosis or near misdiagnosis of key ophthalmic findings, presumed to result from identifiable biases and misleading information. In those four stations, candidates were presented with authentic, file based information and were asked authentic questions, similar to those with which the patients presented. If the candidates were unsuccessful in identifying key findings, the questions were converted into directive questions about the same key findings (i.e. “examine the patient’s eyelids, what is your diagnosis?”), and the candidates re-assessed the patient and re-answered.

Results

Ninety-eight doctor-patient encounters took place. Of those, 35 encounters were analysed for the purpose of this study. In 63% of those encounters, key findings were missed when the question included authentic biases or misleading background information, but rephrasing the question to a directive exam format led to their correct identification (Fail converted to pass). Key findings were detected despite contextual biases or misleading background information in only 23% of encounters. In 14% the findings were missed with either question phrasing.

Conclusions

Presentation authentic questions provide a more realistic and less forgiving measure of diagnostic skills than directive exam questions. Given the prevalence of diagnostic errors and their importance to patient outcomes, known mechanisms contributing to diagnostic errors should be used as one of the assessment tools of advanced speciality trainees.     

Detecting Depression in Patients with Coronary Heart Disease: a Diagnostic Evaluation of the PHQ-9 and HADS-D in Primary Care,Findings From the UPBEAT-UK Study

Objective

People with coronary heart disease (CHD) are at heightened risk of depression, and this co-occurrence of conditions is associated with poorer outcomes including raised mortality. This study compares the diagnostic accuracy of two depression case finding instruments in CHD patients relative to a diagnostic standard, the revised Clinical Interview Schedule (CIS-R).

Methods

The Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the CIS-R depression module were administered to 803 patients identified from the CHD registers of GP practices in Greater London.

Results

Of 730 recruited patients without previously identified depression, 32 (4.4%) met ICD-10 depressive episode criteria according to the CIS-R. For the PHQ-9 and HADS-D lower cut-points than those routinely recommended were associated with improved case identifying properties. The PHQ-9 appeared the superior instrument using a cut-point of ≥8 (sensitivity=94%; specificity=84%). Using categorical scoring the PHQ-9 was 59% sensitive and 95% specific. For the HADS-D using cut-point ≥5, sensitivity was 81% and specificity was 77%.Areas under the curves (AUC) (standard error) were 0.95 (0.01) and 0.88 (0.02) for the PHQ-9 and HADS-D, and 0.91 (0.02) for PHQ-9 using the categorical algorithm. Statistically significant differences between AUCs of the PHQ-9 and the HADS-D favoured the former. Severity ratings compared across measures indicated inconsistency between recommended bandings: the PHQ-9 categorised a larger proportion of participants with mild and moderate depression.

Conclusion

This is the first large-scale investigation of the accuracy of these commonly used measures within a primary care CHD population. Our results suggest that although both scales have acceptable abilities and can be used as case identification instruments for depression in patients with CHD, the PHQ-9 appeared diagnostically superior. Importantly, optimal cut-off points for depression identification in this population appear to differ from standard values, and severity ratings differ between these measures.     

Validation and Diagnostic Efficiency of the Mini-SPIN in Spanish-Speaking Adolescents

Objectives

Social Anxiety Disorder (SAD) is one of the most common mental disorders in adolescence. Many validated psychometric tools are available to diagnose individuals with SAD efficaciously. However, there is a demand for shortened self-report instruments that identify adolescents at risk of developing SAD. We validate the Mini-SPIN and its diagnostic efficiency in overcoming this problem in Spanish-speaking adolescents in Spain.

Methods

The psychometric properties of the 3-item Mini-SPIN scale for adolescents were assessed in a community (study 1) and clinical sample (study 2).

Results

Study 1 consisted of 573 adolescents, and found the Mini-SPIN to have appropriate internal consistency and high construct validity. Study 2 consisted of 354 adolescents (147 participants diagnosed with SAD and 207 healthy controls). Data revealed that the Mini-SPIN has good internal consistency, high construct validity and adequate diagnostic efficiency.

Conclusions

Our findings suggest that the Mini-SPIN has good psychometric properties on clinical and healthy control adolescents and general population, which indicates that it can be used as a screening tool in Spanish-speaking adolescents. Cut-off scores are provided.     

Reliability and Validity of Instruments for Assessing Perinatal Depression in African Settings: Systematic Review and Meta-Analysis

Background

A major barrier to improving perinatal mental health in Africa is the lack of locally validated tools for identifying probable cases of perinatal depression or for measuring changes in depression symptom severity. We systematically reviewed the evidence on the reliability and validity of instruments to assess perinatal depression in African settings.

Methods and Findings

Of 1,027 records identified through searching 7 electronic databases, we reviewed 126 full-text reports. We included 25 unique studies, which were disseminated in 26 journal articles and 1 doctoral dissertation. These enrolled 12,544 women living in nine different North and sub-Saharan African countries. Only three studies (12%) used instruments developed specifically for use in a given cultural setting. Most studies provided evidence of criterion-related validity (20 [80%]) or reliability (15 [60%]), while fewer studies provided evidence of construct validity, content validity, or internal structure. The Edinburgh postnatal depression scale (EPDS), assessed in 16 studies (64%), was the most frequently used instrument in our sample. Ten studies estimated the internal consistency of the EPDS (median estimated coefficient alpha, 0.84; interquartile range, 0.71-0.87). For the 14 studies that estimated sensitivity and specificity for the EPDS, we constructed 2 x 2 tables for each cut-off score. Using a bivariate random-effects model, we estimated a pooled sensitivity of 0.94 (95% confidence interval [CI], 0.68-0.99) and a pooled specificity of 0.77 (95% CI, 0.59-0.88) at a cut-off score of ≥9, with higher cut-off scores yielding greater specificity at the cost of lower sensitivity.

Conclusions

The EPDS can reliably and validly measure perinatal depression symptom severity or screen for probable postnatal depression in African countries, but more validation studies on other instruments are needed. In addition, more qualitative research is needed to adequately characterize local understandings of perinatal depression-like syndromes in different African contexts.     

A Systematic Review of Instruments to Assess Organizational Readiness for Knowledge Translation in Health Care

Background

The translation of research into practices has been incomplete. Organizational readiness for change (ORC) is a potential facilitator of effective knowledge translation (KT). However we know little about the best way to assess ORC. Therefore, we sought to systematically review ORC measurement instruments.

Methods

We searched for published studies in bibliographic databases (Pubmed, Embase, CINAHL, PsychINFO, Web of Science, etc.) up to November 1^st, 2012. We included publications that developed ORC measures and/or empirically assessed ORC using an instrument at the organizational level in the health care context. We excluded articles if they did not refer specifically to ORC, did not concern the health care domain or were limited to individual-level change readiness. We focused on identifying the psychometric properties of instruments that were developed to assess readiness in an organization prior to implementing KT interventions in health care. We used the Standards for Educational and Psychological Testing to assess the psychometric properties of identified ORC measurement instruments.

Findings

We found 26 eligible instruments described in 39 publications. According to the Standards for Educational and Psychological Testing, 18 (69%) of a total of 26 measurement instruments presented both validity and reliability criteria. The Texas Christian University –ORC (TCU-ORC) scale reported the highest instrument validity with a score of 4 out of 4. Only one instrument, namely the Modified Texas Christian University – Director version (TCU-ORC-D), reported a reliability score of 2 out of 3. No information was provided regarding the reliability and validity of five (19%) instruments.

Conclusion

Our findings indicate that there are few valid and reliable ORC measurement instruments that could be applied to KT in the health care sector. The TCU-ORC instrument presents the best evidence in terms of validity testing. Future studies using this instrument could provide more knowledge on its relevance to diverse clinical contexts.     

The Quality of Life of Men Who Have Sex with Men in China: Reliability and Validity Testing of the SF-36 Questionnaire

Objective

The aim of the study was to assess the psychometric properties of the 36-Item Short Form Health Survey (SF-36) in the men who have sex with men (MSM) population in China.

Methods

A cross-sectional survey was conducted among 373 MSM from September to December, 2012, in Zhengzhou and Huludao City, China. Internal reliability of the questionnaire was calculated by Cronbach’s α coefficient. Validity was analyzed through construct validity, divisional validity, and collective validity testing.

Results

The overall Cronbach’s α coefficient of the SF-36 questionnaire was 0.943, while the Cronbach’s α coefficients for each of the dimensions were all > 0.70. Results showed that the SF-36 questionnaire was reliable and valid.

Conclusions

This study provided evidence that the SF-36 is an acceptable, valid and reliable instrument in evaluating the quality of life of MSM in Mainland China.     

Gene Expression Profiling in Leiomyosarcomas and Undifferentiated Pleomorphic Sarcomas: SRC as a New Diagnostic Marker

Background

Undifferentiated Pleomorphic Sarcoma (UPS) and high-grade Leiomyosarcoma (LMS) are soft tissue tumors with an aggressive clinical behavior, frequently developing local recurrence and distant metastases. Despite several gene expression studies involving soft tissue sarcomas, the potential to identify molecular markers has been limited, mostly due to small sample size, in-group heterogeneity and absence of detailed clinical data.

Materials and Methods

Gene expression profiling was performed for 22 LMS and 22 UPS obtained from untreated patients. To assess the relevance of the gene signature, a meta-analysis was performed using five published studies. Four genes (BAD, MYOCD, SRF and SRC) selected from the gene signature, meta-analysis and functional in silico analysis were further validated by quantitative PCR. In addition, protein-protein interaction analysis was applied to validate the data. SRC protein immunolabeling was assessed in 38 UPS and 52 LMS.

Results

We identified 587 differentially expressed genes between LMS and UPS, of which 193 corroborated with other studies. Cluster analysis of the data failed to discriminate LMS from UPS, although it did reveal a distinct molecular profile for retroperitoneal LMS, which was characterized by the over-expression of smooth muscle-specific genes. Significantly higher levels of expression for BAD, SRC, SRF, and MYOCD were confirmed in LMS when compared with UPS. SRC was the most value discriminator to distinguish both sarcomas and presented the highest number of interaction in the in silico protein-protein analysis. SRC protein labeling showed high specificity and a positive predictive value therefore making it a candidate for use as a diagnostic marker in LMS.

Conclusions

Retroperitoneal LMS presented a unique gene signature. SRC is a putative diagnostic marker to differentiate LMS from UPS.     

Diagnostic Accuracy of Computer Tomography Angiography and Magnetic Resonance Angiography in the Stenosis Detection of Autologuous Hemodialysis Access: A Meta-Analysis

Purpose

To compare the diagnostic performances of computer tomography angiography (CTA) and magnetic resonance angiography (MRA) for detection and assessment of stenosis in patients with autologuous hemodialysis access.

Materials and Methods

Search of PubMed, MEDLINE, EMBASE and Cochrane Library database from January 1984 to May 2013 for studies comparing CTA or MRA with DSA or surgery for autologuous hemodialysis access. Eligible studies were in English language, aimed to detect more than 50% stenosis or occlusion of autologuous vascular access in hemodialysis patients with CTA and MRA technology and provided sufficient data about diagnosis performance. Methodological quality was assessed by the Quality Assessment of Diagnostic Studies (QUADAS) instrument. Sensitivities (SEN), specificities (SPE), positive likelihood ratio (PLR), negative likelihood values (NLR), diagnostic odds ratio (DOR) and areas under the receiver operator characteristic curve (AUC) were pooled statistically. Potential threshold effect, heterogeneity and publication bias was evaluated. The clinical utility of CTA and MRA in detection of stenosis was also investigated.

Result

Sixteen eligible studies were included, with a total of 500 patients. Both CTA and MRA were accurate modality (sensitivity, 96.2% and 95.4%, respectively; specificity, 97.1 and 96.1%, respectively; DOR [diagnostic odds ratio], 393.69 and 211.47, respectively) for hemodialysis vascular access. No significant difference was detected between the diagnostic performance of CTA (AUC, 0.988) and MRA (AUC, 0.982). Meta-regression analyses and subgroup analyses revealed no statistical difference. The Deek’s funnel plots suggested a publication bias.

Conclusion

Diagnostic performance of CTA and MRA for detecting stenosis of hemodialysis vascular access had no statistical difference. Both techniques may function as an alternative or an important complement to conventional digital subtraction angiography (DSA) and may be able to help guide medical management.     

Comparison of Diagnostic Value of Conventional Ultrasonography and Shear Wave Elastography in the Prediction of Thyroid Lesions Malignancy

Introduction

Thyroid nodular disease (TND) is a very common disorder. However, since the rate of malignancy is reported to be 3-10%, only a minority of patients require aggressive surgical treatment. As a result, there is a need for diagnostic tools which would allow for a reliable differentiation between benign and malignant nodules. Although a number of conventional ultrasonographic (US) features are proved to be markers of malignancy, Shear Wave Elastography (SWE) is considered to be an improvement of conventional US. The aim of this study was to compare conventional US markers and SWE diagnostic values in the differentiation of benign and malignant thyroid nodules.

Materials and Methods

All patients referred for thyroidectomy, irrespective of the indications, underwent a US thyroid examination prospectively. Patients with TND were included into the study. Results of the US and SWE examinations were compared with post-surgical histopathology.

Results

One hundred and twenty two patients with 393 thyroid nodules were included into the study. Twenty two patients were diagnosed with cancer. SWE turned out to be a predictor of malignancy superior to any other conventional US markers (OR=54.5 using qualitative scales and 40.8 using quantitative data on maximal stiffness with a threshold of 50 kPa).

Conclusions

Although most conventional US markers of malignancy prove to be significant, none of them are characterized by both high sensitivity and specificity. SWE seems to be an important step forward, allowing for a more reliable distinction of benign and malignant thyroid nodules. Our study, assessing SWE properties on the highest number of thyroid lesions at the time of publication, confirms the high diagnostic value of this technique. It also indicates that a quantitative evaluation of thyroid lesions is not superior to simpler qualitative methods.     

A Community-Based Validation Study of the Short-Form 36 Version 2 Philippines (Tagalog) in Two Cities in the Philippines

Objective

To evaluate the validity and reliability of the Philippines (Tagalog) Short Form 36 Health Survey version 2 (SF-36v2^®) standard questionnaire among Filipinos residing in two cities.

Study Design and Setting

The official Philippines (Tagalog) SF-36v2 standard (4-week recall) version was pretested on 30 participants followed by formal and informal cognitive debriefing. To obtain the feedback on translation by bilingual respondents, each SF-36v2 question was stated first in English followed by Tagalog. No revisions to the original questionnaire were needed except that participants thought it was appropriate to incorporate "po" in the instructions to make it more polite. Face-to-face interviews of 562 participants aged 20-50 years living in two barangays (villages) in the highly urbanized city of Makati City (Metro Manila) and in urban and rural barangays in Tanauan City (province of Batangas) were subsequently conducted. Content validity, item level validity, reliability and factor structure of the SF-36v2 (Tagalog) were examined.

Results

Content validity of the SF-36v2 was assessed to be adequate for assessing health status among Filipinos. Item means of Philippines (Tagalog) SF-36v2 were similar with comparable scales in the US English, Singapore (English and Chinese) and Thai SF-36 version 1. Item-scale correlation exceeded 0.4 for all items except the bathing item in PF (correlation: 0.31). In exploratory factor analysis, the US two-component model was supported. However, in confirmatory factor analysis, the Japanese three-component model fit the Tagalog data better than the US two-component model.

Conclusions

The Philippines (Tagalog) SF-36v2 is a valid and reliable instrument for measuring health status among residents of Makati City (Metro Manila) and Tanauan City (Province of Batangas).     

Evaluation of the Psychometric Properties of the Functional Assessment of Cancer Therapy-Cervix Questionnaire in Brazil

Background

Although cervical cancer is ​​the second most common tumor among Brazilian women, studies that evaluate the quality of life of these women are still scarce. This situation is explained by the lack of specific and validated tools for this purpose in Portuguese (Brazil). The aim of this study was to evaluate the psychometric properties of the Portuguese version of the FACT-CX (Functional Assessment of Cancer Therapy-Cervix) questionnaire in a population of Brazilian women with cervical cancer.

Methods

The psychometric properties of the FACT-CX questionnaire were tested in a sample of 100 women diagnosed with cervical cancer who were previously treated in the Barretos Cancer Hospital. We analyzed the internal consistency (Cronbach''s alpha), reproducibility (intraclass correlation coefficient - ICC), confirmatory factor analysis, convergent validity (correlation with the SF-36 questionnaire), and discriminant validity by disease stage and two questions related to self-perception of health was also performed.

Results

The scales had Cronbach´s alpha coefficients ranging from 0.61 to 0.80. However, three scales did not have a statistically significant coefficient greater than 0.70. The ICC ranged from 0.68 to 0.82 and all considered satisfactory. Factor analysis did not generate consistent components. The FACT-G and FACT-CX total scores had good internal consistency and reproducibility, and also correlated well with the General Health and Vitality scales of the SF-36. However, only two FACT-CX scales had a significant correlation with SF-36. Discriminant analysis showed that FACT-CX failed to discriminate groups according to clinical stage but was able to divide the women according to the self-perception of health.

Conclusion

FATC-CX total score had good internal consistency, reproducibility and discriminant validity. In addition, it correlated well with General Health and Vitality scales of SF-36. However, three scales had questionable internal consistency and only two had significant correlation with SF-36.     

Development of the Chinese Family Support Scale in a Sample of Chinese Patients with Hypertension

Background

Despite strong recommendations to involve family social support in hypertension control, few questionnaires have been designed to measure family support in Chinese patients. The Chinese Family Support Scale is a self-rated questionnaire that assesses family support over a 6-month period.

Methods

A total of 282 patients with hypertension participated in this study and 136 of them completed the questionnaire twice within an interval of two to three weeks. Exploratory factor analysis was conducted to assess the structural validity of the scale. Concurrent validity was determined by measuring the correlation between the Chinese Family Support Scale, and Hospital Anxiety and Depression Scale using the Sperman’s Correlation Coefficient. Cronbach’s alpha and intraclass correlation coefficients were employed to evaluate the internal and test-retest reliability of the scale.

Results

Exploratory factor analysis revealed a three-factor solution accounting for 62% of the total variance. The three underlying sub-scale dimensions were kinship, nuclear family, and social resources. Significant correlation (r=-0.266; p<0.01) was found between the depression subscales of the Hospital Anxiety and Depression Scale and the extent of support perceived by the patients as measured by the Chinese Family Support Scale. The Chinese Family Support Scale had an acceptable internal consistency (Cronbach’s alpha = 0.84) and test-retest reliability (intraclass correlation coefficient = 0.82).

Conclusion

The study provides preliminary evidence that the12-item Chinese Family Support Scale is acceptable, valid and reliable for measuring the perceived family support in hypertension patients. It is a promising tool which can be easily incorporated into epidemiological surveys.     

A Qualitative Assessment of the Content Validity of the ICECAP-A and EQ-5D-5L and Their Appropriateness for Use in Health Research

Purpose

The ICECAP-A and EQ-5D-5L are two index measures appropriate for use in health research. Assessment of content validity allows understanding of whether a measure captures the most relevant and important aspects of a concept. This paper reports a qualitative assessment of the content validity and appropriateness for use of the eq-5D-5L and ICECAP-A measures, using novel methodology.

Methods

In-depth semi-structured interviews were conducted with research professionals in the UK and Australia. Informants were purposively sampled based on their professional role. Data were analysed in an iterative, thematic and constant comparative manner. A two stage investigation - the comparative direct approach - was developed to address the methodological challenges of the content validity research and allow rigorous assessment.

Results

Informants viewed the ICECAP-A as an assessment of the broader determinants of quality of life, but lacking in assessment of health-related determinants. The eq-5D-5L was viewed as offering good coverage of health determinants, but as lacking in assessment of these broader determinants. Informants held some concerns about the content or wording of the Self-care, Pain/Discomfort and Anxiety/Depression items (EQ-5D-5L) and the Enjoyment, Achievement and attachment items (ICECAP-A).

Conclusion

Using rigorous qualitative methodology the results suggest that the ICECAP-A and EQ-5D-5L hold acceptable levels of content validity and are appropriate for use in health research. This work adds expert opinion to the emerging body of research using patients and public to validate these measures.     

Toward Meeting the Needs of Homeless People with Schizophrenia: The Validity of Quality of Life Measurement

Objective

To provide new evidence regarding the suitability of using quality of life (QoL) measurements in homeless people with schizophrenia, we assess the acceptability and psychometric properties of a specific QoL instrument (S-QoL 18) in a population of homeless people with schizophrenia, and we compare their QoL levels with those observed in non-homeless people with schizophrenia.

Methods

This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. Two hundred and thirty-six homeless patients with schizophrenia were recruited over a 12 month-period. The S-QoL 18 was tested for construct validity, reliability, external validity and sensitivity to change. The QoL of the 236 homeless patients was compared with 236 French age- and sex-matched non-homeless patients with schizophrenia.

Results

The eight-factor structure of the S-QoL 18 was confirmed by confirmatory factor analysis (RMSEA = 0.035, CFI = 0.95, GFI = 0.99 and SRMR = 0.015). Internal consistency, reliability and sensitivity to change were satisfactory. External validity was confirmed via correlations between S-QoL 18 dimension scores and SF-36, symptomatology and recovery scores. The percentage of missing data did not exceed 5%. Finally, homeless patients had significantly lower QoL levels than non-homeless patients with schizophrenia.

Conclusions

These results demonstrate the satisfactory acceptability and psychometric properties of the S-QoL 18, suggesting the validity of QoL measurement among homeless patients with schizophrenia. Our study also reported that QoL levels in homeless patients with schizophrenia were dramatically low, highlighting the need for new policies to eradicate homelessness and tackle poverty.     

“I Can't Find Anything Wrong: It Must Be a Pulmonary Embolism”: Diagnosing Suspected Pulmonary Embolism in Primary Care,a Qualitative Study

Background

Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care.

Objective

to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected.

Method

Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient''s FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm.

Results

In the FPs'' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process.

Conclusion

This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.     

Visual Search as a Tool for a Quick and Reliable Assessment of Cognitive Functions in Patients with Multiple Sclerosis

Background

Despite the high frequency of cognitive impairment in multiple sclerosis, its assessment has not gained entrance into clinical routine yet, due to lack of time-saving and suitable tests for patients with multiple sclerosis.

Objective

The aim of the study was to compare the paradigm of visual search with neuropsychological standard tests, in order to identify the test that discriminates best between patients with multiple sclerosis and healthy individuals concerning cognitive functions, without being susceptible to practice effects.

Methods

Patients with relapsing remitting multiple sclerosis (n = 38) and age-and gender-matched healthy individuals (n = 40) were tested with common neuropsychological tests and a computer-based visual search task, whereby a target stimulus has to be detected amongst distracting stimuli on a touch screen. Twenty-eight of the healthy individuals were re-tested in order to determine potential practice effects.

Results

Mean reaction time reflecting visual attention and movement time indicating motor execution in the visual search task discriminated best between healthy individuals and patients with multiple sclerosis, without practice effects.

Conclusions

Visual search is a promising instrument for the assessment of cognitive functions and potentially cognitive changes in patients with multiple sclerosis thanks to its good discriminatory power and insusceptibility to practice effects.     

Effect of Aerobic Training on Heart Rate Recovery in Patients with Established Heart Disease; a Systematic Review

Background

Although a delayed decrease in heart rate during the first minute after graded exercise has been identified as a powerful predictor of overall mortality in cardiac patients, the potential to influence this risk factor by aerobic training remains to be proven.

Objective

The aim was to study the relationship between aerobic training and Heart Rate Recovery (HRR) in patients with established heart disease.

Methods

(Quasi) randomized clinical trials on aerobic exercise training in adults with established heart disease were identified through electronic database and reference screening. Two reviewers extracted data and assessed the risk of bias and therapeutic validity. Methodological validity was evaluated using an adapted version of the Cochrane Collaboration’s tool for assessing risk of bias and the therapeutic validity of the interventions was assessed with a nine-itemed, expert-based rating scale (CONTENT). Scores range from 0 to 9 (score ≥ 6 reflecting therapeutic validity).

Results

Of the 384 articles retrieved, 8 studies (449 patients) were included. Three of the included studies demonstrated adequate therapeutic validity and five demonstrated low risk of bias. Two studies showed both adequate therapeutic validity and a low risk of bias. For cardiac patients aerobic exercise training was associated with more improvement in HRR compared to usual care.

Conclusion

The present systematic review shows a level 1A evidence that aerobic training increases HRR in patients with established heart disease.     

Evaluation of Construct and Criterion Validity for the ‘Liverpool Osteoarthritis in Dogs’ (LOAD) Clinical Metrology Instrument and Comparison to Two Other Instruments

Objective

To test the ‘Liverpool Osteoarthritis in Dogs’ (LOAD) questionnaire for construct and criterion validity, and to similarly test the Helsinki Chronic Pain Index (HCPI) and the Canine Brief Pain Inventory (CBPI).

Design

Prospective Study.

Animals

222 dogs with osteoarthritis.

Procedure

Osteoarthritis was diagnosed in a cohort of dogs on the basis of clinical history and orthopedic examination. Force-platform analysis was performed and a “symmetry index” for peak vertical force (PVF) was calculated. Owners completed LOAD, CBPI and HCPI instruments. As a test of construct validity, inter-instrument correlations were calculated. As a test of criterion validity, the correlations between instrument scores and PVF symmetry scores were calculated. Additionally, internal consistency of all instruments was calculated and compared to those previously reported. Factor analysis is reported for the first time for LOAD, and is compared to that previously reported for CBPI and HCPI.

Results

Significant moderate correlations were found between all instruments, implying construct validity for all instruments. Significant weak correlations were found between LOAD scores and PVF symmetry index, and between CBPI scores and PVF symmetry index.

Conclusion and Clinical Relevance

LOAD is an owner-completed clinical metrology instrument that can be recommended for the measurement of canine osteoarthritis. It is convenient to use, validated and, as demonstrated here for the first time, has a correlation with force-platform data.     

Diagnosing Fatty Liver Disease: A Comparative Evaluation of Metabolic Markers,Phenotypes, Genotypes and Established Biomarkers

Background

To date, liver biopsy is the only means of reliable diagnosis for fatty liver disease (FLD). Owing to the inevitable biopsy-associated health risks, however, the development of valid noninvasive diagnostic tools for FLD is well warranted.

Aim

We evaluated a particular metabolic profile with regard to its ability to diagnose FLD and compared its performance to that of established phenotypes, conventional biomarkers and disease-associated genotypes.

Methods

The study population comprised 115 patients with ultrasound-diagnosed FLD and 115 sex- and age-matched controls for whom the serum concentration was measured of 138 different metabolites, including acylcarnitines, amino acids, biogenic amines, hexose, phosphatidylcholines (PCs), lyso-PCs and sphingomyelins. Established phenotypes, biomarkers, disease-associated genotypes and metabolite data were included in diagnostic models for FLD using logistic regression and partial least-squares discriminant analysis. The discriminative power of the ensuing models was compared with respect to area under curve (AUC), integrated discrimination improvement (IDI) and by way of cross-validation (CV).

Results

Use of metabolic markers for predicting FLD showed the best performance among all considered types of markers, yielding an AUC of 0.8993. Additional information on phenotypes, conventional biomarkers or genotypes did not significantly improve this performance. Phospholipids and branched-chain amino acids were most informative for predicting FLD.

Conclusion

We show that the inclusion of metabolite data may substantially increase the power to diagnose FLD over that of models based solely upon phenotypes and conventional biomarkers.