Development and Validation of a Tuberculosis Medication Adherence Scale

Background

Medication adherence is critical in Tuberculosis (TB) treatment success, but existing tools are inadequate in identifying non-adherents, reasons for non-adherence or interventions to improve adherence. This study intended to fill the gap by developing and validating a TB medication adherence scale (TBMAS).

Methods

An initial 41-item TBMAS was designed through review of literature, consultation from an 8-member clinical expert panel and a 15-patient focus group, and pilot-testing in 25 TB patients. The questionnaire was validated in 438 patients who visited 23 community health centers for TB treatment in Wuhan from September 1, 2010, to August 31, 2011, using pharmacy refill records in a 15-week period as external criteria for medication adherence. After removing redundant and cross-loading items, the internal consistency, reliability and validity of TBMAS in identifying non-adherents were examined.

Results

The final TBMAS included 30 items scored on a 5-point Likert scale, and these items were loaded in nine distinct factors that explained 65% of cumulative variance among respondents. Cronbach''s alpha, test-retest reliability and split-half reliability were 0.87, 0.83, and 0.85, respectively. Convergent validity was supported by statistically significant associations between TBMAS scores and adherence measured by pharmacy refill records. Receiver Operating Characteristics curve analysis suggested a cut-off point at 113, with which TBMAS showed a positive predictive value of 65.5% and sensitivity of 82.9% in identifying non-adherents.

Conclusion

TBMAS demonstrated satisfactory internal consistency, reliability and validity in identifying TB patients with poor adherence and potential causes for non-adherence.     

The Effectiveness of an Online Support Group for Members of the Community with Depression: A Randomised Controlled Trial

Background

Internet support groups (ISGs) are popular, particularly among people with depression, but there is little high quality evidence concerning their effectiveness.

Aim

The study aimed to evaluate the efficacy of an ISG for reducing depressive symptoms among community members when used alone and in combination with an automated Internet-based psychotherapy training program.

Method

Volunteers with elevated psychological distress were identified using a community-based screening postal survey. Participants were randomised to one of four 12-week conditions: depression Internet Support Group (ISG), automated depression Internet Training Program (ITP), combination of the two (ITP+ISG), or a control website with delayed access to e-couch at 6 months. Assessments were conducted at baseline, post-intervention, 6 and 12 months.

Results

There was no change in depressive symptoms relative to control after 3 months of exposure to the ISG. However, both the ISG alone and the combined ISG+ITP group showed significantly greater reduction in depressive symptoms at 6 and 12 months follow-up than the control group. The ITP program was effective relative to control at post-intervention but not at 6 months.

Conclusions

ISGs for depression are promising and warrant further empirical investigation.

Trial Registration

Controlled-Trials.com ISRCTN65657330     

Accuracy of the Interpretation of Chest Radiographs for the Diagnosis of Paediatric Pneumonia

Introduction

World Health Organization (WHO) radiological classification remains an important entry criterion in epidemiological studies of pneumonia in children. We report inter-observer variability in the interpretation of 169 chest radiographs in children suspected of having pneumonia.

Methods

An 18-month prospective aetiological study of pneumonia was undertaken in Northern England. Chest radiographs were performed on eligible children aged ≤16 years with clinical features of pneumonia. The initial radiology report was compared with a subsequent assessment by a consultant cardiothoracic radiologist. Chest radiographic changes were categorised according to the WHO classification.

Results

There was significant disagreement (22%) between the first and second reports (kappa = 0.70, P<0.001), notably in those aged <5 years (26%, kappa = 0.66, P<0.001). The most frequent sources of disagreement were the reporting of patchy and perihilar changes.

Conclusion

This substantial inter-observer variability highlights the need for experts from different countries to create a consensus to review the radiological definition of pneumonia in children.     

A Novel Region-Growing Based Semi-Automatic Segmentation Protocol for Three-Dimensional Condylar Reconstruction Using Cone Beam Computed Tomography (CBCT)

Objective

To present and validate a semi-automatic segmentation protocol to enable an accurate 3D reconstruction of the mandibular condyles using cone beam computed tomography (CBCT).

Materials and Methods

Approval from the regional medical ethics review board was obtained for this study. Bilateral mandibular condyles in ten CBCT datasets of patients were segmented using the currently proposed semi-automatic segmentation protocol. This segmentation protocol combined 3D region-growing and local thresholding algorithms. The segmentation of a total of twenty condyles was performed by two observers. The Dice-coefficient and distance map calculations were used to evaluate the accuracy and reproducibility of the segmented and 3D rendered condyles.

Results

The mean inter-observer Dice-coefficient was 0.98 (range [0.95–0.99]). An average 90^th percentile distance of 0.32 mm was found, indicating an excellent inter-observer similarity of the segmented and 3D rendered condyles. No systematic errors were observed in the currently proposed segmentation protocol.

Conclusion

The novel semi-automated segmentation protocol is an accurate and reproducible tool to segment and render condyles in 3D. The implementation of this protocol in the clinical practice allows the CBCT to be used as an imaging modality for the quantitative analysis of condylar morphology.     

Muscle MR Imaging in Tubular Aggregate Myopathy

Purpose

To evaluate with Magnetic Resonance (MR) the degree of fatty replacement and edematous involvement in skeletal muscles in patients with Tubular Aggregate Myopathy (TAM). To asses the inter-observer agreement in evaluating muscle involvement and the symmetry index of fatty replacement.

Materials and Methods

13 patients were evaluated by MR to ascertain the degree of fatty replacement (T1W sequences) according to Mercuri''s scale, and edema score (STIR sequences) according to extent and site.

Results

Fatty replacement mainly affects the posterior superficial compartment of the leg; the anterior compartment is generally spared. Edema was generally poor and almost only in the superficial compartment of the leg. The inter-observer agreement is very good with a Krippendorff''s coefficient >0.9. Data show a total symmetry in the muscular replacement (McNemar-Bowker test with p = 1).

Conclusions

MR reveals characteristic muscular involvement, and is a reproducible technique for evaluation of TAM. There may also be a characteristic involvement of the long and short heads of the biceps femoris. It is useful for aimed biopsies, diagnostic hypotheses and evaluation of disease progression.     

Development and Validation of a Smartphone Addiction Scale (SAS)

Objective

The aim of this study was to develop a self-diagnostic scale that could distinguish smartphone addicts based on the Korean self-diagnostic program for Internet addiction (K-scale) and the smartphone''s own features. In addition, the reliability and validity of the smartphone addiction scale (SAS) was demonstrated.

Methods

A total of 197 participants were selected from Nov. 2011 to Jan. 2012 to accomplish a set of questionnaires, including SAS, K-scale, modified Kimberly Young Internet addiction test (Y-scale), visual analogue scale (VAS), and substance dependence and abuse diagnosis of DSM-IV. There were 64 males and 133 females, with ages ranging from 18 to 53 years (M = 26.06; SD = 5.96). Factor analysis, internal-consistency test, t-test, ANOVA, and correlation analysis were conducted to verify the reliability and validity of SAS.

Results

Based on the factor analysis results, the subscale “disturbance of reality testing” was removed, and six factors were left. The internal consistency and concurrent validity of SAS were verified (Cronbach''s alpha = 0.967). SAS and its subscales were significantly correlated with K-scale and Y-scale. The VAS of each factor also showed a significant correlation with each subscale. In addition, differences were found in the job (p<0.05), education (p<0.05), and self-reported smartphone addiction scores (p<0.001) in SAS.

Conclusions

This study developed the first scale of the smartphone addiction aspect of the diagnostic manual. This scale was proven to be relatively reliable and valid.     

Unilateral Condylar Hyperplasia: A 3-Dimensional Quantification of Asymmetry

Purpose

Objective quantifications of facial asymmetry in patients with Unilateral Condylar Hyperplasia (UCH) have not yet been described in literature. The aim of this study was to objectively quantify soft-tissue asymmetry in patients with UCH and to compare the findings with a control group using a new method.

Material and Methods

Thirty 3D photographs of patients diagnosed with UCH were compared with 30 3D photographs of healthy controls. As UCH presents particularly in the mandible, a new method was used to isolate the lower part of the face to evaluate asymmetry of this part separately. The new method was validated by two observers using 3D photographs of five patients and five controls.

Results

A significant difference (0.79 mm) between patients and controls whole face asymmetry was found. Intra- and inter-observer differences of 0.011 mm (−0.034–0.011) and 0.017 mm (−0.007–0.042) respectively were found. These differences are irrelevant in clinical practice.

Conclusion

After objective quantification, a significant difference was identified in soft-tissue asymmetry between patients with UCH and controls. The method used to isolate mandibular asymmetry was found to be valid and a suitable tool to evaluate facial asymmetry.     

The acceptability of Internet-based treatment and characteristics of an adult sample with obsessive compulsive disorder: an Internet survey

Background

Obsessive-compulsive disorder (OCD) is a disabling anxiety disorder, but most individuals delay seeking treatment. Internet-based cognitive behavioural therapy (iCBT) is an innovative service delivery method that may help to improve access to care, but the acceptability to consumers of such programs has not yet been established.

Methodology

People with symptoms of OCD were invited to complete an online survey enquiring about demographic characteristics, symptom severity, and acceptability of Internet-based treatment. Demographic and symptom severity data were compared with people with OCD identified in a national epidemiological survey and with a sample of patients with OCD from a specialist outpatient anxiety clinic.

Participants

129 volunteers to an online Internet survey, 135 patients at a specialist anxiety disorders outpatient clinic, and 297 cases identified in a national epidemiological survey.

Main Measures

Demographic characteristics, and severity of symptoms as measured by the Kessler 10-Item scale, the 12-item World Health Organisation Disability Assessment Schedule - Second Edition and the Yale Brown Obsessive Compulsive Scale - Self Report Version.

Principal Findings

The Internet sample was similar demographically but reported more severe symptoms than the comparison groups, although had similar severity of symptoms of OCD compared with other clinical samples reported in the literature. Participants reported Internet-based treatment for OCD would be highly acceptable.

Conclusions

Internet-based treatment may reduce barriers to accessing treatment to people with OCD. Individuals in this study were similar demographically to other samples and had similar severity of symptoms as those identified in other clinical samples, suggesting that Internet-based treatment using techniques employed in face-to-face treatment may be effective in this group. Internet-based treatments for OCD need to be developed and evaluated.     

Reporting the Reliability of Accelerometer Data with and without Missing Values

Objectives

Participants with complete accelerometer data often represent a low proportion of the total sample and, in some cases, may be distinguishable from participants with incomplete data. Because traditional reliability methods characterize the consistency of complete data, little is known about reliability properties for an entire sample. This study employed Generalizability theory to report an index of reliability characterizing complete (7 days) and observable (1 to 7 days) accelerometer data.

Design

Cross-sectional.

Methods

Accelerometer data from the Study of Early Child Care and Youth Development were analyzed in this study. Missing value analyses were conducted to describe the pattern and mechanism of missing data. Generalizability coefficients were derived from variance components to report reliability parameters for complete data and also for the entire observable sample. Analyses were conducted separately by age (9, 11, 12, and 15 yrs) and daily wear time criteria (6, 8, 10, and 12 hrs).

Results

Participants with complete data were limited (<34%) and, most often, data were not considered to be missing completely at random. Across conditions, reliability coefficients for complete data were between 0.74 and 0.87. Relatively lower reliability properties were found across all observable data, ranging from 0.52 to 0.67. Sample variability increased with longer wear time criteria, but decreased with advanced age.

Conclusions

A reliability coefficient that includes all participants, not just those with complete data, provides a global perspective of reliability that could be used to further understand group level associations between activity and health outcomes.     

Decreased Functional Brain Connectivity in Adolescents with Internet Addiction

Background

Internet addiction has become increasingly recognized as a mental disorder, though its neurobiological basis is unknown. This study used functional neuroimaging to investigate whole-brain functional connectivity in adolescents diagnosed with internet addiction. Based on neurobiological changes seen in other addiction related disorders, it was predicted that connectivity disruptions in adolescents with internet addiction would be most prominent in cortico-striatal circuitry.

Methods

Participants were 12 adolescents diagnosed with internet addiction and 11 healthy comparison subjects. Resting-state functional magnetic resonance images were acquired, and group differences in brain functional connectivity were analyzed using the network-based statistic. We also analyzed network topology, testing for between-group differences in key graph-based network measures.

Results

Adolescents with internet addiction showed reduced functional connectivity spanning a distributed network. The majority of impaired connections involved cortico-subcortical circuits (∼24% with prefrontal and ∼27% with parietal cortex). Bilateral putamen was the most extensively involved subcortical brain region. No between-group difference was observed in network topological measures, including the clustering coefficient, characteristic path length, or the small-worldness ratio.

Conclusions

Internet addiction is associated with a widespread and significant decrease of functional connectivity in cortico-striatal circuits, in the absence of global changes in brain functional network topology.     

Cytomegalovirus and Herpes Simplex Virus Effect on the Prognosis of Mechanically Ventilated Patients Suspected to Have Ventilator-Associated Pneumonia

Objective

Cytomegalovirus (CMV) and herpes simplex virus (HSV) are common viruses that can affect critically ill patients who are not immunocompromised. The aim of this study was to determine whether the identification of CMV and/or HSV in mechanically ventilated critically ill patients suspected of having pneumonia was associated with an increased mortality.

Design

Prospective epidemiological study.

Setting

Medical intensive care unit of a tertiary medical center.

Patients

Ninety-three patients with suspected pneumonia.

Interventions

Patients with suspected pneumonia had bronchoalveolar lavage and blood samples taken to confirm the diagnosis. Antigenemia was used to detect CMV in the blood. Bronchoalveolar lavage samples were submitted to testing using quantitative real-time Polymerase Chain Reaction.

Measurements and Main Results

We identified 22 patients with a CMV infection, 26 patients with an HSV infection and 45 patients without CMV or HSV infection (control group). Mortality at day 60 was higher in patients with a CMV infection than in patients from the control group (55% vs. 20%, P<0.01). Mortality at day 60 was not significantly increased in the group with HSV infection. Duration of ICU stay and ICU mortality were significantly higher in patients with CMV infections when compared to patients from the control group, whereas ventilator free days were significantly lower in patients with CMV infections when compared to patients from the control group.

Conclusions

In critically ill patients, a CMV infection is associated with an increased mortality. Further interventional studies are needed to evaluate whether treatment could improve the prognosis.     

Evaluation of Mitotic Activity Index in Breast Cancer Using Whole Slide Digital Images

Introduction

Mitotic Activity Index (MAI) is an important independent prognostic factor and an integral part of the breast cancer grading system. Thus, correct estimation of this prognostically relevant feature is essential for guiding treatment decision and assessing patient prognosis.The aim of this study was to validate the use of high resolution Whole Slide Images (WSI) in estimating MAI in breast cancer specimens.

Methods

MAI was evaluated in 100 consecutive breast cancer specimens by three observers on two occasions, microscopically and on WSI with a wash out period of 4 months. MAI was also translated to mitotic scores as in grading. Inter- and intra-observer agreement between microscopic and digital MAI counts and scores was measured.

Results

Almost perfect inter-observer agreements were obtained from counting MAI using a conventional microscope (intra-class correlation coefficient (ICCC) 0.879) as well as on WSI (ICCC 0.924). K coefficients reflected good inter-observer agreements among observers'' microscopic mitotic scores (average kappa 0.642). Comparable results were also observed among digital mitotic scores (average kappa 0.635). There was strong to perfect intra-observer agreements between MAI counts and mitotic scores for the two diagnostic modalities (ICCC 0.716–0.863, kappa 0.506–0.617). There were no significant differences in mitotic scores using both diagnostic modalities.

Conclusion

Scoring mitoses using WSI in breast cancer seems to be just as reliable and reproducible as when using a microscope. Further development of software and image quality will definitely encourage the use of WSI in routine pathology practice.     

Mixing Nulliparous and Multiparous Women in Randomised Controlled Trials of Preeclampsia Prevention Is Debatable: Evidence from a Systematic Review

Background

Nulliparity is a major risk factor of preeclampsia investigated in numerous trials of its prevention.

Objective

We aimed to assess whether these trials considered nulliparity in subject selection or analysis of results.

Search Strategy

01 April 2013 search of MEDLINE via PubMed, EMBASE and the Cochrane Library. 01 April 2013 search of trials registered in Clinicaltrials.gov.

Selection Criteria

Randomised controlled trials and metaanalyses of preeclampsia prevention with no restriction to period of publication or language. Metaanalyses were selected to fully identify relevant trials.

Data Collection and Analysis

One reader appraised each selected article/registered protocol using a pretested, standardized data abstraction form developed in a pilot test. For each article, he recorded whether both nulliparous and multiparous were included and, in case of mixed populations, whether randomisation was stratified, and whether subgroup analyses had been reported. For registered protocols, he only assessed whether it was planned to include mixed populations.

Main Results

88 randomised controlled trials were identified, representing 83,396 included women. In 58 of the 88 articles identified (65.9%), preeclampsia was the primary outcome. In 31 of these (53.4%), the investigation combined nulliparous and multiparous women; only two reports in 31 (6.5%) stated that randomisation was stratified on parity and only four (12.9%) described a subgroup analysis by parity. Of the 30 registered trials, 20 (66.6%) planned to include both nulliparous and multiparous women.

Conclusion

Parity is largely ignored in randomised controlled trials of preeclampsia prevention, which raises difficulties in interpreting the results.     

Precursor or sequela: pathological disorders in people with Internet addiction disorder

Background

This study aimed to evaluate the roles of pathological disorders in Internet addiction disorder and identify the pathological problems in IAD, as well as explore the mental status of Internet addicts prior to addiction, including the pathological traits that may trigger Internet addiction disorder.

Methods and Findings

59 students were measured by Symptom CheckList-90 before and after they became addicted to the Internet. A comparison of collected data from Symptom Checklist-90 before Internet addiction and the data collected after Internet addiction illustrated the roles of pathological disorders among people with Internet addiction disorder. The obsessive-compulsive dimension was found abnormal before they became addicted to the Internet. After their addiction, significantly higher scores were observed for dimensions on depression, anxiety, hostility, interpersonal sensitivity, and psychoticism, suggesting that these were outcomes of Internet addiction disorder. Dimensions on somatisation, paranoid ideation, and phobic anxiety did not change during the study period, signifying that these dimensions are not related to Internet addiction disorder.

Conclusions

We can not find a solid pathological predictor for Internet addiction disorder. Internet addiction disorder may bring some pathological problems to the addicts in some ways.     

Internet-based CBT for depression with and without telephone tracking in a national helpline: randomised controlled trial

Background

Telephone helplines are frequently and repeatedly used by individuals with chronic mental health problems and web interventions may be an effective tool for reducing depression in this population.

Aim

To evaluate the effectiveness of a 6 week, web-based cognitive behaviour therapy (CBT) intervention with and without proactive weekly telephone tracking in the reduction of depression in callers to a helpline service.

Method

155 callers to a national helpline service with moderate to high psychological distress were recruited and randomised to receive either Internet CBT plus weekly telephone follow-up; Internet CBT only; weekly telephone follow-up only; or treatment as usual.

Results

Depression was lower in participants in the web intervention conditions both with and without telephone tracking compared to the treatment as usual condition both at post intervention and at 6 month follow-up. Telephone tracking provided by a lay telephone counsellor did not confer any additional advantage in terms of symptom reduction or adherence.

Conclusions

A web-based CBT program is effective both with and without telephone tracking for reducing depression in callers to a national helpline.

Trial Registration

Controlled-Trials.com ISRCTN93903959     

Weekly self-monitoring and treatment adjustment benefit patients with partly controlled and uncontrolled asthma: an analysis of the SMASHING study

Background

Internet-based self-management has shown to improve asthma control and asthma related quality of life, but the improvements were only marginally clinically relevant for the group as a whole. We hypothesized that self-management guided by weekly monitoring of asthma control tailors pharmacological therapy to individual needs and improves asthma control for patients with partly controlled or uncontrolled asthma.

Methods

In a 1-year randomised controlled trial involving 200 adults (18-50 years) with mild to moderate persistent asthma we evaluated the adherence with weekly monitoring and effect on asthma control and pharmacological treatment of a self-management algorithm based on the Asthma Control Questionnaire (ACQ). Participants were assigned either to the Internet group (n = 101) that monitored asthma control weekly with the ACQ on the Internet and adjusted treatment using a self-management algorithm supervised by an asthma nurse specialist or to the usual care group (UC) (n = 99). We analysed 3 subgroups: patients with well controlled (ACQ ≤ 0.75), partly controlled (0.75>ACQ ≤ 1.5) or uncontrolled (ACQ>1.5) asthma at baseline.

Results

Overall monitoring adherence was 67% (95% CI, 60% to 74%). Improvements in ACQ score after 12 months were -0.14 (p = 0.23), -0.52 (p < 0.001) and -0.82 (p < 0.001) in the Internet group compared to usual care for patients with well, partly and uncontrolled asthma at baseline, respectively. Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma (+278 μg, p = 0.001), but not in patients with well or partly controlled asthma. After one year there were no differences in daily inhaled corticosteroid use or long-acting β₂-agonists between the Internet group and usual care.

Conclusions

Weekly self-monitoring and subsequent treatment adjustment leads to improved asthma control in patients with partly and uncontrolled asthma at baseline and tailors asthma medication to individual patients'' needs.

Trial registration

Current Controlled Trials ISRCTN79864465     

Prevalence and Factors of Addictive Internet Use among Adolescents in Wuhan,China: Interactions of Parental Relationship with Age and Hyperactivity-Impulsivity

Purposes

This study examined the prevalence of addictive Internet use and analyzed the role of parental relationship in affecting this behavior among a random sample of adolescents in Wuhan, China.

Methods

Students (n = 1,101) were randomly selected from four schools, including 638 boys and 463 girls with a mean age of 13.8 (standard deviation = 1.2) years. Addictive Internet use, parental relationship, hyperactivity-impulsivity were measured by validated instruments. Prevalence rate, ANOVA and multiple linear regression method were used to analyze the level of Internet addiction and its association with parental relationship, hyperactivity-impulsivity, as well as the interaction of parental relationship with chronological age and hyperactivity-impulsivity.

Results

The prevalence rate of Internet addiction was 13.5% (16.5% for boys and 9.5% for girls, p<0.01). Compared to non-addictive users, addictive Internet users were scored significantly lower on parental relationships and significantly higher on hyperactivity-impulsivity. Interaction analysis indicated that better parental relationship was associated with more reductions in risk of addictive Internet use for younger students than for older students, and with more risk of Internet addiction among higher than among lower hyperactivity-impulsivity students.

Conclusions

Findings of this study indicate that adolescent addictive Internet use is a significant public health threat in China. Prevention interventions targeting parental relationship must consider adolescent’s age and hyperactivity-impulsivity tendency.     

Ocular Surface Displacement with and without Contact Lenses during Non-Contact Tonometry

Purpose

To evaluate the displacement of the central ocular surface during non-contact tonometry with and without soft contact lenses and determine the factors associated with the displacement of the central ocular surface and intraocular pressure (IOP) reading changes caused by wearing soft contact lenses (CLs).

Methods

One eye each in 21 subjects was studied. The cornea was photographed using a high-speed camera at 5,000 frames/sec during non-contact tonometry without contact lenses (NCL), with -5.0 diopters (D), -0.5 D and +5.0 D CL. The displacement of the ocular surface and the factors affecting displacement at the IOP reading and maximum displacement time were investigated.

Results

The IOP readings while wearing +5 D CL were significantly higher than those obtained while wearing -5 D CL. The ocular surface displacement between +5 D CL and other groups were significantly different. A significant positive correlation was found between the ocular surface displacement of subjects at the IOP reading time and the IOP obtained with the non-contact tonometer. A significant negative correlation was found between the ocular surface curvature and the IOP obtained using the non-contact tonometer. The radius of curvature of the ocular surface affected the displacement during the IOP reading and maximum displacement time.

Conclusions

Our results indicate that soft contact lens use changes the ocular surface behavior and IOP readings during non-contact tonometry. The radius of curvature of the eye affects the ocular surface displacement and IOP readings in this situation.