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Biomedical subjects

D V Cicchetti

Publications and source records attributed to D V Cicchetti.

At least 55 records · Page 3Linked to original sources
PubMed1992

The outpatient treatment of depression. Implications of outcome research for clinical practice.

Multiple studies have demonstrated that individual psychotherapy, pharmacotherapy, and the two in combination are all effective treatments for depressed outpatients. However, the implications of these data for clinical practice have been incompletely considered, and the often drawn mistaken conclusion is that they support routine treatment with psychotherapy and pharmacotherapy together. Analyses of treatment success rates, treatment failure rates, and treatment dropout rates indicate that combined treatment offers no advantage over treatment with psychotherapy alone and only modest advantage over treatment with pharmacotherapy alone. Routine use of combined treatment, therefore, exposes patients to unnecessary costs and side effects. The data suggest that psychotherapy alone should usually be the initial treatment.

Ambulatory Care↗
PubMed1991

Demographic, clinical, and psychosocial predictors of the reliability of mothers' clinical judgments.

The purpose of this study was to investigate to what extent selected adverse demographic, clinical, and psychosocial data measured at the 2-week well child visit could predict poorer reliability of mothers' judgments during acute illness episodes over the next 32 months. The study was a randomized trial of the Acute Illness Observation Scales (AIOS); 369 mothers participated, 183 in the intervention group using the Acute Illness Observation Scales and 186 in the control group using a three-point global assessment scale. There were 704 acute illnesses judged simultaneously and independently by mothers and pediatricians. Standard Pearson r correlations were performed between the independent variables, taken singly and in all possible combinations, and the dependent variable, reliability of mothers' judgments as measured by weighted kappa (kappa W). Group assignment was entered as an independent variable. Analyses were performed separately for all first, second, and third acute illness visits to control for any "practice effect" (analysis 1). To control for consistency of observers, the first, second, and third visits of mothers with three visits were also analyzed (analysis 2). Depending on the visit number, adverse demographic, clinical, and psychosocial characteristics did correlate with poorer reliability independent of group assignment. The correlations ranged from small (analysis 1, first visit, multiple variable r2 = 4%) to large (analysis 2, second visit, multiple variable r2 = 29%). Controlling for both visit number and consistency of observers vs visit number alone (analysis 2 vs analysis 1) increased multivariate correlations to kappa W. The results support the untoward impact that adverse demographic, clinical, and psychosocial factors have on mothers' clinical judgment. These data may assist pediatricians in identifying parents who might benefit from more intensive teaching and support about acute illness episodes in their children.

Acute Disease↗
PubMed1990

Observer variability in echo-Doppler measurements of portal flow in cirrhotic patients and normal volunteers.

The intraobserver and interobserver variability in measuring the portal vein flow by the echo-Doppler technique was evaluated in a blind controlled study. A total of 22 cirrhotic patients and 14 normal volunteers were examined by two skilled operators using duplex Doppler within a period of 1-3 mo (6 cirrhotics and 7 normal volunteers by both observers). Area, mean velocity, and flow were measured (4 measurements: A, B on day 1; C, D on day 2). The intraclass correlation coefficient was used to assess both the statistical and clinical significance of intraobserver and interobserver agreement for the measurements of these three parameters. The level of intraobserver agreement for each parameter on normal subjects and cirrhotics was obtained from the two measurements on the same day and from the two measurements at the same time on consecutive days. Overall agreement between the four measurements was also calculated. Levels of interobserver agreement were obtained by calculating separately the intraclass correlation coefficient from each of the four pairs by measurements made on the same subject by the two observers over the same period of 2 days. The coefficient of variation was also used to compare the variability in these measurements. Overall, intraobserver agreement on normal subjects varied from good to excellent for observer 1, and from fair to good for observer 2. On cirrhotic patients, observer 1 was excellent at all times for all parameters. Observer 2 had lower intraclass correlation coefficient values, especially for velocity on consecutive days. For the best of the two observers on the portal flow, the coefficient of variation in cirrhotic patients ranged from 2%-30% with a mean +/- SEM of 12% +/- 4%. No acceptable interobserver agreement was found between the two observers in either of the two samples of subjects. These results support the use of this technique mainly for the determination of rapid and large changes in portal hemodynamics within a short period of time. The technique seems to have low precision in monitoring chronic changes in portal hemodynamics.

Adult↗
PubMed1990

High agreement but low kappa: I. The problems of two paradoxes.

In a fourfold table showing binary agreement of two observers, the observed proportion of agreement, p0, can be paradoxically altered by the chance-corrected ratio that creates kappa as an index of concordance. In one paradox, a high value of p0 can be drastically lowered by a substantial imbalance in the table's marginal totals either vertically or horizontally. In the second pardox, kappa will be higher with an asymmetrical rather than symmetrical imbalanced in marginal totals, and with imperfect rather than perfect symmetry in the imbalance. An adjustment that substitutes kappa max for kappa does not repair either problem, and seems to make the second one worse.

Models, Statistical↗
PubMed1990

High agreement but low kappa: II. Resolving the paradoxes.

An omnibus index offers a single summary expression for a fourfold table of binary concordance among two observers. Among the available other omnibus indexes, none offers a satisfactory solution for the paradoxes that occur with p0 and kappa. The problem can be avoided only by using ppos and pneg as two separate indexes of proportionate agreement in the observers' positive and negative decisions. These two indexes, which are analogous to sensitivity and specificity for concordance in a diagnostic marker test, create the paradoxes formed when the chance correction in kappa is calculated as a product of the increment in the two indexes and the increment in marginal totals. If only a single omnibus index is used to compared different performances in observer variability, the paradoxes of kappa are desirable since they appropriately "penalize" inequalities in ppos and pneg. For better understanding of results and for planning improvements in the observers' performance, however, the omnibus value of kappa should always be accompanied by separate individual values of ppos and pneg.

Observer Variation↗
PubMed1990

Mothers' clinical judgment: a randomized trial of the Acute Illness Observation Scales.

The purpose of this study was to investigate whether the reliability, sensitivity, and specificity of mothers' judgments about acute illnesses in their children could be improved by using the Acute Illness Observation Scales (AIOS). At the 2-week well child care visit in a primary care center and a private practice, 369 mothers were divided at random into an intervention group (n = 183) and a control group (n = 186). A teaching film and booklet were used to educate mothers in the intervention group about the AIOS; control group mothers were taught a 3-point global scoring system for evaluating the chance of serious illness. In the 32 months of follow-up, 704 acute illnesses were evaluated in tandem and independently by mothers and pediatricians before the history and physical examination; 20 of these illnesses were serious. The judgments of the intervention group were more reliable than those of the control group (weighted kappa = 0.50 vs 0.26, respectively), as was the specificity of their judgments (85% vs 52%, respectively; p less than 0.0001). No difference was noted in the sensitivity of intervention group and control group mothers' judgments (80% vs 90%, respectively). Teaching parents to assess specific clinical information, as represented in the AIOS, has its greatest effect on the reliability and specificity, not the sensitivity, of their judgments. Such teaching could lead to fewer unnecessary office visits during acute illnesses.

Acute Disease↗
PubMed1990

The Structured Clinical Interview for DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument.

The authors describe the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D), which investigates five groups of dissociative symptoms (amnesia, depersonalization, derealization, identity confusion, and identity alteration) and systematically rates both the severity of individual symptoms and the evaluation of overall diagnosis of dissociative disorder. Preliminary findings from a study of 48 subjects with and without psychiatric diagnoses indicate good to excellent reliability and discriminant validity for the SCID-D as a diagnostic instrument for the five dissociative disorders and as a tool for the evaluation of dissociative symptoms encountered within nondissociative syndromes.

Adult↗
PubMed1989

Blood cultures in private pediatric practice: an eleven-year experience.

We describe an 11-year experience with bacteremia in a two-physician suburban private pediatric practice. Patients studied were ages 3 to 24 months with a body temperature of greater than or equal to 39.4 degrees C and nonfocal illness. During these 11 years, 23 such babies had bacteremia, 21 with Streptococcus pneumoniae. Three risk factors for bacteremia were identified: absolute neutrophil counts greater than or equal to 10,500/microliters; cool season (November to April), and Yale observation score greater than 10. The positive predictive values for bacteremia were 33, 41 and 57%, respectively, when (1) absolute neutrophil count was greater than or equal to 10,500, (2) absolute neutrophil count was greater than or equal to 10,500 and it was the cool season, and (3) all 3 risk factors existed. Of 158 babies at low risk for bacteremia by these criteria, none was treated and none developed serious complications of bacteremia. Eight of the 23 bacteremic infants received no expectant antibiotic therapy and 15 received presumptive amoxicillin treatment in dosages ranging from 20 to 174 mg/kg/day. Twelve bacteremic infants either were not treated or received dosages of 100 mg/kg/day or less; complications developed in 5 of the 12 (persistent bacteremia, 2; facial cellulitis, 3). The remaining 11 bacteremic babies received approximately 150 mg/kg/day (range, 136 to 174) and none had complications (P = 0.03 by Fisher's exact test). The costs of identifying and treating infants suspected of having possible occult bacteremia were examined.

Anti-Bacterial Agents↗
PubMed1988

An evaluation of the Autism Behavior Checklist.

The Autism Behavior Checklist (ABC), an assessment instrument for autistic individuals, was evaluated in a group of 157 subjects, 94 clinically autistic and 63 nonautistic. The two groups differed significantly in ratings of pathology. Both false positive and false negative diagnostic classifications were made when the results of the checklist were compared with clinical diagnosis. Effects of developmental level and age were observed. The ABC appears to have merit as a screening instrument, though results of the checklist alone cannot be taken as establishing a diagnosis of autism. Important issues of reliability and validity remain to be addressed.

Adolescent↗
PubMed1988

When diagnostic agreement is high, but reliability is low: some paradoxes occurring in joint independent neuropsychology assessments.

Two paradoxes can occur when neuropsychologists attempt to assess the reliability of a dichotomous diagnostic instrument (e.g., one measuring the presence or absence of Dyslexia or Autism). The first paradox occurs when two pairs of examiners both produce the same high level of agreement (e.g., 85%). Nonetheless, the level of chance-corrected agreement is relatively high for one pair (e.g., 70) and quite low for the other (e.g., .32). To illustrate the second paradox, consider two examiners who are in 80% agreement in their overall diagnosis of Dyslexia. Assume, further, that they are in 100% agreement in the proportion of cases they both diagnose as Dyslexic (20%) and as Non-Dyslexic (80%). Somewhat paradoxically, the level of chance-corrected interexaminer agreement for this pair of examiners calculates to only .37. In distinct contrast, a second set of examiners also in 80% overall agreement, is in appreciable disagreement with respect to diagnostic assignments. Thus, the first neuropsychologist: (a) classifies 65% of the cases as Non-Dyslexic, as opposed to 45% so diagnosed by the second neuropsychologist; and (b) classifies the remaining 35% as Dyslexic, as compared to the 55% so classified by the second examiner. Despite these phenomena, this second pair of examiners produces a much higher level of chance-corrected agreement than did the first pair, that is, a value of .61. The underlying reasons for both of these paradoxes, as well as their resolution, are presented.

Autistic Disorder↗
PubMed1988

Null hypothesis disrespect in neuropsychology: dangers of alpha and beta errors.

To understand why there are so many inconsistencies and contradictory findings among hemispheric-asymmetry studies, data were analyzed from a large study of 300 left-handers. These data included information on familial sinistrality (FS), handwriting posture (HPO), a measure of cognitive performance, and five measures of hemispheric specialization. Using computer simulation methodology, 40 independent samples of 36 to 65 subjects each were drawn randomly with replacement. The sample data were analyzed and the results compared to those of the parent "population." Often, the samples poorly reflected the parent "population," and some procedures substantially inflated error rates. These procedures are discussed and specific guidelines suggested. These results are also discussed in the broader context of the necessity for investigators in neuropsychology to differentiate between the statistical and clinical significance of research findings; and to develop a more positive attitude toward the design, execution, and publication of replication studies.

Adult↗
PubMed1988

DSM-III and DSM-III-R diagnoses of autism.

The authors examined the reliability, sensitivity, and specificity of DSM-III and DSM-III-R criteria for autism in relation to each other and to clinical diagnoses in 114 children and adults (52 diagnosed by clinicians' best judgment as autistic and 62 as nonautistic but developmentally disordered). They used a standard, structured coding scheme to evaluate each patient. The reliability of specific criteria was generally high. Although DSM-III criteria were highly specific, they were less sensitive; the reverse was true for DSM-III-R. The authors conclude that the diagnostic concept of autism in DSM-III-R appears to have been substantially broadened.

Adolescent↗
PubMed1987

Observation, history, and physical examination in diagnosis of serious illnesses in febrile children less than or equal to 24 months.

To determine if observational assessment performed in a systematic manner adds to the efficacy of the traditional history and physical examination in detecting serious illnesses in febrile children, and to determine the sensitivity of the combined evaluation, we studied consecutive patients less than or equal to 24 months of age seen for evaluation of fever at the Primary Care Center-Emergency Room (PCC-ER) of the Yale-New Haven Hospital (n = 143) and a suburban private practice (n = 207). An attending pediatrician performed the observation using the previously reported Acute Illness Observation Scales (AIOS). Subsequently, the history and physical examination were done by an attending pediatrician, and findings were scored as to whether they suggested the presence of a serious illness. Thirty-six patients, 28 in the PCC-ER and eight in the private practice, had a serious illness. The combined AIOS, history, and physical examination had a higher sensitivity and r correlation for serious illness than did the traditional history and physical examination. Three children with serious illnesses, all of whom had no abnormalities on history and physical examination, were identified only by use of AIOS. We conclude that assessment of appearance in a child with fever, when performed in a careful, integrated, stepwise fashion, improves the sensitivity of the history and physical examination in detecting serious illnesses in febrile children.

Evaluation Studies as Topic↗
PubMed1987

Do mothers overestimate the seriousness of their infants' acute illnesses?

The purpose of this study was to determine if mothers generally perceive their infants as more ill than do pediatricians, and if the presence of fever has an impact on the perceptions of either the mother or pediatrician. One hundred eighty-seven mothers and their infants, from a primary care clinic (n = 109) and private practice (n = 78), were enrolled at the 2-week well-child visit and were asked to contact a physician participating in the study whenever their infants became acutely ill. The mothers were asked to rate the severity of their infants' illness according to a 3-point scale, first at home and then simultaneously, but independently, with a physician in the office. In general, mothers rated their infants equally as ill at home as in the office (kappa = 0.59). However, both their home ratings (kappa = 0.15) and office ratings (kappa = 0.29) were in poor agreement with the ratings of the physicians. The mothers consistently rated their infants as more ill than did the pediatricians (p less than 0.0001). Both the mothers and physicians perceived infants with higher temperatures (greater than or equal to 38.9 degrees C) as significantly (p = 0.0004) more ill than infants with lower temperatures (less than 38.9 degrees C). We conclude that mothers generally perceive their infants as more ill than do pediatricians, and that it is important for pediatricians to address the perceptions of mothers in order to establish effective communication with them.

Acute Disease↗