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PubMed2001

[Radioguided surgery for primary hyperparathyroidism. Experience in 75 cases].

STUDY AIM: To report feasibility and efficacy of radioguided mini invasive hyperparathyroidism surgery. PATIENTS AND METHOD: From November 1998 to August 2000, 75 patients with primary hyperparathyroidism have been operated on by radioguided surgery within 90 to 180 minutes following i.v. injection of a diagnostic dose of MIBI and after parathyroid scanning with planar and oblique views. Exclusion criteria were thyroid pathology requiring surgery and suspicion of multiple endocrine neoplasia. A 20% step-up between the background noise and tissue uptake was the diagnostic threshold for parathyroid hyperfunctioning tissue. RESULTS: A 20% step-up was observed in only 17% of cases overall; all cured, but two. Various angles of application of the probe can result in significant discrepancies of recorded uptake for the same spot. These results demonstrate a physiological step-up between the ipsilateral unaffected upper and lower quadrants of the neck (range: -17 to -8%), because of the proximity of supraortic vessels (upper neck-upper mediastinal gradient: -44 to -30%). Therefore, significant ratios are meaningful only between either the symmetrical left and right controlateral quadrants respectively, and not between the upper and the lower ipsilateral quadrants. Eleven per cent (8/75) of preoperative scannings were non-contributory, and probe detection was contributory in 3/8 cases only. CONCLUSION: Benefit of the technique is limited in routine, but it can be helpful in redo cases if the offending gland is not located in close surroundings of tissues physiologically taking up the radiopharmaceutical (salivary glands, great vessels and heart).

Adult↗
PubMed2002

The borderline diagnosis I: psychopathology, comorbidity, and personality structure.

Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.

Borderline Personality Disorder↗
PubMedDate not supplied

Identifying personality disorders: towards the development of a clinical screening instrument.

The study objective was to identify a set of personality disorder (PD) criteria from the DSM PD diagnostic sets that can be used to detect subjects with an increased likelihood of having a PD diagnosis. In a series of outpatients evaluated systematically in two waves for every criteria item for 12 DSM-III-R PDs, stepwise logistic regression identified 45 criteria as discriminative for their specific PDs, which are selected for further analysis to assess their ability to discriminate for any PD. Receiver operating characteristic (ROC) analysis is used to evaluate their discriminative power in an independent conjoined sample (N = 1,342) from six centers that assessed every PD criteria item by structured instrument (Structured Clinical Interview for DSM-III-R PDs [SCID-II, Personality Disorder Examination [PDE], and Structured Interview for DSM-III-R PDs [SIDP-R]). The cutoff that maximizes information gain is used to determine the diagnostic threshold (DT). Initially, 15 of 45 criteria are identified. At the 0.43 PD prevalence, a DT of 2 or more of the 15 PD criteria across samples is optimal. The maximum information gain (MIG) is .42 bits, and the AUR is 0.94+/-.007. Other performance indices at this cutoff are .90 sensitivity, .84 specificity, .81 positive predictive power (PPP), .91 negative predictive power (NPP), and .86 hit rate (HR). Taken collectively, the 15 PD criteria selected by the data reduction techniques suggest a narrowed set to be assessed in screening for the presence or absence of any PD with comparable or better psychometric properties than other tests routinely used for diagnosing medical and psychiatric disorders. If specific PD categorization is needed, a second-step comprehensive assessment should follow.

Algorithms↗
PubMedDate not supplied

The catatonia rating scale I--development, reliability, and use.

The study objective is to present reliability data on the Catatonia Rating Scale (CRS). The CRS is a 21-item clinician-administered rating scale. Items are individually defined and are scored from 0 (absent) to 4 (severe). A definition for each degree of severity is provided for each item. The diagnostic threshold for catatonia is 4 symptoms rated at least 2 (moderate). The CRS requires, at most, 45 minutes to administer. Reliability data were evaluated in a sample of 120 inpatients, 71 of whom were catatonic. Ratings were performed by 4 pairs of raters. Interrater reliability was high (Pearson correlation coefficient = .91 to .99, intraclass correlation coefficient = .94 to .99). Internal consistency was very good (Cronbach's alpha = .8890). Analysis of individual items showed that all were frequently endorsed and occurred across a wide range of severity. The CRS is a reliable rating scale for the diagnosis of catatonia. Advantages of the scale, areas of use, and clinical implications are discussed.

Adult↗
PubMedDate not supplied

Latent structure analysis of DSM-IV borderline personality disorder criteria.

The aim of this study was to evaluate the structure of DSM-IV borderline personality disorder (BPD) criteria. The study group consisted of 564 consecutively admitted inpatients and outpatients. BPD criteria discriminatory power was tested by using corrected item-to-total and item-to-diagnosis correlations. Weighted least-squares (WLS) confirmatory factor analysis (CFA) was used to assess the fit of DSM-IV BPD unidimensional model. The categorical model of BPD was tested by exploratory latent class analysis (LCA). Item analysis suggested a hierarchy in BPD criteria discriminatory power, even if with different rank order with respect to the DSM-IV model. CFA showed a unifactorial structure with congeneric items as the best fitting model for DSM-IV BPD criteria (chi2 = 18.89, df= 27, P > .87). LCA showed evidence for three latent classes; heterogeneity was observed only among subjects falling below DSM-IV diagnostic threshold for BPD. These results support the categorical model of BPD, even if with several differences with respect to DSM-IV.

Adult↗
PubMed1998

Intrapartum amniotic fluid index: a poor predictor of abnormal fetal size.

OBJECTIVE: Using receiver-operating characteristic (ROC) curves, we tried to determine the diagnostic threshold of amniotic fluid index (AFI) that will identify abnormal fetal size (birth weights under 2500 g or at least 4000 g) at 37 weeks or beyond. METHODS: We analyzed prospectively over 2 years all parturients with intact membranes and known AFI in early labor. Patients with the following conditions were excluded: pregestational or gestational diabetes, known anomalies, and preterm labor. Two ROC curves were constructed, and the areas (+/- standard error of the mean [SE]) under the curves were calculated. P < .05 was considered significant. RESULTS: Of the 1038 subjects meeting study criteria, 3.6% and 11.5% gave birth to infants who were small for gestational age (SGA) or macrosomic, respectively. Overall, 28.7% had oligohydramnios (AFI at most 5.0 cm) and 3.6% had hydramnios (AFI at least 24.0 cm). Small for gestational age was more common in patients with AFI at most 5.0 cm (6.4%) than in those with adequate fluid (AFI 5.1-23.9; 2.5%), or hydramnios (2.7%; P = .012). Macrosomic newborns were less likely to be born to women with oligohydramnios (7.7%) than to those with adequate amniotic fluid (13.1%) or hydramnios (13.5%). Areas under ROC curves are not significantly different from the area under the nondiagnostic line, indicating that AFI (0-34 cm) cannot differentiate between newborns under 2500 g and at or over 2500 g or under 4000 and at or more 4000 g. CONCLUSION: Intraparterium AFI appears to be a poor screening test to identify risk for delivery of SGA or macrosomic fetus.

Adult↗
PubMed1999

Troponin concentrations for stratification of patients with acute coronary syndromes in relation to therapeutic efficacy of tirofiban. PRISM Study Investigators. Platelet Receptor Inhibition in Ischemic Syndrome Management.

BACKGROUND: A major challenge for physicians is to identify patients with acute coronary syndromes who may benefit from treatment with glycoprotein-IIb/IIIa-receptor antagonists. We investigated whether troponin concentrations can be used to stratify patients for benefit from treatment with tirofiban. METHODS: We enrolled 2222 patients of the Platelet Receptor Inhibition in Ischemic Syndrome Management study with coronary artery disease and who had had chest pain in the previous 24 h. All patients received aspirin and were randomly assigned treatment with tirofiban or heparin. We took baseline measurements of troponin I and troponin T. We recorded death, myocardial infarction, or recurrent ischaemia after 48 h infusion treatment and at 7 days and 30 days. FINDINGS: 629 (28.3%) patients had troponin I concentrations higher than the diagnostic threshold of 1.0 microg/L and 644 (29.0%) troponin T concentrations higher than 0.1 microg/L. 30-day event rates (death, myocardial infarction) were 13.0% for troponin-I-positive patients compared with 4.9% for troponin-I-negative patients (p<0.0001), and 13.7% compared wth 3.5% for troponin T (p<0.001). At 30 days, in troponin-I-positive patients, tirofiban had lowered the risk of death (adjusted hazard ratio 0.25 [95% CI 0.09-0.68], p=0.004) and myocardial infarction (0.37 [0.16-0.84], p=0.01). This benefit was seen in medically managed patients (0.30 [0.10-0.84], p=0.004) and those undergoing revascularisation (0.37 [0.15-0.93] p=0.02) after 48 h infusion treatment. By contrast, no treatment effect was seen for troponin-I-negative patients. Similar benefits were seen for troponin-T-positive patients. INTERPRETATION: Troponin I and troponin T reliably identified high-risk patients with acute coronary syndromes, managed medically and by revascularisation, who would benefit from tirofiban.

Aged↗
PubMed2002

Parental attitudes towards early intervention in children at high risk for affective disorders.

BACKGROUND: Parents volunteered to complete surveys on attitudes toward treatment intervention in children at a theoretically high (20-30%) or very high (70%) risk for affective disorders because of an assumed uni-lineal or bi-lineal family history of bipolar illness. METHODS: Questions focused on examining at what ages and stage of symptom and syndrome evolution parents would wish their child to begin treatment with different types of therapeutic approaches and clinical trial designs. Sixty percent of the respondents had a personal history of unipolar or bipolar affective disorders. RESULTS: In 156 completed surveys, 83% of parents favored acute medication intervention and 67% favored long-term medication treatment for those children at very high risk at or before the development of severe symptoms (i.e. even prior to meeting full diagnostic thresholds). On the average, parents indicated that they would enter their child in a trial of: two types of psychotherapy at a point in illness evolution between moderate and severe symptoms, two types of open medications between severe symptoms and a definite diagnosis, two blind medications at a definite diagnosis, and a blind trial of placebo and medication after a definite diagnosis but before multiple recurrences of the illness. Parents, primarily on the basis of perceived safety, would allow their children to use medications that have been found to be effective in adults. LIMITATIONS: In addition to a number of methodological limitations, responders to the survey were self-selected. CONCLUSIONS: The results indicate a willingness on the part of most parents to treat a child at high risk for affective illness early in the course of symptom evolution, even prior to a full syndromic illness or diagnosis. This and other parental views of the risk-benefit and ethical dimensions of early intervention may be helpful in the initiation and design of studies aimed at assessing the efficacy of early interventions in childhood-onset bipolar illness and its prodromes.

Attitude to Health↗
PubMed1999

Diagnosis of ventilator-associated pneumonia.

The diagnosis of ventilator-associated pneumonia (VAP) is problematic despite numerous attempts at defining acceptable diagnostic criteria and the optimal technique for routine respiratory sampling. Clinical criteria have imperfect diagnostic reliability in ventilated patients, but remain crucial for defining those patients who may require respiratory sampling. Quantitative clinical scoring systems may improve the accuracy of clinical diagnosis in some ventilated patients. Review of published studies suggest that fibreoptic bronchoscopic techniques have greater diagnostic reliability than qualitative endotracheal aspirates, despite inconsistent results when comparing the same techniques in different centres. However, the cost and invasive nature of bronchoscopic methods precludes their use as first-line techniques in VAP. Non-bronchoscopic, non-directed techniques are cheaper, safer and more widely available alternatives to fibreoptic bronchoscopy techniques and have comparable accuracy. Quantitation of respiratory tract cultures is useful in excluding VAP in patients with equivocal signs of pneumonia. The diagnostic threshold of bacterial load that defines the presence of VAP should vary according to the pre-test probability of pneumonia, length of ventilation, antibiotic administration and immunocompetence of the patient.

Adult↗
PubMed2001

Serum melanotransferrin, p97 as a biochemical marker of Alzheimer's disease.

The protein melanotransferrin (p97) is associated with the brain lesions of Alzheimer's disease (AD) and is a potential marker of the disorder. We measured serum p97 concentrations in 211 subjects: 71 patients with AD, 56 patients with non-AD-type dementia, and 84 normal control subjects. Serum p97 concentrations were elevated 3- to 4-fold in AD (median 15.00 pg/microl, interquartile range 10.20-17.00 pg/microl) as compared to non AD dementia (2.85 pg/microl, 1.93-7.15 pg/microl) and normal controls (3.20 pg/microl, 2.55-3.95 pg/microl). The mean elevation was significant at 13.54 +/- 3.72 pg/microl, even in the 38 subjects with mild AD (CDR stage 0.5-1). Receiver operating characteristic analyses confirmed an optimal diagnostic threshold of 10.0 pg/microl, which yielded over-all accuracy of 0.882 to 0.915. Serum p97 is a candidate marker of AD, even in the early stage when clinical diagnosis is most uncertain.

Adult↗
PubMed2001

Reference values for clinic pulse pressure in a nonselected population.

A wide pulse pressure (PP) may constitute an independent predictor of cardiovascular morbidity and mortality. We assessed the reference values of brachial clinic PP, according to age and gender in a nonselected population (61,724 subjects) who were undergoing a routine systematic health examination. According to mean values, 50 mm Hg is likely the reference value for clinic PP in both men and women. Diagnostic thresholds for clinic PP (> or =65 mm Hg) determined either by adding 2 SD to the means or from the 95th percentiles are in close agreement with clinic PP values previously reported to be associated with increased cardiovascular morbidity and mortality.

Adolescent↗
PubMed1998

Neural network-assisted ("NNA") analysis of cervical smears: pooled effectiveness results and economic analysis.

Objective: To determine the sensitivity of cervical cancer smear screening with neural network-assisted ("NNA") rescreening.Methods: The Papnet system of NNA analysis of cervical smears has been in clinical use worldwide for over 3 years and has been the subject of over 22 published manuscripts reporting on data from over 202,000 smears. This investigation reviewed the results of these studies and classified each study according to study design using a systematic protocol based on reference validation, diagnostic threshold for abnormal, and outcome metric. This classification taxonomy allowed for weighted (based on number of cases in each study) pooling of studies for each study design class. The pooled effectiveness metrics were used to derive the sensitivity of cervical cancer screening with NNA rescreening, using a baseline unassisted screening sensitivity of 85%. Other effectiveness metrics determined by this analysis include NNA's sensitivity as a primary screener, comparisons with primary unassisted screening, and comparisons of NNA rescreening and unassisted rescreening.Results: Analyses of the weighted, pooled mean estimates for each of the principal outcome metrics indicate the sensitivity of cervical cancer screening with NNA ranges from 90% to 99%; most pooled estimates fall in the range of 97-99%. An economic analysis using the APL-based "Cervical Cancer Screen" computer model developed by Eddy (Eddy DM. Screening for cervical cancer. Ann Intern Med 1990;113:214-26) and these effectiveness estimates as inputs showed that NNA analysis involves an accepted level of resource expenditure (approximately $40,000 per life year saved) when added to unassisted screening on a triennial basis.Conclusion: The sensitivity of cervical cancer screening with NNA rescreening using the Papnet system yields sensitivities in excess of 90% and approaching 99%.

Journal Article↗
PubMed2002

Clinical significance of nocturnal oximeter monitoring for detection of sleep apnea syndrome in the elderly.

OBJECTIVES: The sensitivity and specificity of overnight monitoring of arterial oxygen saturation (SaO(2)) using an oximeter were evaluated in elderly subjects who are being investigated for possible sleep apnea syndrome (SAS). METHODS: Seventy-five consecutive elderly subjects with habitual snoring (47 men, 28 women; mean (+/-SE) age 75.5+/-0.9 years (range 65-94 years)) were studied. The SaO(2) was measured with an oximeter and a chart recorder during the night immediately before detailed polysomnographic studies. The SaO(2) recordings were classified by two observers as positive or negative using a number of significant oxyhemoglobin desaturation (SDS) of more than 2, 4, and 6%. The sensitivity of the oximeter alone for the recognition of the SAS was calculated as the number of true positive SaO(2) records divided by the total number of positive definitive (polysomnographic) records. The specificity was defined as the number of true negative SaO(2) records divided by the total number of negative definitive records. RESULTS: Of the 75 subjects, 24 had moderate SAS (apnea index (AI)>15) and 55 had mild to moderate SAS (AI>5). The sensitivity and specificity of the dosimeter as a screening test were determined with the two diagnostic thresholds of the AI. For AI exceeding 5 or 15, the respective sensitivity by using the criterion of SDS of more than 4% was 85.5 or 91.7%, with corresponding specificity of 85.0 or 92.2%. CONCLUSIONS: The nocturnal oximeter monitoring allows recognition of elderly subjects with a mild to moderate SAS, and 4% desaturation of SaO(2) is a candidate index to detect a significant number of apneas in elderly SAS patients with an oximeter.

Journal Article↗
PubMed1987

Psychiatric morbidity in an Italian general practice.

A two-stage screening strategy was applied in a single-handed general practice in northern Italy. The study was designed so that all the second-stage psychiatric interviews were conducted during the first phase of the study (group A patients), while self-report questionnaire (GHQ) and GP assessments only were collected during the second phase (group B patients). The estimated true case rate of psychiatric disorder (36%) did not differ between the two phases of the study, but there were marked differences in the general practitioner's diagnostic behaviour. During the first phase (when psychiatric interviews were being conducted in the practice), her behaviour was heavily biased towards diagnosing psychiatric disorder; 61% of the patients were regarded by her as psychiatric cases and the hidden psychiatric morbidity rate was only 9%. During the second phase of the study (no psychiatric interviews in the practice), only 37% of the patients were regarded as psychiatric cases by the GP, and the hidden morbidity rate was 59%. The results are interpreted as demonstrating that the presence of a psychiatrist conducting a two-stage screening survey in the practice had a profound effect on the diagnostic threshold. They also provide support for the use of the GHQ as a case-finding instrument in general practice.

Adult↗
PubMed2002

Understanding cross-national differences in depression prevalence.

UNLABELLED: BACKGROUND. Previous epidemiological studies indicate large cross-national differences in prevalence of depression. METHODS: At 15 centres in 14 countries. 25,916 primary care patients were screened for common mental disorders. A stratified random sample of 5,447 primary care patients completed a baseline diagnostic assessment and 3,197 completed a 12-month follow-up assessment. Psychiatric symptoms and diagnoses were assessed using the Composite International Diagnostic Interview (CIDI). Interviewer-rated disability was assessed using the Social Disability Schedule (SDS). RESULTS: Prevalence of current major depression varied 15-fold across centres. When centres were divided into three groups according to prevalence rates, the symptom pattern or latent structure of depressive illness was generally similar at low-, medium-, and high-prevalence centres. Depression was universally associated with disability, but this association varied significantly (t = 3.51, P = 0.0005) across centres. At higher-prevalence centres, depression was associated with lower levels of impairment. At 1 year follow-up, higher prevalence centres had both significantly higher rates of depression onset (t = 3.11, P = 0.002) and higher rates of persistence among those depressed at baseline (t = 2 49, P = 0.013). CONCLUSIONS: Large cross-national variations in depression prevalence cannot be attributed to 'category fallacy' (cross-national differences in the nature or validity of depressive disorder). Use of identical measures and diagnostic criteria may actually identify different levels of depression severity in different countries or cultures. Cross-national differences in the onset and outcome of depression may reflect either true prevalence differences or differences in diagnostic threshold.

Cross-Cultural Comparison↗
PubMed2005

A direct interview family study of obsessive-compulsive disorder. II. Contribution of proband informant information.

BACKGROUND: Overall findings of our first direct interview family study of obsessive-compulsive disorder (OCD) indicated that OCD is familial. In this replication study, we carefully examined the role of informant data in ascertaining OCD in relatives. METHOD: We interviewed 112 relatives of 57 OCD patients and 115 relatives of 41 not ill controls predominantly by telephone. Additional analyses included a combined sample of relatives about whom any diagnostic information was available (228 OCD and 239 controls). To examine the contribution of proband information about relatives, we considered two sets of best-estimate diagnoses. First, we ascertained best-estimate diagnoses for relatives using information from direct interviews and from all informants except the proband. Then, we re-diagnosed relatives based on all available information, including reports from the proband about their relatives. RESULTS: When relative diagnoses were derived without the benefit of proband informant reports, no evidence of familial OCD transmission was found. When diagnoses were made including information from the proband about the relative, evidence of familial OCD was found, but only when the diagnostic threshold was lowered to include cases with probable OCD or OCD symptoms. Other diagnoses (generalized anxiety disorder, social phobia, drug use disorder) were also higher among OCD relatives. CONCLUSIONS: This second study provides less robust support for familial transmission of OCD. Evidence for familial transmission of OCD was found only when diagnoses were made using information from the affected proband about their relatives. Taken in context of past findings, our own inconsistent results suggest that OCD may be heterogeneous with regard to familial transmission. Also, more careful attention should be paid to the contribution of informant reports, especially from relatives affected by the same disorder.

Adult↗
PubMed2002

Social phobia: overview of community surveys.

OBJECTIVE: Social phobia has in recent years been recognized as a considerable public health concern. This paper presents an overview of community studies that have estimated the prevalence of social phobia, its subtypes, and specific social fears in the adult general population. Sociodemographic findings are also summarized. METHOD: Forty-three epidemiological studies from 1980 to the present were located in electronic databases and by complementary searches of citations in journal articles and book chapters. RESULTS: Recent surveys estimate the lifetime prevalence of social phobia at about 7-13% in Western countries. However, prevalence rates vary considerably and are prone to several influencing methodological variables such as the diagnostic criteria, diagnostic threshold, assessment method, number of situational probes, and prevalence period selected by the researcher. CONCLUSION: Although there are difficulties in delineating social phobia from subsyndromal social anxiety or shyness, social phobia is even when narrowly defined remarkably common in the general population.

Adult↗
PubMed2002

Accuracy of computer-automated caries detection in digital radiographs compared with human observers.

The aim of this study was to compare diagnostic accuracy of a caries detection program with that of human observers. A total of 190 extracted teeth were radiographed with two Trophy RVG (RadioVisioGraphy) digital sensor systems. Four observers scored the approximal surfaces in all images on a disease severity scale. Each observer thereafter used the Logicon Caries Detector (LCD) program to analyse the surfaces in the digital images and recorded their outcome. To determine the true absence or presence of caries, histological validation was used. Sensitivities, specificities, positive and negative predictive values were calculated and differences between the diagnostic methods tested. Specificities for the outcome with the LCD were significantly lower for three observers than when they themselves assessed the RVG images and, correspondingly, the positive predictive values were lower for the LCD outcome for three of the observers. Sensitivity was also lower for two observers on the diagnostic threshold caries in dentine. It was concluded that the automated caries detection program is less accurate than human observers in detecting approximal caries lesions.

Bicuspid↗