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PubMed2007

Rationale and public health implications of changing CHD risk factor definitions.

The definition of disease is central to the practice of medicine and to public health policy. Practice guidelines set standards for disease identification and treatment. Quality care is often defined as adherence to these guidelines. Over the past few years, the diagnostic thresholds for several common medical conditions have been lowered, resulting in a substantial expansion in the market for health care. The most recent guidelines for high blood pressure, high cholesterol, and impaired fasting glucose each define a high percentage of the adult population as in need of regular medical attention. Under the latest proposed thresholds, virtually the entire adult population qualifies for a chronic condition diagnosis. We evaluate the health and financial outcomes associated with changes in diagnostic thresholds for the prevention of three risk factors for cardiovascular disease and stroke: blood pressure, serum cholesterol, and fasting plasma glucose. Estimates of the numbers of people affected, the cost implications, and the overall public health consequences are offered.

Coronary Disease↗
PubMed1998

Threshold analysis of Helicobacter pylori therapy.

OBJECTIVE: Conflicting recommendations have been made on whom to treat with antibacterials to eradicate Helicobacter pylori. The present analysis aims to explain the basis of such discrepancies. DESIGN AND SETTING: The decision in favour of or against antibacterial therapy in patients with upper gastrointestinal symptoms is modelled as a threshold analysis. The threshold is the lowest probability for a given diagnosis at which the decision in favour of antibacterial therapy yields a higher expected outcome than the decision against it. A strong indication for antibacterial therapy is shown by a low threshold value. MAIN OUTCOME MEASURES AND RESULTS: In patients with suspected peptic ulcer disease, both the high success rate of antibacterial therapy and its low cost make it the most favourable treatment option, its threshold being less than 35%. In ulcer patients receiving nonsteroidal anti-inflammatory drugs, the threshold is 73% if based on success rates of different treatment modalities, but only 7% if treatment costs are considered. The relatively poor success rate of antibacterial therapy in non-ulcer dyspepsia raises the diagnostic threshold for antibacterial therapy to 76% if based on therapeutic success rates. The small marginal cost of antibacterial therapy lowers the diagnostic threshold to 16%. CONCLUSION: If therapeutic success is the primary concern, patients with vague abdominal symptoms should not be given antibacterial therapy, unless H. pylori has been established as a probable cause of their symptoms. If healthcare costs are the driving force for choosing one type of therapy over another, a trial of antibacterials appears indicated irrespective of any firm validation of H. pylori playing a role in the patient's disease.

Anti-Bacterial Agents↗
PubMed2003

Adrenal insufficiency during septic shock.

OBJECTIVE: To determine whether a baseline (random) cortisol concentration <25 microg/dL in patients with septic shock was a better discriminator of adrenal insufficiency than the standard (250 microg) and the low-dose (1 microg) corticotropin stimulation tests as assessed by the hemodynamic response to steroid replacement. SETTING: Intensive care unit. PATIENTS: Fifty-nine patients with septic shock. Their mean age was 57 +/- 16.7 yrs; 29 were male. INTERVENTIONS: A baseline cortisol concentration was obtained. Patients then received an intravenous injection of 1 microg of corticotropin (low-dose test) followed 60 mins later by an injection of 249 microg of corticotropin (high-dose test). Cortisol concentrations were obtained 30 and 60 mins after low- and high-dose corticotropin. All patients were administered hydrocortisone (100 mg every 8 hrs) for the first 24 hrs while awaiting results of cortisol assessment. Patients were considered steroid responsive if the pressor agent could be discontinued within 24 hrs of the first dose of hydrocortisone. MEASUREMENTS AND MAIN RESULTS: Forty-seven percent of patients died. Twenty-two percent of patients met the diagnostic criteria of adrenal insufficiency by the low-dose test and 8% by the high-dose test. However, 61% of patients met the criteria of adrenal insufficiency when we used a baseline cortisol concentration of <25 microg/dL. Twenty-two patients (37%) were steroid responsive; the baseline serum cortisol was 14.1 +/- 5.2 microg/dL in the steroid-responsive patients compared with 33.3 +/- 18 microg/dL in the steroid-nonresponsive patients (p <.0001). Ninety-five percent of steroid-responsive patients had a baseline cortisol concentration <25 microg/dL. Fifty-four percent of steroid responders had a diagnostic low-dose test and 22% a diagnostic high-dose test. Receiver operating characteristic curve analysis revealed that a stress cortisol concentration of 23.7 microg/dL was the most accurate diagnostic threshold for determination of the hemodynamic response to glucocorticoid therapy. CONCLUSIONS: Adrenal insufficiency is common in patients with septic shock, the incidence depending largely on the diagnostic test and criteria used to make the diagnosis. There is clearly no absolute serum cortisol concentration that distinguishes an adequate from an insufficient adrenal response. However, we believe that a random cortisol concentration of <25 microg/dL in a highly stressed patient is a useful diagnostic threshold for the diagnosis of adrenal insufficiency.

Adrenal Cortex Function Tests↗
PubMed1998

The sensitivity and specificity of the caffeine-halothane contracture test: a report from the North American Malignant Hyperthermia Registry. The North American Malignant Hyperthermia Registry of MHAUS.

BACKGROUND: The caffeine-halothane contracture test (CHCT) is the only recognized laboratory test to diagnose malignant hyperthermia (MH). The authors report the results of their analysis of pooled data from the North American Malignant Hyperthermia Registry database to determine the sensitivity and specificity of the CHCT. METHODS: The MH Clinical Grading Scale was used to identify 32 case subjects who were "almost certain" to be MH susceptible based on clinical criteria alone. Their CHCT results were compared with those of a group of 120 control subjects considered to be at low risk for MH. Diagnostic thresholds of the CHCT were adjusted, and its component tests were combined to generate receiver operating characteristic curves. The maximal Youden index for each component test was chosen as the diagnostic threshold indicative of MH susceptibility. RESULTS: The highest sensitivity (97%; 95% CI, 84-100%) was achieved with a two-component test with thresholds of > or = 0.5 g contracture for 3% halothane, > or = 0.3 g contracture at 2 mM caffeine, or both, considered positive for MH. The test specificity was 78% (95% CI, 69-85%). The addition of other CHCT component tests did not improve CHCT sensitivity or specificity. CONCLUSION: The CHCT achieves high sensitivity and acceptable specificity as a clinical laboratory diagnostic test when it is performed according to published standards. However, it cannot be used as a screening test because of the low prevalence of MH in the general population.

Adult↗
PubMed2001

Child psychiatric symptoms and psychosocial impairment: relationship and prognostic significance.

BACKGROUND: Relatively little is known about the relationships between psychiatric symptoms, diagnosis and psychosocial impairment. AIMS: To examine these contemporaneous relationships and prognostic significance in a large general population sample. METHOD: Symptoms of major depression, conduct and oppositional defiant disorders were assessed by interview in two waves of the Virginia Twin Study of Adolescent behavioural Development (2800 children aged 8-16 years). RESULTS: Many children below the DSM-III-R diagnostic threshold, especially for depression, had symptom-related impairment, whereas many children reaching the symptom threshold for conduct and oppositional defiant disorders were little impaired. Impairment score was linearly related to symptom count, with no evidence of any additional impairment at the diagnostic threshold. For depression, only symptoms predicted later symptoms and diagnosis. For conduct and oppositional defiant disorders, impairment was additionally predictive of later symptoms and diagnosis. CONCLUSIONS: Impairment, in addition to symptoms, is important for both nosology and prognosis.

Activities of Daily Living↗
PubMed1998

Minimal sizes of deletions detected by comparative genomic hybridization.

Comparative genomic hybridization (CGH) has been used widely for the molecular cytogenetic analysis of tumors. Until now, the spatial resolution of this technique for diagnosing deletions of chromosomal sequences has not been assessed in detail. In the present study, we performed CGH analyses on five DNA samples derived from B-cell leukemias with 11q deletions, the sizes of which ranged from 3 Mbp to 14-18 Mbp. CGH experiments were evaluated by two established commercial analysis systems. Deletions down to a size of 10-12 Mbp were diagnosed based on a diagnostic threshold value of 0.8, if the vast majority of cells carried the deletion. For cases with smaller deletions, the ratio profiles were shifted toward underrepresentation at the respective chromosomal bands; however, the diagnostic threshold value was not reached. In all five cases, there was complete agreement between the two image analysis systems.

Chromosome Deletion↗
PubMed1979

Aids to the evaluation of diagnostic performance, as applied to immunological creatine kinase-MB assay in myocardial infarction.

Immunoassay of creatine kinase-MB provides numerical information, which makes it possible to estimate quantitatively the diagnostic performance following myocardial infarction. Two graphical methods for such an evaluation are presented. The relationship between technical sensitivity and specificity was analyzed using a continuous function, the receiver-operator characteristic curve. Using this function, a diagnostic threshold ("upper normal limit") was chosen, which balances both technical specificity and sensitivity on the first day following infarction. On the second and third days this threshold caused a progressive loss of technical sensitivity. The relationship between effectiveness and the prevalence of myocardial infarction in the tested population was evaluated with a nomogram correlating these two quantities. With the chosen diagnostic threshold, effectiveness is independent of prevalence on the first day, but the loss in technical sensitivity on subsequent days causes effectiveness to decay when the prevalence is high.

Creatine Kinase↗
PubMed2002

Short-term diagnostic stability of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders.

OBJECTIVE: Personality disorders are defined as enduring patterns of maladaptive behaviors and traits that are stable over time. This study prospectively examined the stability of four personality disorders (schizotypal, borderline, avoidant, and obsessive-compulsive) over a 1-year follow-up period. METHOD: Subjects (N=668) were recruited from multiple clinical settings at four collaborating institutions. Subjects met criteria for one or more of the four personality disorders or were part of a comparison group of subjects with major depressive disorder and no personality disorder. Diagnoses were established by using semistructured interviews. Follow-up assessments, conducted 6 and 12 months after the baseline assessment, included monthly ratings of all criteria for the four personality disorders and weekly ratings of the course of major depressive disorder. The current report is based on 621 subjects with complete data through 12 months of the follow-up period. RESULTS: Significantly more subjects in each personality disorder group remained at diagnostic threshold throughout the 12 months of the follow-up period than did those in the major depressive disorder group. A continuous measure of number of criteria met was highly correlated across the three assessments. The majority of personality disorder subjects, however, did not consistently remain at diagnostic threshold, and the mean number of criteria met decreased significantly for each group. CONCLUSIONS: Individual differences in personality disorder features appear to be highly stable, although the number of criteria present decreases over time. Personality disorders may be characterized by stable trait constellations that fluctuate in degree of maladaptive expression.

Adaptation, Psychological↗
PubMed1999

Deletions below 10 megabasepairs are detected in comparative genomic hybridization by standard reference intervals.

Comparative genomic hybridization (CGH) is a widely used technique for studying chromosomal imbalances. The sensitivity of the technique is, however, relatively low. Deletions down to a size of 10-12 Mbp have been detected by the use of fixed diagnostic thresholds. In this study, we applied standard reference intervals as detection criteria on a number of deletions in the range of 3 Mbp to 14-18 Mbp. All deletions were detected. Thus, detection by standard reference intervals confers a considerably higher sensitivity to CGH analysis compared to fixed diagnostic thresholds. Genes Chromosomes Cancer 25:410-413, 1999.

Chromosome Aberrations↗
PubMed2005

Identification of osteopenic women at high risk of fracture: the OFELY study.

UNLABELLED: About one-half of women with incident fractures have BMD above the WHO diagnostic threshold of osteoporosis. In the OFELY study, low BMD, increased markers of bone turnover, and prior fracture could be used to identify, within osteopenic women, those at high risk of fracture. INTRODUCTION: Recent data suggest that about one-half of women with incident fractures have BMD above the World Health Organization (WHO) diagnostic threshold of osteoporosis (T score<or=-2.5). We aimed to identify, within osteopenic women, those at high risk of fracture. MATERIALS AND METHODS: In the 671 postmenopausal women (mean age: 62 years) belonging to the Os des Femmes de Lyon (OFELY) population-based prospective cohort, we measured at baseline BMD by DXA at the spine and total hip, bone turnover markers (BTM) and clinical risk factors for osteoporosis. All fragility vertebral or nonvertebral fractures, confirmed by radiographs, were assessed during a median follow-up of 9.1 years (IQ: 2.3). RESULTS: 158 incident fractures were recorded in 116 women: 8% in normal, 48% in osteopenic, and 44% in osteoporotic women. Among osteopenic women, low BMD (-2.5<T score<or=-2.0) was associated with an increased fracture risk with an age-adjusted hazard ratio (HR) of 2.5 (1.3-4.6). In addition, age, prior fracture, and high BTM-but not other risk factors-were independently associated with an increased fracture risk with an age-adjusted HR of 2.2 (1.2-4.3) for prior fractures and 2.2 (1.4-3.8) for bone alkaline phosphatase (BALP) in the highest quartile. In the whole group of osteopenic women, a large majority of incident fractures occurred in those with a low BMD, prior fractures, or BALP in the highest quartile, with an age-adjusted HR of 5.3 (2.3-11.8). The 10-year probability of fracture in osteopenic women was 26% if at least one predictor was present, contrasting with 6% in those without any of the three risk factors. CONCLUSIONS: In postmenopausal women with osteopenia, low BMD, increased BTM, and prior fracture are associated with an increased risk of fracture in the subsequent 10 years. Their assessment may play an important role in identifying women at high risk of fracture who could not be adequately detected by BMD measurement alone and who may benefit from a therapeutic intervention.

Adult↗
PubMed1994

[Validity of epidemiologic criteria in the detection of hypertension].

We wish to find out the quality of the diagnostic test commonly used in epidemiological studies to detect hypertension, and in so doing, we study the validity of epidemiological criteria in the detection of hypertension (diagnostic test) and compare the diagnostic thresholds of the World Health Organization (WHO) and the Joint National Committee (JNC). Two methods of detection for arterial hypertension are used in this study of 674 people. One is population-based (mobile unit), and the other is opportunistic sampling. (systematic measurements of blood pressure in medical consultations). As a test of certainty, clinical confirmation is performed. The methodology of Haynes and Sackett is used in the validation study. The epidemiological criteria obtains a sensibility of 90.4 percent and a specificity of 94.4 percent with the diagnostic thresholds of WHO, and a sensibility of 97 percent and a specificity of 81.2 percent with those of JNC, which are defined as effective methods of screening in the detection of hypertension. The excess prevalence of HBP obtained using the diagnostic criteria of WHO is 4.5 percent (that is to say of 12.2 percent of the cases of hypertension found by the epidemiological criteria, that figure decreases to 7.7% percent with clinical confirmation). With the JNC criteria, it is 14.5 percent (from 34.1 percent, it goes to 19.6 percent). This excess can be used to adjust numbers found in epidemiological studies to their real values.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Prognostic value of troponin T in hemodialysis patients is independent of comorbidity.

BACKGROUND: Patients on long-term hemodialysis have a high mortality. Various clinical and biochemical markers are of prognostic value. Cardiac troponin T (cTnT) is a sensitive and specific marker for myocardial damage. Asymptomatic dialysis patients have a high prevalence of cTnT concentrations above the diagnostic threshold for myocardial damage. There is controversy over whether this represents a false positive cTnT or an underlying pathology with a poor outcome. It is not known whether cTnT reflects comorbidity in these patients. METHODS: A cohort of 73 long-term hospital hemodialysis patients had cTnT estimated once prior to a mid-week dialysis. Samples were analyzed using the second-generation cTnT assay from Boehringer Mannheim on an Elecsys 1010 analyzer. The standard diagnostic threshold for myocardial damage of 0.1 ng/mL was used. A commonly employed measure of comorbidity (Khan) was applied at the time cTnT was measured. Patients were followed for 15 months. Mortality was used as the clinical end point. Kaplan-Meier survival analysis was employed and differences between groups were assessed using the Cox-Mantel log-rank test. RESULTS: Of the 73 patients, 20 were positive for cTnT and 53 were negative, at the cut-off of 0.1 ng/mL. At fifteen months, 65% of the positive patients were dead, whereas only 15% of the negative patients were dead. Survival analysis confirmed that this difference was statistically significant (P < 0.00001), and that the effect of cTnT on survival was independent of comorbidity. CONCLUSIONS: There is a high prevalence of positive cTnT in stable hemodialysis patients. A single estimation of cTnT in this group has significant prognostic value, independent of comorbidity.

Adult↗
PubMed2005

Monitoring exposure of northern cardinals, Cardinalis cardinalis, to cholinesterase-inhibiting pesticides: enzyme activity, reactivations, and indicators of environmental stress.

Northern cardinals (Cardinalis cardinalis) frequently use agricultural field edges in northeast Arkansas, USA, and may be at risk of exposure to cholinesterase (ChE)-inhibiting pesticides. We monitored northern cardinal exposure to ChE-inhibiting pesticides by comparing plasma total ChE (TChE) activity to reference-derived benchmarks and TChE reactivations. Total ChE and acetylcholinesterase (AChE) were measured for 128 plasma samples from 104 northern cardinals from nine study sites. Of birds sampled from sites treated with ChE-inhibiting pesticides, 4.3% of the samples had TChE activities below the diagnostic threshold (2 standard deviations [SD] below the reference mean) and 8.7% of the samples had TChE reactivations. No difference was found in TChE (p = 0.553) and AChE (p = 0.288) activity between treated and reference sites; however, activity varied among treated sites (p = 0.003). These data do not suggest uniform exposure to individuals, but rather exposure was variable and likely influenced by mitigating factors at individual and site scales. Furthermore, monitoring of TChE reactivation appeared to be a more sensitive indicator of exposure than the diagnostic threshold. Fluctuating asymmetry (FA) was greater at agricultural sites than reference sites (p = 0.016), supporting the hypothesis that FA may be useful for assessing a combination of habitat- and contaminant-related environmental stress.

Acetylcholinesterase↗
PubMed2001

Home blood pressure monitoring. Current knowledge and directions for future research.

Home blood pressure (BP) monitoring has become popular in clinical practice and several automated devices for home BP measurement are now recommendable. Home BP is generally lower than clinic BP, and similar to daytime ambulatory BP. Home BP measurement eliminates the white coat effect and provides a high number of readings, and it is considered more accurate and reproducible than clinic BP. It can improve the sensitivity and statistical power of clinical drug trials and may have a higher prognostic value than clinic BP. Home monitoring may improve compliance and BP control, and reduce costs of hypertension management. Diagnostic thresholds and treatment target values for home BP remain to be established by longitudinal studies. Until then, home BP monitoring is to be considered a supplement. However, high home BP may support or confirm the diagnosis made in the doctor's office, and low home BP may warrant ambulatory BP monitoring. During long-term follow-up, home BP monitoring provides an opportunity for close attention to BP levels and variations. The first international guidelines have established a consensus document with recommendations, including a proposal of preliminary diagnostic thresholds, but further research is needed to define the precise role of home BP monitoring in clinical practice.

Blood Pressure Determination↗
PubMed1993

Diagnosis of pneumonia in mechanically ventilated patients. Repeatability of the protected specimen brush.

The repeatability (i.e., the variation in repeated measurements of the same quantity) of the protected specimen brush (PSB) with quantitative cultures was assessed in 22 consecutive mechanically ventilated (MV) patients with suspected nosocomial pneumonia. Five PSB samples were collected in the same lung area during the same bronchoscopic procedure and processed for bacteriologic identification and quantitative culture. A laboratory control was also performed in order to assess the in vitro repeatability of the quantitative culture technique. The five PSB always recovered the same microorganisms, indicating a 100% qualitative repeatability for the PSB. Conversely, the quantitative repeatability was somewhat lower since in 59% of the patients the quantitative results varied by more than one log10, which is the minimal precision affordable with quantitative cultures. The distinction between presence or absence of infection based on the 10(3) cfu/ml recommended diagnostic threshold was, however, only moderately affected by the variability of the quantitative results since only three of 22 patients (13.6%) displayed results spread out on each side of the 10(3) cfu/ml break point. Intrasubject variability of quantitative results was not explained by problems with the quantitative culture technique, which proved excellent repeatability in the laboratory. This study indicated that, although the PSB technique with quantitative cultures displays an acceptable level of repeatability, caution is advisable when interpreting PSB results in critically ill patients with suspected pneumonia, especially if one refers to the 10(3) cfu/ml recommended diagnostic threshold and if a decision to treat or to abstain from treating is to be made.

Bacteria↗
PubMed2006

Candida sp. isolated from bronchoalveolar lavage: clinical significance in critically ill trauma patients.

OBJECTIVE: Based on limited data, Candida sp. isolates from bronchoalveolar lavage (BAL) cultures in immunocompetent patients are thought to be contaminants rather than pathogens. The objective of this study was to determine the clinical significance of Candida sp. isolated from BAL cultures in critically ill trauma patients. DESIGN AND SETTING: Retrospective study in a level 1 trauma intensive care unit. PATIENTS AND PARTICIPANTS: All patients with Candida sp. isolated from BAL cultures over a 3-year period; 85 Candida positive BAL cultures from 62 patients were studied. MEASUREMENTS AND RESULTS: The primary outcomes were the incidence of Candida sp. in BAL, antifungal use, course of the possible infection, and mortality. Of 1077 BAL cultures 85 (8%) grew Candida sp., representing 64 episodes of possible Candida sp. ventilator-associated pneumonia. No colony counts exceeded the diagnostic threshold for bacterial VAP (>or=10(5) cfu/ml). Only 2 of 64 episodes (3%) were treated with systemic antifungals. Three other episodes (5%) were treated because of concomitant therapy for Candida sp. at other sites. The majority of episodes were not treated with antifungals and were considered contaminants (59/64, 92%). No patients developed subsequent candidemia, and most follow-up BALs (74%) were negative for Candida sp. Overall mortality (17%) was similar to previous patients with similar severity of injury at the study center (18%). CONCLUSIONS: The results of this study suggest that isolation of Candida sp. from BAL in quantities below the diagnostic threshold for VAP in this population does not require antifungal therapy.

Adult↗
PubMed1998

Is functional dyspepsia largely explained by gastro-oesophageal reflux disease?

Functional dyspepsia is a chronic disorder of unknown aetiology. The lack of endoscopic abnormalities in patients with this disorder has led many physicians to believe that gastro-oesophageal reflux disease may be responsible for most symptoms. Our group has addressed this issue, by pathophysiological studies in a large cohort of Dundee patients with persistent dyspeptic symptoms. Peptic ulcer and gallstones were excluded in all patients by appropriate tests. Ambulatory pH monitoring showed oesophageal acid reflux that lay above the conventional diagnostic threshold in approximately 20% of patients. This subset was diagnosed as having gastro-oesophageal reflux disease. In the remainder, moderate or severe reflux-like symptoms were reported by approximately 44% patients, who were categorized as reflux-like functional dyspepsia. Reflux symptoms were mild or absent in 36% patients, who were categorized as non-reflux-like dyspepsia. While oesophageal pH profiles lay within the conventional normal range in both of these functional dyspepsia subgroups, patients with reflux-like functional dyspepsia had significantly greater acid exposure values, including total oesophageal acid exposure time, percentage time at a pH of less than 4.0, DeMeester scores and pain reflux event correlation. Hence patients with reflux-like functional dyspepsia have oesophageal acid exposure that lies below the diagnostic threshold for gastro-oesophageal reflux disease but exceeds that of patients with non-reflux dyspepsia. The high pain/reflux event correlation in reflux-like functional dyspepsia suggests that subthreshold oesophageal acid exposure may be associated with troublesome reflux symptoms.

Dyspepsia↗
PubMed1998

DSM-IV substance use disorder criteria for adolescents: a critical examination based on a statewide school survey.

OBJECTIVE: The DSM-IV criteria for substance use disorders were incorporated into the 1995 Minnesota Student Survey in order to estimate the need for alcohol/drug treatment among adolescents in the state. This study used data from the survey to examine the utility of individual diagnostic criterion items, diagnostic categories, and diagnostic thresholds in a general adolescent population. METHOD: The survey was administered to ninth- and 12th-grade public school students. Participation was voluntary, and survey questionnaires were anonymous. The survey included questions about the use of substances during the past year and the presence of DSM-IV criterion symptoms for substance abuse and dependence. This study was based on responses from 74,008 students who answered these questions. RESULTS: Of the students who reported any substance use in the past 12 months, 13.8% of the ninth graders and 22.7% of the 12th graders met the criteria for a substance abuse diagnosis, and 8.2% of the ninth graders and 10.5% of the 12th graders met the criteria for dependence. The presence of multiple criterion symptoms was strongly associated with the use of multiple drugs. Analyses of positive and negative predictive value, sensitivity, and specificity did not support the diagnostic distinction between dependence criteria and abuse criteria. CONCLUSIONS: A combined set of criteria, with empirically derived diagnostic threshold categories based on total number of symptoms, may be more suitable for estimates of substance use disorders and need for treatment among adolescents.

Adolescent↗