When stroke survivors' self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Background Stroke survivors' self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as 'impaired self-awareness' (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling). Methods Forty-five subacute stroke survivors participated (Age M (s.d.) =  71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures. Results Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R 2  = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R 2  = 0.66). Conclusions Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships.

Patient-specific spinal rods in adult spinal deformity surgery reduce proximal junctional failure: a review of patient outcomes and surgical technique in a prospective observational cohort

Background

Spinal rods used for adult spinal deformity (ASD) correction are usually manufactured straight and bent manually during surgery. Pre-bent patient-specific spinal rods (PSSR) developed with software provide the surgeon with an intraoperative deformity correction consistent with the surgical plan. Our aim was to report clinical and radiological outcomes using PSSR. We investigated rates of junctional complications both proximally [kyphosis (PJK) and failure (PJF)] and distally [failure (DJF)].

Methods

Prospective case series of 20 consecutive patients who underwent ≥4 level ASD surgery with PSSR at a single institution between January 2019 and December 2022. Preoperative, 6-week, 6-month, 12-month, 24-month, and final follow-ups assessed patient satisfaction (Ottawa decision regret questionnaire) and patient reported outcome measures (PROMs) [visual analogue scale (VAS; Back/Leg), Oswestry disability index (ODI), and 12-Item Short Form Survey (SF-12)]. Sagittal spinopelvic parameters [sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence and lumbar lordosis mismatch (PI-LL)] measured by serial EOS scans were performed preoperatively then compared to planned correction and postoperative measures. Interoperative cages (narrow/wide) were placed for interbody support. PJK risk score assessed likelihood of developing kyphosis. Serial computed tomography (CT) imaging assessed complication (fusion/subsidence).

Results

The mean age of the patients (75% female) was 71.9±6.9 years, and the mean follow-up was 25.2±8.6 [7-40] months. Preoperative mean PROMs showed statistically significant overall improvement (P<0.001) postoperatively to final follow-up. Four patients without wide footprint cages at L4/5 or L5/S1, suffered DJF and reported regret undergoing surgery. Statistically significant difference (P<0.001) between preoperative and surgical plan in SVA and PI-LL but not in PT (P=0.058). No statistically significant difference in surgical plan versus the postoperative SVA, PI-LL, and PT (due to difficulty achieving the surgical plan, and also to maintaining the correction). One patient suffered PJF. There was a mean proximal kyphotic angle (PKA) of 17.8±13.0 degrees and PJK risk score of 3.7±1.0 with 40% who experienced PJK. No rod breakages were observed.

Conclusions

In this series, PSSR improved PROMs and treated ASD. Sagittal parameters planned preoperatively correlated with postoperative correction. PJF was reduced, compared to the literature (35%), but PJK was observed over time. DJF occurred and was related to the absence of interbody cages at the lumbosacral junction and decisional regret.

The adequacy of user seal checking for N95 respirators compared to formal fit testing: A multicentred observational study

OBJECTIVE

The objective of this study was to evaluate the adequacy of the user seal check (USC) in predicting N95 respirator fit.

DESIGN

This was a prospective, observational study conducted from May to September 2020.

SETTING

The study setting included three private intensive care units (ICUs) in Victoria, Australia.

PARTICIPANTS

ICU staff members in three private ICUs in Melbourne and regional Victoria participated in this study.

MAIN OUTCOME MEASURES

The main outcome measure is the proportion of participants who passed a USC and subsequently failed fit testing of an N95 respirator.

INTERVENTION

Three different respirators were available: two N95 respirator brands and CleanSpace HALO® powered air-purifying respirator. Participants were sequentially tested on N95 respirators followed by powered air-purifying respirators until either successful fit testing or failure of all three respirators. The first N95 tested was based on the availability on the day of testing. The primary outcome was failure rate of fit testing on the first N95 respirator type passing a USC.

RESULTS

Of 189 participants, 22 failed USC on both respirators, leaving 167 available for the primary outcome. Fifty-one of 167 (30.5%, 95% confidence interval = 23.7-38.1) failed fit testing on the first respirator type used that had passed a USC.

CONCLUSION

USC alone was inadequate in assessing N95 respirator fit and failed to detect inadequate fit in 30% of participants. Mandatory fit testing is essential to ensure adequate respiratory protection against COVID-19 and other airborne pathogens.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12620001193965.

Reduction in Offset Is Associated With Worse Functional Outcomes Following Total Hip Arthroplasty

BACKGROUND

Conflicting reports exist about the effect of offset variation on functional outcomes following total hip arthroplasty. Reproducing native hip offset is thought to optimize function by restoring biomechanics and appropriately tensioning the hip abductor muscles. The aim of this study is to assess the effect of failing to restore global hip offset in comparison to the native contralateral hip.

METHODS

A retrospective analysis of a prospective patient cohort was performed on patients undergoing an elective primary total hip arthroplasty. A total of 414 patients who had a minimum of 12 months of follow-up were included. Postoperative plain radiographs were analyzed for offset and compared to the contralateral native hip. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Veterans RAND 12 (VR-12) scores were assessed preoperatively and at 12 months postoperatively.

RESULTS

Regression analyses indicated that a reduction in offset of >20 mm resulted in worse WOMAC pain (P = .005) and motion (P = .015) scores compared to those with maintained offset. WOMAC function (P = .063), global (P = .025), and VR-12 scores were not affected (physical P = .656; mental P = .815). Reduction in offset up to 20 mm and increased offset were not significantly associated with patient-reported outcome measures (P-values ranged from .102 to .995).

CONCLUSION

This study demonstrated an association between reduction in offset by >20 mm and worse WOMAC pain and motion scores following total hip arthroplasty. Surgeons should avoid decreases in offset >20 mm in order to optimize functional outcomes.

Predicting strength outcomes for upper limb nerve transfer surgery in tetraplegia

We report a retrospective study of 112 nerve transfers in 39 participants to investigate predictors of strength outcomes after nerve transfer surgery for upper limb reanimation in tetraplegia. We measured clinical and pre- and intraoperative neurophysiological assessment variables and compared them with strength outcomes 2 years after nerve transfer surgery. We found statistically significant improvement in Medical Research Council strength grades after nerve transfer surgery with lower cervical spine injuries (between one and two grades), lower donor nerve stimulation thresholds (half of a grade), greater motor evoked potential activity in recipient nerves (half of a grade) and greater muscle responses to intraoperative stimulation of donor (half of a grade) and recipient nerves (half of a grade).Level of evidence: III.

Dose-escalated radiotherapy to 82 Gy for prostate cancer following insertion of a peri-rectal hydrogel spacer: 3-year outcomes from a phase II trial

Background

Dose-escalation to above 80 Gy during external beam radiotherapy for localised prostate cancer leads to improved oncological outcomes but also substantially increased rectal toxicity. The aim of this study was to demonstrate the safety and efficacy of escalating the dose to 82 Gy following insertion of a peri-rectal hydrogel spacer (HS) prior to radiotherapy.

Methods

This was a single arm, open-label, prospective study of men with localised prostate cancer who were prescribed a course of intensity modulated radiotherapy escalated to 82 Gy in 2 Gy fractions following insertion of the SpaceOAR™ HS (Boston Scientific, Marlborough, MA). Patients were prescribed a standard course of 78 Gy in 2 Gy fractions where rectal dose constraints could not be met for the 82 Gy plan. The co-primary endpoints were the rate of grade 3 gastrointestinal (GI) and genitourinary (GU) adverse events (CTCAE, v4), and patient-reported quality of life (QoL) (EORTC QLQ-C30 and PR25 modules), up to 37.5 months post-treatment.

Results

Seventy patients received treatment on the study, with 64 (91.4%) receiving an 82 Gy treatment course. The median follow-up time post-treatment was 37.4 months. The rate of radiotherapy-related grade 3 GI and GU adverse events was 0% and 2.9%, respectively. There were 2 (2.9%) grade 3 adverse events related to insertion of the HS. Only small and transient declines in QoL were observed; there was no clinically or statistically significant decline in QoL beyond 13.5 months and up to 37.5 months post-treatment, compared to baseline. No late RTOG-defined grade ≥ 2 GI toxicity was observed, with no GI toxicity observed in any patient at 37.5 months post-treatment. Nine (12.9%) patients met criteria for biochemical failure within the follow-up period.

Conclusions

Dose-escalation to 82 Gy, facilitated by use of a hydrogel spacer, is safe and feasible, with minimal toxicity up to 37.5 months post-treatment when compared to rates of rectal toxicity in previous dose-escalation trials up to 80 Gy. Trials with longer follow-up of oncological and functional outcomes are required to robustly demonstrate a sustained widening of the therapeutic window.

Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12621000056897, 22/01/2021. Retrospectively registered.

Risk Factors Associated With Poor Outcomes Following Temporomandibular Joint Discectomy and Fat Graft

PURPOSE

Temporomandibular joint (TMJ) discectomy is performed for patients with degenerative joint disease with an unsalvageable disc, but with a salvageable condylar head and glenoid fossa. The purpose of this study was to estimate the incidence and risk factors associated with poor postoperative outcomes following TMJ discectomy and abdominal fat grafting.

METHODS

A retrospective cohort study was conducted on patients who underwent TMJ discectomy. Included in this study were patients who had complete data sets with a minimum of 1-year follow-up. Potential risk factors included demographics, preoperative findings (mouth opening, pain levels, previous TMJ surgery), operative findings (disc degeneration, state of TMJ components), and postoperative outcomes (pain levels, mouth opening). Failed outcomes were those who had return of pain postoperatively, no improvement in mouth opening following TMJ discectomy, and/or those who progressed to TMJ total joint replacement (TJR). Statistical methods included Kaplan-Meier curves and Cox proportional hazards regression time to event analyses.

RESULTS

This study included 129 patients who had undergone 132 TMJ discectomies. Most patients were female (89.9%), with a mean age of 43.2 years, standard deviation 14.2. The success rate for discectomy was 75.2% and the conversion rate of TMJ discectomy to TJR was 11.7%. A total of 32 patients (24.8%) experienced return of pain. The median time to return of pain or second surgery was 94.4 months (95% CI = 88.3 to 101.8). No risk factors were statistically significant, although mouth opening improvement of less than 10% was associated with higher risk of poor outcome (P = .77).

CONCLUSION

The findings of this study suggest that lower improvement in mouth opening at 1 year following surgery is likely to result in failure of the TMJ discectomy procedure although the result was not statistically significant. This outcome may ultimately necessitate a TJR.

Does cognitive decline occur decades after moderate to severe traumatic brain injury? A prospective controlled study

This prospective controlled study examined long-term trajectories of neuropsychological performance in individuals with traumatic brain injury (TBI) compared to healthy controls, and the impact of IQ, age at injury, time since injury, and injury severity on change over time. Fifty-three individuals with moderate to severe TBI (60.37% male; M = 59.77 yrs, SD = 14.03), and 26 controls (46.15% male; M = 63.96 yrs, SD = 14.42) were studied prospectively (M = 12.72 yrs between assessments). Participants completed measures of premorbid IQ (Weschler Test of Adult Reading), processing speed (Digit Symbol Coding Test), working memory (Digit Span Backwards), memory (Rey Auditory Verbal Learning Test) and executive function (Trail Making Test Part B; Hayling Errors), at a mean of 10.62 yrs (Initial) and 23.91 yrs (Follow-Up) post injury. Individuals with TBI did not show a significantly greater decline in neuropsychological performance over time compared with demographically similar controls. There was no association between change over time with IQ, time since injury or injury severity. Being older at injury had a greater adverse impact on executive function at follow-up. In this small sample, a single moderate to severe TBI was not associated with ongoing cognitive decline up to three decades post injury. Changes in cognitive function were similar between the groups and likely reflect healthy aging.

Relative risks and odds ratios: Simple rules on when and how to use them

AIM

Relative risks and odds ratios are widely reported in the medical literature, but can be very difficult to understand. We sought to further clarify these important indices.

METHODS

We illustrated both relative risks and odds ratios using bar charts, then looked at the types of study for which each statistic is suited. We demonstrated calculation of relative risks and odds ratios through analysis of tabled data from a recent published longitudinal study, using a 2 × 2 table and R, the open-source statistical programming language. Simple rules for when and how to use relative risks and odds ratios are presented.

CONCLUSION

Understanding the difference between relative risks and odds ratios and when and how to use them may aid clinical interpretation, dissemination and translation of research findings.

Fractionated stereotactic body radiotherapy for up to five prostate cancer oligometastases: Interim outcomes of a prospective clinical trial

Stereotactic body radiotherapy (SBRT) can delay escalation to systemic treatment in men with oligometastatic prostate cancer (PCa). However, large, prospective studies are still required to evaluate the efficacy of this approach in different patient groups. This is the interim analysis of a prospective, single institution study of men relapsing with up to five synchronous lesions following definitive local treatment for primary PCa. Our aim was to determine the proportion of patients not requiring treatment escalation following SBRT. In total, 199 patients were enrolled to receive fractionated SBRT (50 Gray in 10 fractions) to each visible lesion. Fourteen patients were castration resistant at enrolment. The proportion of patients not requiring treatment escalation 2 years following SBRT was 51.7% (95% CI: 44.1-59.3%). The median length of treatment escalation-free survival over the entire follow-up period was 27.1 months (95% CI; 21.8-29.4 months). Prior androgen deprivation therapy (ADT) predicted a significantly lower rate of freedom from treatment escalation at 2 years compared to no prior ADT (odds ratio = 0.21, 95% CI: 0.08-0.54, p = 0.001). There was no difference in the efficacy of SBRT when treating 4-5 vs. 1-3 initial lesions. A prostate-specific antigen (PSA) decline was induced in 75% of patients, with PSA readings falling to an undetectable level in six patients. No late grade three toxicities were observed. These interim results suggest that SBRT can be used to treat up to five synchronous PCa oligometastases to delay treatment escalation.

Beta-blocker use is an independent risk factor for thunderstorm asthma

OBJECTIVE

To identify risk factors for thunderstorm asthma (TA) in subjects ≥15 years of age from information available in routine clinical records.

METHODS

Retrospective and hospital-based case-control study of various clinical factors in all TA cases (n = 53) who presented to a single-site ED in November 2016 (TA16) and in a control group of patients (n = 156) who presented to the same ED with asthma during the pollen season over eight non-TA years. Bivariate analysis and multivariable logistic regression modelling was performed to calculate the odds of TA asthma in the presence of potential risk factors.

RESULTS

A logistic regression model revealed that the odds of TA were lower for age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95-0.99), higher for Asian country of birth (OR 4.09, 95% CI 1.40-11.95) and higher for oral beta-blocker use (OR 6.43, 95% CI 1.58-26.33) compared to controls. No difference was found between TA16 cases and controls for allergies (to medication, grass pollen, animal), hayfever, smoking, oral non-steroidal anti-inflammatory drugs, or aspirin. Newly diagnosed asthma was higher in TA16 cases versus controls (32.1% vs 12.2%, P = 0.001).

CONCLUSIONS

Oral beta-blocker medications, younger age and Asian-born heritage are risk factors for TA. Further study is required to explore the potential association between beta-blockers and TA.

Measuring postnatal demoralisation: adaptation of the Demoralisation Scale-II (DS-II) for postnatal use

OBJECTIVE

To examine the psychometric properties of the Demoralisation Scale II (DS-II) and adapt it for use with women in the postnatal period.

BACKGROUND

Demoralisation is a psychological state characterised by a sense of incompetence and feelings of helplessness and hopelessness in response to a stressful situation. The postnatal period is a life stage of many disruptions. Women may lose their confidence and become demoralised if feeling unprepared for the tasks of motherhood. The DS-II is a 16-item scale developed among cancer patients, but with content that is also relevant postnatally, including items on sense of failure, helplessness, hopelessness, isolation, entrapment and loss of purpose.

METHODS

Rasch analysis was used to investigate the psychometric properties of the DS-II and refine the scale for postnatal use.

RESULTS

Participants were 209 women admitted with their babies to a residential early parenting programme. A 14-item revised scale was derived, the Postnatal DS-II, showing good psychometric properties, discriminant validity and sensitivity to change, and being well targeted to the sample.

CONCLUSION

The Postnatal DS-II could have utility as an assessment tool, helping clinicians to understand better women's postnatal experiences, assess the effectiveness of interventions and communicate with women in a meaningful and non-stigmatising way.

Key Hospital Anxiety and Depression Scale (HADS) items associated with DSM-IV depressive and anxiety disorder 12-months post traumatic brain injury

BACKGROUND

Anxiety and depression are common problems following traumatic brain injury (TBI), warranting routine screening. Self-report rating scales including the Hospital Anxiety and Depression Scale (HADS) are associated with depression and anxiety diagnoses in individuals with TBI. The relationship between individual HADS symptoms and structured clinical interview methods (SCID) requires further investigation, particularly in regard to identifying a small number of key items that can potentially be recognised by clinicians and carers of individuals with TBI.

METHODS

138 individuals sustaining a complicated-mild to severe TBI completed the HADS, and the Structured Clinical Interview for DSM-IV, Research Version (SCID) at 12-months post-injury. The associations between individual HADS items, separately and in combination, as well as overall depression and anxiety subscale scores, and SCID-diagnosed depressive and anxiety disorders were analysed.

RESULTS

CART (Classification and Regression Tree) analysis found HADS depression item 2 "I still enjoy the things I used to enjoy" and a combination of two anxiety items, 3 "I get a sort of frightened feeling as if something awful is about to happen" and 5 "worrying thoughts go through my mind", performed similarly to total depression and anxiety subscales in terms of their association with depressive and anxiety disorders respectively, at 12-months post-injury.

LIMITATIONS

Patients were predominantly injured in motor vehicle accidents and received comprehensive care within a no-fault accident compensation system and so may not be representative of the wider TBI population.

CONCLUSIONS

Although validation is required, a small number of self-report items are highly associated with 12-month post-injury diagnoses.

The impact of sexual orientation on body image, self-esteem, urinary and sexual functions in the experience of prostate cancer

Prostate cancer (PCa) poses a large health burden globally. Research indicates that men experience a range of psychological challenges associated with PCa including changes to identity, self-esteem and body image. The ways in which sexual orientation plays a role in the experience of PCa, and the subsequent impact on quality of life (QoL), body image and self-esteem have only recently been addressed. By addressing treatment modality, where participant numbers were sufficient, we also sought to explore whether gay (homosexual) men diagnosed with PCa (PCaDx) and with a primary treatment modality of surgery would report differences in body image and self-esteem compared with straight (heterosexual) men with PCaDx with a primary treatment modality of surgery, compared with gay and straight men without PCaDx. The results of our study identified overall differences with respect to PCaDx (related to urinary function, sexual function and health evaluation), and sexual orientation (related to self-esteem), rather than interactions between sexual orientation and PCaDx. Gay men with PCaDx exhibited higher levels of urinary functioning than straight men with PCaDx, the difference being reversed for gay and straight men without PCaDx; but this result narrowly failed to achieve statistical significance, suggesting a need for further research, with larger samples.

Comparison between electromagnetic transponders and radiographic imaging for prostate localization: A pelvic phantom study with rotations and translations

The aim of this study was to evaluate the differences in target localization between Calypso^®, kV orthogonal imaging and cone‐beam computed tomography (CBCT) for combined translations and rotations of an anthropomorphic pelvic phantom. The phantom was localized using all three systems in 50 different positions, with applied translational and rotational offsets randomly sampled from representative normal distributions of prostate motion. Lin's concordance correlation coefficient (ρc) and 95% confidence intervals were calculated to assess the agreement between the localization systems. Mean differences and difference vectors between the three systems were also calculated. Agreement between systems for lateral, vertical, and longitudinal translations was excellent, with ρc values of greater than 0.98 between all three systems in all axes. There was excellent agreement between the systems for rotations around the lateral axis (pitch) (ρc > 0.99), and around the vertical axis (yaw) (ρc > 0.97). However, somewhat poorer agreement for rotations around the longitudinal axis (roll) was observed, with the lowest correlation observed between Calypso and kV orthogonal imaging (ρc = 0.895). Mean differences between the phantom position reported by Calypso and the radiographic systems were less than 1 mm and 1° for all translations and rotations. The results for translations are consistent with the publications of previous authors. There is no comparable published data for rotations. While there is lower correlation between the three systems for roll than for the other angles, the mean differences in reported rotations are not clinically significant.

Kapcom: A Program for the Comparison of Kappa Coefficients Obtained from the Same Sample of Observations

A PC program for comparing two kappa coefficients of agreement obtained from the same sample of observations is described. The program employs a Monte Carlo permutation test to assess the statistical significance of the difference between kappa values.

Postnatal demoralisation among women admitted to a hospital mother-baby unit: validation of a psychometric measure

Demoralisation is a psychological state characterised by experiences of distress and sadness, helplessness, subjective incompetence and hopelessness, in the context of a stressful situation. Experiences of demoralisation may be particularly relevant to women who have recently given birth, who can feel incompetent, isolated and helpless. The psychometric properties of the Demoralisation Scale among women in the postnatal period participating in a clinical program were examined. Women admitted with their infants to a hospital mother-baby unit in Australia for five nights were recruited consecutively (N = 209) and assessed at admission and discharge. The Demoralisation Scale was perceived as relevant and exhibited high reliability, acceptable construct validity and good sensitivity to change. The mean demoralisation score was high (M = 30.9, SD = 15.5) and associated with negative experiences of motherhood and functional impairment, independent of depression and anxiety symptoms. Mean demoralisation decreased significantly after program completion (M = 18.4, SD = 12.4). More participants showed a significant improvement in demoralisation (57.5 %) than in depression (34.8 %) and anxiety (9.8 %) symptoms. Demoralisation can provide a useful framework for understanding and measuring the experiences of women participating in postnatal clinical programs and in directing treatment towards helping women to acquire the necessary caregiving skills and increasing parental efficacy. The Demoralisation Scale is a useful clinical tool for assessing intervention effects.

Early postnatal demoralisation among primiparous women in the community: measurement, prevalence and associated factors

Background

Demoralisation is a psychological state occurring in stressful life situations where a person feels unable to respond effectively to their circumstances, characterised by feelings of distress, subjective incompetence, helplessness and hopelessness. The period after the birth of a first baby is a time of great changes and disruptions to many aspects of the mother's physical, psychological and social functioning. This can lead to feelings of distress, a sense of incompetence and helplessness. This study aimed to examine: (1) the psychometric properties of the Demoralisation Scale in a community setting; (2) the prevalence of demoralisation symptoms among primiparous women in the community; and (3) factors that are uniquely associated with demoralisation in the early postnatal period.

Methods

Primiparous women attending community maternal health centres (n = 400) were recruited and administered the study's questionnaires through a telephone interview.

Results

The Demoralisation Scale was found to be a reliable and valid tool among women in the community who had recently given birth. Higher levels of demoralisation were independently associated with lower confidence on going home from the hospital after birth, lower rating of mother's self-rated global health, more than 3 h of infant crying and fussing in the last 24 h, and a controlling partner, after symptoms of depression and anxiety, and vulnerable personality characteristics were controlled for.

Conclusions

The relevance of demoralisation to postnatal health practitioners in the community is in helping them to better understand women's experiences and to intervene in a way that is more meaningful and less stigmatising to women.

The meaning of a high plasma free haemoglobin: retrospective review of the prevalence of haemolysis and circuit thrombosis in an adult ECMO centre over 5 years

AIMS

In adults requiring extracorporeal membrane oxygenation (ECMO), we wanted to determine; i) the frequency of elevated plasma free haemoglobin (PFHb), ii) the reasons for circuit changes and iii) whether elevated PFHb was associated with higher in-hospital mortality.

MATERIALS AND METHODS

Patients requiring ECMO between January 2010 and August 2014 were identified from a prospectively collected ECMO database. Their scanned medical records and pathology results were reviewed. Relevant patient, biochemical and circuit data were collected on an Excel spreadsheet and analysed using Stata 13 (StataCorp, College Station, TX). The patients were analysed in three groups, depending on their peak PFHb during ECMO: 'Normal PFHb' (<0.1 g/L), 'Low level PFHb' (0.1 - 0.5 g/L), 'High level PFHb' (>0.5 g/L).

MAIN RESULTS

There were 184 ECMO runs (56 VV, 128 VA) - 61 'Normal PFHb', 99 'Low level PFHb', 24 'High level PFHb'. Circuit thrombosis (pump, oxygenator) or haemolysis requiring exchanges were significantly more common in VV ECMO compared to VA ECMO - 23.21% (13/56) vs. 0.78% (1/128), p<0.001. Elevated PFHb was associated with a longer duration of haemofiltration (p<0.001) and ECMO support (p<0.001). In-hospital mortality rates for the 'Normal PFHb', 'Low level PFHb' and 'High level PFHb' groups were 16.39% (10/61), 30.30% (30/99) and 37.50% (9/24), respectively, p=0.067.

CONCLUSION

Elevated PFHb values during adult ECMO were common. Severe haemolysis or thrombosis requiring circuit changes were uncommon and occurred almost exclusively on VV ECMO. There was a non-statistically significant increase in in-hospital mortality with elevated PFHb and studies of larger registry data may clarify the prognostic value of PFHb in adult patients.

Evaluating the impact of depression, anxiety & autonomic function on health related quality of life, vocational functioning and health care utilisation in acute coronary syndrome patients: the ADVENT study protocol

BACKGROUND

Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome patients. Somatic and cognitive subtypes of depression and anxiety in acute coronary syndrome have been shown to be associated with mortality although their association with patient outcomes is unknown, as are the mechanisms that underpin these associations. We are conducting a prospective cohort study which aims to examine in acute coronary syndrome patients: (1) the role of somatic subtypes of depression and anxiety as predictors of health related quality of life outcomes; (2) how somatic subtypes of depression and anxiety relate to long term vocational functioning and healthcare utilisation; and (3) the role of the autonomic nervous system assessed by heart rate variability as a moderator of these associations.

METHODS

Patients are being screened after index admission for acute coronary syndrome at a single, high volume centre, MonashHeart, Monash Health, Victoria, Australia. The inclusion criterion is all patients aged > 21 years old and fluent in English admitted to MonashHeart, Monash Health with a diagnosis of acute coronary syndrome. The primary outcome is mean health related quality of life (Short Form-36) Physical and Mental Health Summary scores at 12 and 24 months in subtypes with somatic symptoms of depression and anxiety. Depressive domains are assessed by the Beck Depression Inventory II and the Cardiac Depression Scale. Anxiety is measured using the Speilberger State-Trait Anxiety Inventory and the Crown Crisp Phobic Anxiety questionnaire. Secondary outcomes include clinical variables, healthcare service utilisation and vocational functioning.

DISCUSSION

This manuscript presents the protocol for a prospective cohort study which will investigate the role of somatic subtypes of depression and anxiety as predictors of health related quality of life, long-term vocational functioning and health service use, and the role of the autonomic nervous system in moderating these associations. Findings from the study have the potential to inform more effective pharmacological, psychological and behavioural interventions and better guide health policy on the use of health care resources.

Predicting future depression in adolescents using the Short Mood and Feelings Questionnaire: a two-nation study

BACKGROUND

Adolescence is a key life period for the development of depression. Predicting the development of depression in adolescence through detecting specific early symptoms may aid in the development of timely screening and intervention programmes.

METHODS

We administered the Short Mood and Feelings Questionnaire (SMFQ) to 5769 American and Australian students aged 10 to 15 years, at two time points, separated by 12 months. We attempted to predict high levels of depression symptoms at 12 months from symptoms at baseline, using statistical approaches based upon the quality, as well as the quantity, of depression symptoms present. These approaches included classification and regression trees (CART) and logistic regression.

RESULTS

A classification tree employing four SMFQ items, such as feelings of self-hatred and of being unloved, performed almost as well as all 13 SMFQ items at predicting subsequent depression symptomatology.

LIMITATIONS

Depression was measured using a self-report instrument, rather than a criterion standard diagnostic interview.

CONCLUSION

Further validation on other populations of adolescents is required: however the results suggest that several symptoms of depression, especially feelings of self-hatred, and being unloved, are associated with increased levels of self-reported depression at 12 months post baseline. Although screening for depression can be problematic, symptoms such as the ones above should be considered for inclusion in screening tests for adolescents.

Pessimism, worthlessness, anhedonia, and thoughts of death identify DSM-IV major depression in hospitalized, medically ill patients

BACKGROUND

Major depression can be difficult to diagnose in medically ill patients, as distinct mood states may not be adequately differentiated. Previous research has found several dimensions of mood states, including demoralization (hopelessness/helplessness) and anhedonia (inability to experience pleasure). DSM-IV major depression was highly prevalent in the clusters of participants typified by high levels of demoralization, and to a slightly lesser extent, anhedonia.

OBJECTIVE

The present study provides a further analysis of 312 medically ill patients, examining how key individual symptoms of demoralization and anhedonia relate to DSM-IV major depression.

METHOD

The authors used logistic-regression and classification and regression-tree (CART) analysis to relate variables of demoralization/anhedonia and major depression.

RESULTS

Two combinations of symptoms 1) pessimism and worthlessness; and 2) pessimism, loss of interest in others, and thoughts of death, were highly associated with major depression.

CONCLUSION

The identification of key symptoms, particularly those involving pessimism, may aid clinical understanding and treatment of depression.

Comorbidity of PTSD and depression in Korean War veterans: prevalence, predictors, and impairment

BACKGROUND

Rates of PTSD and depression are high in Korean War veterans. The prevalence and impact of the two disorders occurring comorbidly, however, has not been investigated. This paper aims to investigate the extent to which PTSD and depression co-occur in Australian veterans of the Korean War, the symptom severity characteristics of comorbidity, the impact on life satisfaction and quality, and the association with war-related predictors.

METHODS

Veterans (N=5352) completed self-report questionnaires including the Posttraumatic Stress Disorder Checklist, the Hospital Anxiety and Depression Scale, the Life Satisfaction Scale, the brief World Health Organisation Quality of Life questionnaire and the Combat Exposure Scale.

RESULTS

Seventeen percent of veterans met criteria for comorbid PTSD and depression, 15% had PTSD without depression, and a further 6% had depression without PTSD. Compared with either disorder alone, comorbidity was associated with impaired life satisfaction, reduced quality of life, and greater symptom severity. Several war-related factors were associated with comorbidity and with PTSD alone, but not with depression alone.

LIMITATIONS

The reliance on self-reported measures and the necessity for retrospective assessment of some deployment-related factors renders some study data vulnerable to recall bias.

CONCLUSIONS

Comorbid PTSD and depression, and PTSD alone, are prevalent among Korean War veterans, are both associated with war-related factors 50 years after the Korean War, and may represent a single traumatic stress construct. The results have important implications for understanding complex psychopathology following trauma.

Which factors predict the persistence of DSM-IV depression, anxiety, and somatoform disorders in the medically ill three months post hospital discharge?

OBJECTIVE

This study sought to assess the persistence of DSM-IV depression, anxiety, and somatoform disorders in a sample of 206 medical patients 3 months after hospital discharge and to examine which baseline factors predicted the persistence of disorder.

METHODS

Patients were interviewed using the Monash Interview for Liaison Psychiatry (a structured psychiatric interview for the medically ill) during admission and again at 3 months post discharge. Scales completed during admission elicited sociodemographic data, psychiatric history, mental and physical functioning, illness behavior, coping modes, and number of close relationships. Best-subset logistic regression was employed to find the best combination of these potential predictors of the persistence of psychiatric disorder.

RESULTS

Persistence of anxiety disorders [n=43; 50.6%; 95% CI=39.5-61.6], depression (n=55; 44.4%; 95% CI=35.4-53.5), and somatoform disorders (n=35; 42.2%; 95% CI=31.3-53.0) was moderately high, with no statistically significant difference in the rate of persistence of the three groups of disorder. Family psychiatric history, education, and poorer physical and mental functioning during hospitalization predicted persistence of depression. Poorer mental functioning, less denial, and greater number of close relationships predicted persistence of anxiety disorders. Higher levels of education, use of acceptance-resignation as a coping mechanism, and greater hypochondriasis predicted persistence of somatoform disorders.

CONCLUSION

The belief that psychiatric disorders in hospitalized medically ill patients spontaneously remit after discharge is false. A substantial proportion persist for at least 3 months. Early detection and treatment is possible and warranted. Features of the illness (poorer physical and mental health) and personal and social factors identifiable at hospital admission identify patients at risk for persistence.

Physical, psychological, and functional comorbidities of multisymptom illness in Australian male veterans of the 1991 Gulf War

Multisymptom illness is more prevalent in 1991 Gulf War veterans than in military comparison groups; less is known about comorbidities. The authors compared physical, psychological, and functional comorbidities in Australian male Gulf War I veterans with those in actively (non-Gulf) deployed and nondeployed military personnel by using a questionnaire and medical assessment in 2000-2002. Multisymptom illness was more common in male Gulf War veterans than in the comparison group (odds ratio (OR) = 1.80, 95% confidence interval (CI): 1.48, 2.19). Stratifying by deployment status in the comparison group made little difference in this association. Gulf War veterans with multisymptom illness had increased psychiatric disorders, including major depression (OR = 6.31, 95% CI: 4.19, 9.52) and posttraumatic stress disorder (OR = 9.77, 95% CI: 5.39, 18.59); increased unexplained chronic fatigue (OR = 13.32, 95% CI: 7.70, 23.05); and more reported functional impairment and poorer quality of life, but objective physical and laboratory outcomes were similar to those for veterans without multisymptom illness. Similar patterns were found in the comparison groups; differences across the 3 groups were statistically significant for only hospitalization, obstructive liver disease, and Epstein-Barr virus exposure. Multisymptom illness is more prevalent in Gulf War I veterans, but the pattern of comorbidities is similar for actively deployed and nondeployed military personnel.

Dehydroepiandrosterone sulfate levels are associated with more favorable cognitive function in women

CONTEXT

It has been proposed that dehydroepiandrosterone and dehydroepiandrosterone sulfate (DHEAS) exert neuroprotective effects in the brain, yet evidence of associations between the endogenous levels of these steroids and measures of cognitive function is lacking.

OBJECTIVE

The objective of the study was to investigate whether circulating levels of DHEAS independently contribute to aspects of cognitive function in women in the community.

DESIGN

This was a community-based, cross-sectional study.

SETTING AND PARTICIPANTS

Two hundred ninety-five women, aged 21-77 yr, were recruited from a community-based data set and participated between September 2003 and December 2004. Women were excluded if they reported any health condition that might potentially adversely affect cognitive function.

MAIN OUTCOME MEASURES

The individual scores of a comprehensive battery of tests of cognitive function and the serum level of DHEAS (square root transformed) were measured.

RESULTS

In the multiple linear regression analysis, the DHEAS term made a significant independent positive contribution to the Controlled Oral Word Association Test score, a measure of executive function. In addition, women with a DHEAS level in the highest tertile who also had more than 12 yr of education performed better on both Digit Span Forward and Digit Span Backward tests, which are tests of simple concentration and working memory, respectively.

CONCLUSIONS

Higher endogenous DHEAS levels are independently and favorably associated with executive function, concentration, and working memory.

Endogenous androgen levels and cardiovascular risk profile in women across the adult life span

OBJECTIVE

Whether endogenous androgen levels contribute to the cardiovascular disease (CVD) risk profile in women is controversial. The purpose of this study was to investigate systematically the relationships between serum levels of endogenous androgens and sex hormone-binding globulin (SHBG) and biochemical CVD risk profile, taking other known risk factors into account.

DESIGN

This community-based cross-sectional study included 587 non-healthcare-seeking-women, aged 18 to 75 years, who were randomly recruited from the community via the electoral roll from April 2002 to August 2003. Participants were euthyroid; had no usage of exogenous steroids; had no history of tubal ligation, hysterectomy, or bilateral oophorectomy; and did not have hyperprolactinemia or polycystic ovarian syndrome. The relationships between total testosterone, SHBG, free testosterone, dehydroepiandrosterone sulfate, and androstenedione and high-sensitivity C-reactive protein (CRP) and lipids were explored using linear regression with natural logarithm (ln) -or square root-transformed data as indicated. Issues of nonlinearity and interaction were addressed by the inclusion of extra regression terms where appropriate. We determined the change in the proportion of variation for each marker of the CVD risk profile explained by the addition of each hormone term to the models, having adjusted for age, body mass index, smoking, alcohol, and exercise.

RESULTS

Menopausal status did not influence the statistical models for high-sensitivity CRP and high-density lipoprotein cholesterol, but for both low-density lipoprotein cholesterol and triglycerides, the proportion of variation explained by the models was substantially less in postmenopausal than in premenopausal women. Almost all of the highly statistically significant findings were related to the addition of the SHBG terms to the models. The changes in r2 values were highly statistically significant for the addition of the SHBG terms to the models for ln CRP and ln high-density lipoprotein for both pre- and postmenopausal women (P <= 0.01 and < 0.001, respectively) and for ln triglycerides in postmenopausal (P < 0.001) and premenopausal women (P < 0.01).

CONCLUSIONS

Endogenous testosterone and the adrenal preandrogens per se are not significant independent determinants of circulating high-sensitivity CRP or lipoprotein lipids. Our analyses provide further support for the independent predictive value of low SHBG levels for CVD risk profile and an independent contribution of the menopausal transition to the determination of low-density lipoprotein cholesterol and triglycerides.

Comparison of first, last, and longest-held jobs as surrogates for all jobs in estimating cumulative exposure in cross-sectional studies of work-related asthma

BACKGROUND

Previous occupational studies have used exposure in most recent job as a surrogate for all jobs or "total work history" exposure. This method may not be valid for diseases in which disability brought on by one job may influence later work history, such as asthma. We investigated different surrogates for total work history for the outcome of asthma symptoms.

METHODS

In a cross-sectional study, we quantitatively compared three exposure surrogates (last job, first job, and longest-held job) with the total cumulative work exposure (all jobs) in a cohort of 1778 aluminium industry workers. The chemical exposures we compared were total fluoride dust, inspirable dust, and sulfur dioxide with the respiratory symptoms of wheeze, chest tightness, and rhinitis.

RESULTS

When extrapolated over time, all surrogates quantitatively overestimated the gold standard "all jobs" for all three exposures investigated. For the symptom of wheeze, last job was found to be the worst surrogate for all jobs for the three exposure types investigated. Prevalence ratios for fluoride exposure and the symptom of occupational wheeze were last job 1.07 (95% confidence interval, 0.92-1.26), longest job 1.10 (0.94-1.30), first job 1.14 (0.97-1.35), and all jobs 1.27 (1.05-1.53).

CONCLUSIONS

Although last job has been found to be a satisfactory surrogate for all jobs in cancer studies, we do not recommend the use of this metric in studies of chronic diseases where development of disability may occur with early exposure. We found that both first job and longest job held were better metrics in studies where the adverse health effect may influence the job history of subject.

Anxiety, post-traumatic stress disorder and depression in Korean War veterans 50 years after the war

BACKGROUND

There has been no comprehensive investigation of psychological health in Australia's Korean War veteran population, and few researchers are investigating the health of coalition Korean War veterans into old age.

AIMS

To investigate the association between war service, anxiety, post-traumatic stress disorder (PTSD) and depression in Australia's 7525 surviving male Korean War veterans and a community comparison group.

METHOD

A survey was conducted using a self-report postal questionnaire which included the PTSD Checklist, the Hospital Anxiety and Depression scale and the Combat Exposure Scale.

RESULTS

Post-traumatic stress disorder (OR 6.63, P<0.001), anxiety (OR 5.74, P<0.001) and depression (OR 5.45, P<0.001) were more prevalent in veterans than in the comparison group. These disorders were strongly associated with heavy combat and low rank.

CONCLUSIONS

Effective intervention is necessary to reduce the considerable psychological morbidity experienced by Korean War veterans. Attention to risk factors and early intervention will be necessary to prevent similar long-term psychological morbidity in veterans of more recent conflicts.

Reproductive health of male Australian veterans of the 1991 Gulf War

Background

Since the 1991 Gulf War concerns have been raised about the effects of deployment to the Gulf War on veterans' health. Studies of the reproductive health of Gulf War veterans have reported varied findings.

Methods

We undertook a cross-sectional study of male Australian Gulf War veterans (n = 1,424) and a randomly sampled military comparison group (n = 1,548). The study was conducted from August 2000 to April 2002. A postal questionnaire included questions about difficulties achieving pregnancy, pregnancy outcomes including live births, stillbirths, miscarriages and terminations; and for all live births gestation, birth weight, sex, and any cancers, birth defects, chromosomal abnormalities or serious health problems.

Results

Male Gulf War veterans reported slightly increased risk of fertility difficulties following the Gulf War (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.0–1.8), but were more successful at subsequently fathering a child (OR 1.8; 95% CI 1.3–2.6). The study groups reported similar rates of pregnancies and live births. There was no increased risk in veterans of miscarriage, stillbirth, or terminations. Children of male Gulf War veterans born after the period of the Gulf War were not at greater risk of being born prematurely, having a low birth weight, or having a birth defect or chromosomal abnormality (OR 1.0; 95% CI 0.6–1.6). The numbers of cancers and deaths in children were too small to draw any firm conclusions.

Conclusion

The results of this study do not show an increased risk of adverse reproductive outcome in Australian male Gulf War veterans.

Hazardous or harmful alcohol use in Royal Australian Navy veterans of the 1991 Gulf War: identification of high risk subgroups

Elevated alcohol use disorders have been observed in 1991 Gulf War veterans from a variety of countries. This study used a self-report instrument, the Alcohol Use Disorders Identification Test (AUDIT), to ascertain whether any subgroups of 1232 male Royal Australian Navy (RAN) Gulf War veterans were at higher risk of hazardous or harmful alcohol use. Recursive partitioning/classification and regression tree (CART) analysis, followed by logistic regression, found five subgroups among the veterans, with differing risks of AUDIT caseness. The highest risk subgroup comprised current smokers. The other two high risk groups both consisted of former or never smokers of lower rank who were (1) not married, or (2) married, with a current diagnosis of major depression. The above subgroups were over three times as likely to exhibit AUDIT caseness than those who were former or never smokers of higher rank. The findings have important implications for effective development of public health initiatives designed to encourage safe alcohol use among veterans.

Family focused grief therapy: a randomized, controlled trial in palliative care and bereavement

OBJECTIVE

The aim of family focused grief therapy is to reduce the morbid effects of grief among families at risk of poor psychosocial outcome. It commences during palliative care of terminally ill patients and continues into bereavement. The authors report a randomized, controlled trial.

METHOD

Using the Family Relationships Index, the authors screened 257 families of patients dying from cancer: 183 (71%) were at risk, and 81 of those (44%) participated in the trial. They were randomly assigned (in a 2:1 ratio) to family focused grief therapy (53 families, 233 individuals) or a control condition (28 families, 130 individuals). Assessments occurred at baseline and 6 and 13 months after the patient's death. The primary outcome measures were the Brief Symptom Inventory, Beck Depression Inventory, and Social Adjustment Scale. The Family Assessment Device was a secondary outcome measure. Analyses allowed for correlated family data and employed generalized estimating equations based on intention to treat and controlling for site.

RESULTS

The overall impact of family focused grief therapy was modest, with a reduction in distress at 13 months. Significant improvements in distress and depression occurred among individuals with high baseline scores on the Brief Symptom Inventory and Beck Depression Inventory. Global family functioning did not change. Sullen families and those with intermediate functioning tended to improve overall, whereas depression was unchanged in hostile families.

CONCLUSIONS

Family focused grief therapy has the potential to prevent pathological grief. Benefit is clear for intermediate and sullen families. Care is needed to avoid increasing conflict in hostile families.

Family focused grief therapy: a randomized, controlled trial in palliative care and bereavement

OBJECTIVE

The aim of family focused grief therapy is to reduce the morbid effects of grief among families at risk of poor psychosocial outcome. It commences during palliative care of terminally ill patients and continues into bereavement. The authors report a randomized, controlled trial.

METHOD

Using the Family Relationships Index, the authors screened 257 families of patients dying from cancer: 183 (71%) were at risk, and 81 of those (44%) participated in the trial. They were randomly assigned (in a 2:1 ratio) to family focused grief therapy (53 families, 233 individuals) or a control condition (28 families, 130 individuals). Assessments occurred at baseline and 6 and 13 months after the patient's death. The primary outcome measures were the Brief Symptom Inventory, Beck Depression Inventory, and Social Adjustment Scale. The Family Assessment Device was a secondary outcome measure. Analyses allowed for correlated family data and employed generalized estimating equations based on intention to treat and controlling for site.

RESULTS

The overall impact of family focused grief therapy was modest, with a reduction in distress at 13 months. Significant improvements in distress and depression occurred among individuals with high baseline scores on the Brief Symptom Inventory and Beck Depression Inventory. Global family functioning did not change. Sullen families and those with intermediate functioning tended to improve overall, whereas depression was unchanged in hostile families.

CONCLUSIONS

Family focused grief therapy has the potential to prevent pathological grief. Benefit is clear for intermediate and sullen families. Care is needed to avoid increasing conflict in hostile families.

Psychological morbidity and quality of life in women with advanced breast cancer: A cross-sectional survey

Objective:Our purpose was to determine the frequency of psychiatric morbidity and to assess the quality of life of women with advanced breast cancer.

Methods:The 227 women in the sample were recruited in Melbourne, Australia, and were interviewed (prior to intervention) for a randomized controlled trial of supportive-expressive group therapy. The main outcome measures were DSM–IV psychiatric diagnoses plus quality of life data based on the EORTC QLQ-C30 (core) and QLQ-BR23 (breast module) instruments.

Results:Forty-two percent of the women (97/227) had a psychiatric disorder; 35.7% (81) of these had depression or anxiety or both. Specific diagnoses were minor depression in 58 women (25.6%), major depression in 16 (7%), anxiety disorder in 14 (6.2%), and phobic disorder in 9 (4%). Seventeen (7.5%) women had more than one disorder. In terms of quality of life, one-third felt less attractive, one-quarter were dissatisfied with their body image, and, in most, sexual interest had waned. Menopausal symptoms such as hot flashes affected less than one-third, whereas symptoms of lymphedema were experienced by 26 (11.5%).

Significance:Women with advanced breast cancer have high rates of psychiatric and psychological disturbance. Quality of life is substantially affected. Clinicians need to be vigilant in monitoring psychological adjustment as part of a comprehensive biopsychosocial approach.

Psychiatric disorder and separation from military service: a 10-year retrospective study

OBJECTIVE

This study investigated the association between the onset of psychiatric morbidity and separation from military service over a 10-year period (1991-2001).

METHOD

The prevalence of affective, anxiety, somatic, and substance use disorders was assessed in 2,215 male Australian Navy personnel with the Composite International Diagnostic Interview.

RESULTS

The onset of a psychiatric disorder during military service was related to a 19% greater risk of separation overall. The majority of those leaving military service did so in the first year after symptom onset. Personnel who remained in service past this period had no significantly elevated risk of separation in subsequent years.

CONCLUSIONS

Psychiatric morbidity represents a significant potential cost to defense forces. Improved recognition and early management of mental health problems among military personnel may improve retention rates.

Models developed by three techniques did not achieve acceptable prediction of binary trauma outcomes

BACKGROUND AND OBJECTIVES

To develop prediction models for outcomes following trauma that met prespecified performance criteria. To compare three methods of developing prediction models: logistic regression, classification trees, and artificial neural networks.

METHODS

Models were developed using a 1996-2001 dataset from a major trauma center in Victoria, Australia. Developed models were subjected to external validation using the first year of data collection, 2001-2002, from a state-wide trauma registry for Victoria. Different authors developed models for each method. All authors were blinded to the validation dataset when developing models.

RESULTS

Prediction models were developed for an intensive care unit stay following trauma (prevalence 23%) using information collected at the scene of the injury. None of the three methods gave a model that satisfied the performance criteria of sensitivity >80%, positive predictive value >50% in the validation dataset. Prediction models were also developed for death (prevalence 2.9%) using hospital-collected information. The performance criteria of sensitivity >95%, specificity >20% in the validation dataset were not satisfied by any model.

CONCLUSION

No statistical method of model development was optimal. Prespecified performance criteria provide useful guides to interpreting the performance of developed models.

Interactions between psychosocial problems and management of asthma: who is at risk of dying?

Adjustment for psychosocial and family problems is common in epidemiological research. Recursive partitioning algorithms, such as CHi Square Automatic Interaction Detection (CHAID), can be used to explore complex interactions between these factors and predictor and outcome variables. We investigated the nature of interactions between asthma management variables and psychosocial problems and how these interactions changed the risk of asthma mortality; 50 cases of asthma death and 201 emergency department controls were recruited. A validated questionnaire was used to collect data. An extended version of CHAID was used to identify statistically significant (p < or = 0.05) interactions controlling for asthma severity. Family problems were associated with increased risk of mortality for patients aged > 31 years (OR = 6.5; 95% CI 2.6-16.1) but not for younger patients. Males were at increased risk overall, but females with family problems (OR = 4.3; 95% CI 1.7-10.7) were at greater risk then males (OR = 3.1; 95% CI 1.2-7.9) with family problems. Alcohol use increased risk of mortality for individuals with verbal instructions (OR = 5.4; 95% CI 1.5-19.5) or without a written action plan (OR = 4.4; 95% CI 1.0-19.4). Individuals with severe asthma and who reported having lung function tests were at increased risk for mortality if family (OR = 8.2; 95% CI 1.6-41.6) or financial problems (OR = 11.5; 95% CI 2.0-65.9) were present. This analysis highlights some important interactions and the magnitude of additional risk for mortality associated with psychosocial or family problems. Psychosocial problems need to be identified and addressed as part of asthma management, because even with best practice, these problems place patients at an increased risk of dying.

War zone stress without direct combat: the Australian naval experience of the Gulf War

This study examines psychological stressors reported by Australian Navy Gulf War veterans in relation to the 1991 Gulf War and other military service. Using a 44-item questionnaire, veterans reported few direct-combat encounters during the Gulf War; however, they reported many other stressful experiences, including fear of death and perceived threat of attack, more frequently in relation to the Gulf War than other military service. Reporting of stressful experiences was associated with younger age, lower rank, and deployment at the height of the conflict. These experiences may partly explain increased rates of psychological disorders previously demonstrated in this Navy veteran population. Findings highlight the importance of documenting war experiences in close proximity to deployment, and developing war exposure instruments which include naval activities and which reflect stressors other than those related to direct combat.

The health of Australian veterans of the 1991 Gulf War: factor analysis of self-reported symptoms

BACKGROUND

A recent report showed that Australian veterans of the 1991 Gulf War displayed a greater prevalence of a multitude of self-reported symptoms than a randomly sampled comparison group of military personnel who were eligible for deployment but were not deployed to the Gulf.

AIMS

To investigate whether the pattern, rather than frequency, of symptom reporting in these Australian Gulf War veterans differed from that of the comparison group personnel.

METHODS

Factor analysis was used to determine whether the co-occurrence of 62 symptoms in 1322 male Gulf War veterans can be explained by a number of underlying dimensions, called factors. The methodology was also applied to 1459 male comparison group subjects and the factor solutions of the two groups were compared.

RESULTS

For the Gulf War veterans, a three factor solution displayed replicability and construct validity. The three factors were labelled as psycho-physiological distress, somatic distress, and arthro-neuromuscular distress, and were broadly similar to those described in previous studies of Gulf War veterans. A concordant three factor solution was also found for the comparison group subjects, with strong convergence of the factor loadings and factor scores across the two groups being displayed.

CONCLUSION

Results did not display evidence of a unique pattern of self-reported symptoms among Gulf War veterans. Results also indicated that the differences between the groups lie in the degrees of expression of the three underlying factors, consistent with the well documented evidence of increased self-reported symptom prevalence in Gulf War veterans.

Symptoms and medical conditions in Australian veterans of the 1991 Gulf War: relation to immunisations and other Gulf War exposures

AIMS

To investigate whether Australian Gulf War veterans have a higher than expected prevalence of recent symptoms and medical conditions that were first diagnosed in the period following the 1991 Gulf War; and if so, whether these effects were associated with exposures and experiences that occurred in the Gulf War.

METHODS

Cross-sectional study of 1456 Australian Gulf War veterans and a comparison group who were in operational units at the time of the Gulf War, but were not deployed to that conflict (n = 1588). A postal questionnaire was administered and the likelihood of the diagnosis of self-reported medical conditions was assessed and rated by a medical practitioner.

RESULTS

Gulf War veterans had a higher prevalence of all self-reported health symptoms than the comparison group, and more of the Gulf War veterans had severe symptoms. Increased symptom reporting was associated with several exposures, including having more than 10 immunisations, pyridostigmine bromide tablets, anti-biological warfare tablets, pesticides, insect repellents, reportedly being in a chemical weapons area, and stressful military service experiences in a strong dose-response relation. Gulf War veterans reported psychological (particularly post-traumatic stress disorder), skin, eye, and sinus conditions first diagnosed in 1991 or later more commonly than the comparison group. Over 90% of medical conditions reported by both study groups were rated by a medical practitioner as having a high likelihood of diagnosis.

CONCLUSION

More than 10 years after the 1991 Gulf War, Australian veterans self-report all symptoms and some medical conditions more commonly than the comparison group. Further analysis of the severity of symptoms and likelihood of the diagnosis of medical conditions suggested that these findings are not due to over-reporting or to participation bias.

Psychological health of Australian veterans of the 1991 Gulf War: an assessment using the SF-12, GHQ-12 and PCL-S

BACKGROUND

Elevated rates of psychological morbidity and symptomatology have been widely reported in 1991 Gulf War veterans. The present study used brief self-report instruments to compare the psychological health of Australian Gulf War veterans with that of a randomly sampled military comparison group.

METHOD

The 12-item Short Form Health Survey (SF-12), 12-item General Health Questionnaire (GHQ-12), Posttraumatic Stress Disorder Checklist--Specific (PCL-S) and Military Service Experience (MSE) questionnaire were administered to 1424 male Australian Gulf War veterans and 1548 male Australian Defence Force members who were operational at the time of the Gulf War conflict, but were not deployed there.

RESULTS

The Gulf War veterans exhibited poorer psychological health, as measured by the above three instruments, than the comparison group members. For Gulf War veterans, the number of stressful experiences, as measured by the MSE questionnaire, was correlated with scores on the three instruments. SF-12 mental health component summary scores and PCL-S caseness, but not GHQ-12 caseness, differed significantly between Gulf War veterans and comparison group members who had been on at least one active deployment.

CONCLUSIONS

More than a decade after the 1991 Gulf War, Australian Gulf War veterans are exhibiting higher levels of current (past month) psychological ill-health, as measured using the GHQ-12 and PCL-S, as well as lower mental health status, as measured by the SF-12, than the comparison group. Although not a replacement for formal psychiatric diagnosis, instruments such as those above may aid in the assessment of veterans' psychological health.

Respiratory health status of Australian veterans of the 1991 Gulf War and the effects of exposure to oil fire smoke and dust storms

BACKGROUND

Since the 1991 Gulf War concerns have been raised about the effects on veterans' health of exposures to Kuwaiti oil fire smoke and to dust storms.

METHODS

A cross sectional study compared 1456 Australian Gulf War veterans with a randomly sampled military comparison group (n = 1588). A postal questionnaire asked about respiratory conditions, exposures, medications, tobacco use, demographic characteristics, and military service details. During a medical assessment, spirometric tests and a physical examination were performed and a respiratory questionnaire was administered.

RESULTS

The response rate for the Gulf War veteran group was 80.5% and for the comparison group 56.8%. Australian Gulf War veterans had a higher than expected prevalence of respiratory symptoms and respiratory conditions suggesting asthma (OR 1.4; 95% CI 1.1 to 1.9) and bronchitis first diagnosed since the Gulf War (OR 1.9; 95% CI 1.2 to 3.1) but did not have poorer lung function or more ventilatory abnormalities than the comparison group. Veterans who reported exposure to oil fire smoke had slightly poorer forced vital capacity (difference between means -0.10 l; 95% CI -0.18 to -0.03) and those exposed to dust storms had a slightly better peak expiratory flow rate (difference between means 12.0 l/min; 95% CI 0.6 to 23.4) than veterans who did not report exposure. Veterans who were in the Gulf at or after the start of the oil fires had more respiratory conditions suggesting asthma (OR 1.7; 95% CI 1.0 to 2.9) than those who completed their deployment before this time.

CONCLUSIONS

Increased self-reporting of respiratory symptoms, asthma, and bronchitis by veterans was not reflected in poorer lung function. The findings do not suggest major long term sequelae of exposure to oil fire smoke or dust storms.

War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War

BACKGROUND

Questions remain about the long-term health impacts of the 1991 Gulf War on its veterans.

AIMS

To measure psychological disorders in Australian Gulf War veterans and a military comparison group and to explore any association with exposure to Gulf War-related psychological stressors.

METHOD

Prevalences of DSM-IV psychological disorders were measured using the Composite International Diagnostic Interview. Gulf War-related psychological stressors were measured using a service experience questionnaire.

RESULTS

A total of 31% of male Gulf War veterans and 21% of the comparison group met criteria for a DSM-IV disorder first present in the post-Gulf War period. The veterans were at greater risk of developing post-Gulf War anxiety disorders including post-traumatic stress disorder, affective disorders and substance use disorders. The prevalence of such disorders remained elevated a decade after deployment. The findings can be explained partly as a 'war-deployment effect'. There was a strong dose-response relationship between psychological disorders and number of reported Gulf War-related psychological stressors.

CONCLUSIONS

Service in the 1991 Gulf War is associated with increased risk of psychological disorders and these are related to stressful experiences.

Psychosocial morbidity associated with patterns of family functioning in palliative care: baseline data from the Family Focused Grief Therapy controlled trial

Family Focused Grief Therapy (FFGT) is a new model of brief intervention, which is commenced during palliative care for those families shown to be at high risk of poor adaptation, and continued preventively into bereavement with the aim of improving family functioning and reducing the morbid consequences of grief. In this paper, baseline data on 81 families (363 individuals) selected by screening from a palliative care population are explored to confirm our previously reported observation that high levels of psychosocial morbidity are positively associated with worsening family dysfunction. The Family Relationships Index (FRI) was used for screening and the Family Assessment Device (FAD) as an independent family outcome measure. The Beck Depression Inventory (BDI), Brief Symptom Inventory (BSI) and Social Adjustment Scale (SAS) were the psychosocial measures. Families were classified according to their functioning based on the FRI. To allow for correlated family data, statistical analyses employed the generalized estimating equation (GEE) method, controlling for gender and depression (BDI). Screening of 257 families (701 individuals) revealed 74 (29%) well-functioning families and 183 (71%) at some risk of morbid outcome. Of the latter, 81 (44%) gave informed consent to enter a randomized controlled trial of FFGT. Patients had a mean age of 57 years, 51% were male and they suffered from cancer, with a median length of illness from diagnosis to death of 25 months. In accordance with the FFGT model, their family types were identified as Intermediate 51%, Sullen 26% and Hostile 23%. These were significantly associated with steadily increasing levels of distress (BSI) and poor social adjustment (SAS). The FAD confirmed the concurrent accuracy of the FRI. As significantly greater levels of psychosocial morbidity were present in families whose functioning as a group was poorer, support was generated for a clinical approach that screens for families rather than individuals at high risk. The predictive validity of the FRI as a screening measure was confirmed. Overall, these baseline data point to the importance of a family-centred model of care.

An empirically derived taxonomy of common distress syndromes in the medically ill

OBJECTIVE

Contemporary psychiatric classifications have not proved to be useful in the understanding and care of people with physical illness. Distress syndromes are common, but classifications fail to differentiate syndromes relevantly. We sought to take a fresh look at the common distress syndromes in the medically ill.

METHODS

312 medical inpatients were interviewed using a structured psychiatric interview [the Monash Interview for Liaison Psychiatry (MILP)] to elicit the presence of mood, anxiety and somatoform symptoms. A previously reported examination of these data using latent trait analysis revealed the dimensions of demoralization, anhedonia, autonomic anxiety, somatoform symptoms and grief. Patients were scored on these dimensions and, on the basis of these, subjected to cluster analysis. Derived classes were compared on a range of demographic and clinical data including psychiatric diagnosis.

RESULTS

Six classes were found, distinguished by general levels of distress (measured by demoralization, autonomic anxiety and somatoform symptoms), anhedonia and grief. The most distressed groups were Demoralization and Demoralized Grief. Anhedonic Depression showed moderate levels of distress but the highest level of social dysfunction. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) categories of mood disorders did not follow any particular pattern other than reflecting severity of distress. The classes of high distress (Demoralization and Demoralized Grief) were significantly associated with younger age, past history of psychiatric treatment, low Global Assessment of Functioning (GAF) scores over the previous 12 months and DSM-IV somatoform disorders. Patients with Demoralized Grief tended to acknowledge their illness as a significant and relevant stressor. Patients with Demoralization identified other stressors as significant.

CONCLUSION

Concepts of demoralization, anhedonia and grief differentiate between important clinical syndromes and have informed the development of a taxonomy of common distress syndromes in the medically ill. Research is required to further explore the validity and utility of these concepts.