The Montreal Cognitive Assessment (MoCA) with a double threshold: improving the MoCA for triaging patients in need of a neuropsychological assessment.

OBJECTIVES: Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders. DESIGN: In this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy. SETTING/PARTICIPANTS: Patients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (n = 693). RESULTS: The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who's course should be monitored actively as they are at increased risk (21<26). CONCLUSION: By using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring.

Evaluation of opening a type III/IV medical psychiatric unit.

OBJECTIVE: The aim of this study is to examine the impact of opening a medical psychiatric unit (MPU) on a variety of outcomes. METHODS: In this non-equivalent groups design, there were two groups: 'pre-MPU' and 'actual MPU'. Staff assessed whether patients in the pre-MPU group were eligible for admission to a planned MPU, resulting in virtual admissions and discharges. The actual MPU group consisted of patients admitted after opening of the MPU. RESULTS: The length of stay (LOS) in the hospital was one day longer for patients in the MPU group (8.68 vs. 9.89, p = .004), but the LOS on the MPU was comparable in both groups (5.63 vs. 6.06, p = .231). The LOS on the intensive care unit (ICU) was longer in the MPU group (0.10 vs. 0.40, p < .001), even as the time patients were physically restraint (0.28 vs. 0.83, p < .001). In the pre-MPU group, the odds were not significantly different for involuntary commitment (OR = 0.92; p = .866) and death within six months after discharge (OR = 1.84; p = .196). CONCLUSIONS: Both physical restraint and ICU admission have a link with patient complexity, it therefore seemed that opening of the MPU resulted in the treatment of more complex patients with a comparable LOS on the MPU.KEY POINTSThe LOS on the MPU was not significantly different between the groups before and after opening of the MPU.Opening of the MPU resulted in the admission of patients that were admitted more days to the ICU and to more days of physically restraint.It can be considered that opening of the MPU resulted in an increased ability to treat complex patients.

STARD 2015: An Updated List of Essential Items for Reporting Diagnostic Accuracy Studies.

Incomplete reporting has been identified as a major source of avoidable waste in biomedical research. Essential information is often not provided in study reports, impeding the identification, critical appraisal, and replication of studies. To improve the quality of reporting of diagnostic accuracy studies, the Standards for Reporting of Diagnostic Accuracy Studies (STARD) statement was developed. Here we present STARD 2015, an updated list of 30 essential items that should be included in every report of a diagnostic accuracy study. This update incorporates recent evidence about sources of bias and variability in diagnostic accuracy and is intended to facilitate the use of STARD. As such, STARD 2015 may help to improve completeness and transparency in reporting of diagnostic accuracy studies.

STARD 2015: An Updated List of Essential Items for Reporting Diagnostic Accuracy Studies.

Incomplete reporting has been identified as a major source of avoidable waste in biomedical research. Essential information is often not provided in study reports, impeding the identification, critical appraisal, and replication of studies. To improve the quality of reporting of diagnostic accuracy studies, the Standards for Reporting of Diagnostic Accuracy Studies (STARD) statement was developed. Here we present STARD 2015, an updated list of 30 essential items that should be included in every report of a diagnostic accuracy study. This update incorporates recent evidence about sources of bias and variability in diagnostic accuracy and is intended to facilitate the use of STARD. As such, STARD 2015 may help to improve completeness and transparency in reporting of diagnostic accuracy studies.

Quality of life and academic functioning 6 years after paediatric referral for chronic pain.

AIM: To assess health-related quality of life (HR-QoL) and academic functioning in adolescents and young adults 6 years after paediatric referral for chronic pain. METHODS: In 99 children and adolescents with chronic pain (aged 8-17) referred to a paediatric outpatient clinic, pain and psychiatric disorders were assessed between 2000 and 2002. Participants were reassessed after minimal 5 years (aged 13-24). HR-QoL [Medical Outcomes Study 36-item Short-Form (SF-36)] was compared with Dutch population norms. Academic functioning (structured questionnaire) was compared with baseline. RESULTS: Participant's ratings in most HR-QoL dimensions did not differ from population norms. Outcome was significantly decreased in Bodily Pain (p = 0.001 males, p < 0.000 females) and female General Health (p = 0.001). Poor general health perceptions (p = 0.002), poor global general health (p = 0.003) and a high somatic symptom level (p = 0.004) at baseline predicted poor HR-QoL outcome. School/work attendance was significantly better than at baseline (p = 0.002). CONCLUSION: Six years after paediatric referral for chronic pain, HR-QoL was mostly comparable to that of peers, and academic functioning improved. Self-evaluated global health at referral may be an important predictor of HR-QoL outcome of children with chronic pain, rather than psychiatric comorbidity.

Identifying value-based quality indicators for general hospital psychiatry.

OBJECTIVE: To define generic quality indicators for general hospital psychiatry from the perspectives of patients, professionals (physicians, nurses, and managers), and payers (health insurance companies). METHODS: Quality variables were identified by reviewing the relevant literature. A working. group consisting of patients', professionals' and payers' representatives was mandated by their respective umbrella organizations. The working group prioritized the quality variables that were identified. Core values were defined and subsequently linked to preliminary quality indicators. These were tested for feasibility in ten hospitals in a four-week period. Stakeholder consultation took place by means of two invitational conferences and two written commentary rounds. RESULTS: Forty-one quality variables were identified from the literature. After prioritization, seven core values were defined and translated to 22 preliminary indicators. Overall, the feasibility study showed high relevance scores and good implementability of the preliminary quality indicators. A final set of twenty-two quality indicators (17 structure, 3 process and 2 outcome indicators) was then established using a consensus-based approach. CONCLUSION: Consensus on a quality framework for general hospital psychiatry was built by incorporating the perspectives of relevant stakeholders. Results of the feasibility study suggest broad support and good implementability of the final quality indicators. Structural indicators were broadly defined, and process and outcome indicators are generic to facilitate quality measurement across settings. The quality indicator set can now be used to facilitate quality and outcome assessment, stimulate standardization of services, and help demonstrate (cost-) effectiveness.

Towards complete and accurate reporting of studies of diagnostic accuracy: The STARD Initiative.

BACKGROUND: To comprehend the results of diagnostic accuracy studies, readers must understand the design, conduct, analysis, and results of such studies. That goal can be achieved only through complete transparency from authors. OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in the study and to evaluate its generalizability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, methodologists and statisticians, and members of professional organizations shortened this list during a 2-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines on diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. The consensus meeting shortened the list to 25 items, using evidence on bias whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution, and the numbers of patients undergoing the test under evaluation, the reference standard, or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of the clinicians, researchers, reviewers, journals, and the public.

The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration.

The quality of reporting of studies of diagnostic accuracy is less than optimal. Complete and accurate reporting is necessary to enable readers to assess the potential for bias in the study and to evaluate the generalizability of the results. A group of scientists and editors has developed the STARD (Standards for Reporting of Diagnostic Accuracy) statement to improve the reporting the quality of reporting of studies of diagnostic accuracy. The statement consists of a checklist of 25 items and flow diagram that authors can use to ensure that all relevant information is present. This explanatory document aims to facilitate the use, understanding, and dissemination of the checklist. The document contains a clarification of the meaning, rationale, and optimal use of each item on the checklist, as well as a short summary of the available evidence on bias and applicability. The STARD statement, checklist, flowchart, and this explanation and elaboration document should be useful resources to improve reporting of diagnostic accuracy studies. Complete and informative reporting can only lead to better decisions in health care.

The diagnostic odds ratio: a single indicator of test performance.

Diagnostic testing can be used to discriminate subjects with a target disorder from subjects without it. Several indicators of diagnostic performance have been proposed, such as sensitivity and specificity. Using paired indicators can be a disadvantage in comparing the performance of competing tests, especially if one test does not outperform the other on both indicators. Here we propose the use of the odds ratio as a single indicator of diagnostic performance. The diagnostic odds ratio is closely linked to existing indicators, it facilitates formal meta-analysis of studies on diagnostic test performance, and it is derived from logistic models, which allow for the inclusion of additional variables to correct for heterogeneity. A disadvantage is the impossibility of weighing the true positive and false positive rate separately. In this article the application of the diagnostic odds ratio in test evaluation is illustrated.

Toward complete and accurate reporting of studies of diagnostic accuracy. The STARD initiative.

Our objective was to improve the accuracy and completeness of reporting of studies of diagnostic accuracy, to allow readers to assess the potential for bias in the study, and to evaluate its generalizability. The Standards for Reporting of Diagnostic Accuracy Steering Committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organizations shortened this list during a 2-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. The search for published guidelines regarding diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25-item checklist, using evidence whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution, and the numbers of patients undergoing the test under evaluation, the reference standard, or both. Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve, to the advantage of clinicians, researchers, reviewers, journals, and the public.

Characteristics of good diagnostic studies.

Whether or not patients are better off from undergoing a diagnostic test will depend on how test information is used to guide subsequent decisions on starting, stopping, or modifying treatment. Consequently, the practical value of a diagnostic test can only be assessed by taking into account subsequent health outcomes. In the appraisal of diagnostic test studies, it is essential to discriminate between studies that report on the accuracy of a diagnostic test and studies that report on health outcomes of strategies that incorporate diagnostic tests. In a study that reports on diagnostic accuracy, a cohort of patients is subjected to at least two diagnostic tests: the index test and the reference test, the latter usually being the best method available to detect the target condition. The accuracy of the index test can be expressed in terms of sensitivity, specificity, or likelihood ratios. Studies that compare two or more strategies that incorporate diagnostic tests as well as therapeutic interventions should be approached differently. Such studies do not require expression of test accuracy in terms of sensitivity and specificity. The merit of diagnostic tests evaluated in such studies can be expressed by comparing relevant outcomes of both strategies. The effectiveness of such strategies can be compared similarly as the effectiveness of treatment. However, due to the fact that the effect of a diagnostic test on health outcome is not as direct as the effect of treatment on health outcome, the design of outcome studies reporting on diagnostic tests requires special attention. It is important to establish a clear link between the result of the test under study and subsequent therapeutic management. Furthermore, trial efficiency can be improved by moving the point of randomization from the decision point, whether or not to test, to the point where a decision has to be made regarding what to do with the positive test results.

Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.

OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in the study and to evaluate its generalisability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organizations shortened this list during a two-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines regarding diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to 25 items, using evidence on bias whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution and the numbers of patients undergoing the test under evaluation, the reference standard or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of the clinicians, researchers, reviewers, journals, and the public.

Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.

BACKGROUND: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in a study and to evaluate the generalizability of its results. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors and members of professional organizations shortened this list during a 2-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines regarding diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to 25 items, using evidence on bias whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution and the numbers of patients undergoing the test under evaluation, the reference standard or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of the clinicians, researchers, reviewers, journals and the public.

Toward complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.

RATIONALE AND OBJECTIVES: To comprehend the results of diagnostic accuracy studies, readers must understand the design, conduct, and analysis of such studies. The authors sought to develop guidelines for improving the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers better to assess the validity and generalizability of study results. MATERIALS AND METHODS: The Standards for Reporting of Diagnostic Accuracy group steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and to extract potential guidelines for authors and editors. An extensive list of items was prepared. Members of the steering committee then met for 2 days with other researchers, editors, methodologists, statisticians, and members of professional organizations to develop a checklist and a prototypical flowchart to guide authors and editors of studies of diagnostic accuracy. RESULTS: The search for published guidelines on diagnostic research yielded 33 previously published checklists, from which the group produced an initial list of 75 items. This list was honed to 25 key items by group consensus and on the basis of published research on bias. A prototypical flowchart was developed as a tool for conveying information about the method of patient recruitment, the order of test execution, and the numbers of patients undergoing the test under evaluation, the reference test, or both. Potential users reviewed the conference version of the checklist and flowchart and provided additional suggestions, which were then incorporated. CONCLUSION: Use of these carefully developed, consensus-based guidelines should enable clearer and more complete reporting of studies of diagnostic accuracy, as well as better reader understanding of the validity and generalizability of study results.

Red blood cell polyunsaturated fatty acids measured in red blood cells and schizophrenia: a meta-analysis.

Alterations of polyunsaturated fatty acids (PUFA) in schizophrenia have been reported, but there is substantial variation in the findings. We performed a systematic review and meta-analysis for docosapentaenoic acid (DPA), docosahexaenoic acid (DHA), linoleic acid (LA), and arachidonic acid (AA). We identified 18 studies which compared PUFA in the erythrocyte cell membrane between patients with schizophrenia and controls. A total of 642 patients (169 were antipsychotic-naïve) and 574 controls participated in these studies. We found suggestive evidence that the levels of DPA (C22:5n3) and DHA (C22:6n3) are decreased both in patients currently being treated with antipsychotic medication and antipsychotic-naïve patients. Our findings furthermore suggest that the levels of LA (C18:2n6) are decreased in the medicated subgroup, but not in the antipsychotic-naive group. Finally, we found decreased levels of AA (C20:4n6), most convincingly in antipsychotic-naive patients. Taken together, there is substantial evidence that decreased levels of DPA (C22:5n3), DHA (C22:6n3), and AA (C20:4n6) are associated with the schizophrenia syndrome, apart from a possible influence of antipsychotic medication. Given the large heterogeneity in results, these conclusions should be interpreted cautiously.

The course of chronic pain with and without psychiatric disorders: a 6-year follow-up study from childhood to adolescence and young adulthood.

OBJECTIVE: Psychiatric disorders are common in children with chronic pain, but their course and impact when children grow up are unknown. This study examines the 6-year clinical outcome of children referred for chronic pain with and without comorbid psychiatric disorders. METHOD: In 91 children and adolescents (aged 8 to 17 years) referred to a university outpatient clinic for chronic pain, child psychiatric disorders were assessed using the Diagnostic Interview Schedule for Children-parent version (DISC-P) between 2000 and 2002. Participants (aged 13 to 24 years) were reassessed on average 6-years later. Outcome measures were chronic pain and psychiatric disorders assessed with the Diagnostic Interview Schedule for Children-children version (DISC-C) or the Composite International Diagnostic Interview (CIDI) and Diagnostic Interview Schedule IV (DIS). RESULTS: After 6 years, 75% of the participants still experienced chronic pain and 15% were in complete remission of both chronic pain and psychiatric disorder. The prevalence of psychiatric disorders (both persistent and new onset disorders) at follow-up was 32%. Baseline psychiatric disorder was a predictor of psychiatric disorder at follow-up (OR = 2.6, 95% CI = 1.1-6.5, P = .04; adjusted OR = 2.8, 95% CI = 1.1-7.1, P = .03) but did not predict persistence of chronic pain. CONCLUSIONS: Children referred for chronic pain frequently continue to suffer from chronic pain and psychiatric disorders in adolescence and young adulthood. In this population, comorbid psychiatric disorder at study entry was a predictor of psychiatric disorder, but not of persistent chronic pain, in adolescence and young adulthood.

Impaired neuroendocrine and immune response to acute stress in medication-naive patients with a first episode of psychosis.

Little is known about how the biological stress response systems--the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal (HPA) axis, and the immune system--function during psychosis. Results of studies on the effect of stress on the immune and autonomic system in patients with schizophrenia are inconsistent. The present study investigates whether the stress response is impaired in medication-naive patients with a first episode of psychosis. Ten male patients with a first episode of psychosis and 15 controls were exposed to the stress of public speaking. Parameters of the ANS (heart rate and catecholamines), the HPA axis (plasma adrenocorticotropic hormone [ACTH] and cortisol), and the immune system (number and activity of natural killer [NK] cells) were measured. Peak responses were calculated to examine the relationship between stress-induced activation of the different systems. Subjective stress and anxiety before and during the task were assessed. Patients and controls displayed similar autonomic responses to acute stress. However, there was an impaired HPA axis response, slow onset and return of ACTH, and flattened cortisol response and a reduced increase in number NK cells and NK cell activity in patients with a first episode of psychosis. Furthermore, in patients, the relationship between the different stress response systems was weaker or absent compared with controls. These findings indicate that impairments in stress processing are associated with the endophenotype of psychosis and are not a result of illness progression or antipsychotic medication.

Various randomized designs can be used to evaluate medical tests.

OBJECTIVE: To explore designs for evaluating the prognostic and predictive value of medical tests and their effect on patient outcome. STUDY DESIGN: Theoretical analysis with examples from the medical literature. RESULTS: For evaluating the prognostic value of a test, one can include the test at baseline in prognostic studies. To evaluate the value of test in predicting treatment outcome, the test results can be used as baseline information in randomized controlled trials of treatment. To compare the prognostic or predictive value of two or more tests, the test result combinations can be used as baseline information. To evaluate the effect on patient outcome, randomized controlled trials of test strategies are an option. Randomization can apply to all tested or be restricted to specific subgroups, such as those with discordant test results, to increase the efficiency of trials. CONCLUSION: The prognostic and predictive value of medical tests can and should be evaluated, to demonstrate the test's ability to guide clinical decision making and to improve patient outcome. Various randomized designs can be used to evaluate the effects on testing on patient outcome.