Assessment of Malingering among Servicemembers with a Focused Examination of Explanatory Models.

Umbrasas briefly mentioned established models of malingering that sought to understand the driving motivations for feigning mental disorders. He used these models as a point of departure to consider the unique experiences and enduring challenges of active and retired servicemembers. For military malingering, he identified acute distress malingering and disability malingering with the former occurring within the first five years and the latter after a military career had been established. To provide a strong foundation, this commentary revisits three explanatory models of malingering (i.e., pathogenic, criminological, and adaptational) that have been empirically tested. Of these, the adaptational model appears the best suited in the military context to explain nongenuine responding because most mandatory evaluations carry highly negative consequences, such as seriously damaging future careers in the armed forces. Most examinees would be seen as denying and defensive, however, the polar opposite of malingering. When symptoms are eventually reported, Umbrasas acknowledges the temptation to consider this atypical presentation as possible evidence of malingering. We concur with Umbrasas's conclusion that such an extrapolation would be generally unwarranted. In summary, the overriding goal of this commentary is to understand Umbrasas's thought-provoking contributions to military malingering in the larger landscape of explanatory models of malingering.

Health services utilization and cost of abusive head trauma in Taiwan: A population-based retrospective matched cohort study.

BACKGROUND: Abusive head trauma (AHT) is a serious health problem that results the highest mortality among children who are maltreated. Many AHT survivors suffer from long-term sequelae and require medical treatment. However, the knowledge of AHT-attributable health services utilization and costs at national level are limited. OBJECTIVE: To estimate health services utilization and costs attributable to AHT among children aged 0-4 years in Taiwan. PARTICIPANTS AND SETTING: Sixty-three fatal and 664 survival AHT cases were identified using Taiwan national population database between 2003 and 2015. A total of 2656 non-AHT children were exactly 4:1 matched to the survival cases based on their birth year, gender, the calendar year of the index date, insured location, and health insurance premium (social economic status indicator). METHODS: Health services utilization and costs were calculated on an annual basis for 3 years after the index date. AHT-attributable health services utilization and costs during 3-year follow-up period was evaluated by regression models. RESULTS: AHT diagnosis was positively associated with inpatient admissions, length of stay, emergency room (ER) visits, and outpatient visits. AHT-attributable medical costs were 1.64-17.27 times, 1.25-5.22 times, and 1.77-2.36 times greater for inpatient, ER, and outpatient during 3-year period than matched controls, respectively. Fatal AHT cases had higher inpatient utilization and greater medical costs than AHT survivors. CONCLUSIONS: Children with AHT had greater health services utilization and higher costs for years. Strategies to reduce the burden of AHT on health care system are imperative.

A psychometric analysis of a short form of the Chinese version of the ISPCAN child abuse screening tools - Children's home version (SC-ICAST-CH) using multidimensional item response theory.

BACKGROUND: The development of measures of child maltreatment for the Chinese population were limited until the Chinese version of the ISPCAN Child Abuse Screening Tools - Children's Home version (ICAST-CH-C) was proposed. Although the ICAST-CH-C was found to be effective in assessing the scope and prevalence of child maltreatment, it has several potential drawbacks. The time that is required to complete the ICAST-CH-C scale is longer than usual for a 36-item scale, because many of its items have one or more follow-up questions. Moreover, each item requires child victims to recall unpleasant experiences. Both phenomena can cause increases in invalid responses and in turn damage the data quality. OBJECTIVE: The goal of this study was to propose a short form of the ICAST-CH-C (called the SC-ICAST-CH) to reduce the test length and response time in order to improve the measurement quality. PARTICIPANTS AND SETTING: A dataset from a national survey of 5236 adolescents in Taiwan was used. METHODS: A multidimensional version of the rating scale model (MRSM) was fitted to the data. The model parameters were estimated with the ConQuest software. RESULTS: The results indicated the reliability of the SC-ICAST-CH was fairly good, with only 61 % of the original test length. Disordered thresholds were found in all five subscales; the underlying reasons for this phenomenon need further investigation. Specific cultural differences related to item retention/removal decisions were also discussed. CONCLUSION: The efficient, shorter SC-ICAST-CH was shown to be a valid and reliable instrument for assessing the prevalence of child maltreatment.

Risk assessment of macrovascular and microvascular events in patients with type 2 diabetes by analyzing the amplitude variation of the fourth harmonic component of radial pulse wave.

This investigation explored the hypothesis that whether the coefficient of variation of the fourth harmonic amplitude of the radial pulse wave (C4CV) predicts the risk of macrovascular and microvascular events in patients with type 2 diabetes mellitus (T2DM). Radial pulse wave and brachial blood pressure were measured at baseline in 2324 patients with T2DM and C4CV was calculated using the Fourier series method. Macrovascular and microvascular events during follow-up were determined by medical records. We plotted the Kaplan-Meier curve and performed a Cox proportional hazard model and a log-rank test to estimate the effectiveness of C4CV as a risk predictor. We divided patients into quartile groups based on C4CV (<4.3%, 4.3% to 6.8%, 6.8% to 11.4%, and >11.4%). Compared with patients with C4CV < 4.3%, patients with C4CV> 11.4% had a double incidence of macrovascular events (hazard ratio, 2.13; 95% CI, 1.70-2.67) and microvascular events (hazard ratio, 2.08; 95% CI, 1.67-2.58), and the incidence of cardiovascular death was three times (hazard ratio, 3.03; 95% CI, 1.10-8.83). The Cox regression analysis demonstrated that the risk of both macrovascular and microvascular outcomes increases with the increase in quartile level of C4CV value (P < 0.0001). These associations remained after adjustment for age, gender, smoking, systolic blood pressure, diastolic blood pressure, dyslipidemia, diabetes duration, Hba1c, and cardiovascular disease (P < 0.0001). C4CV is a novel independent predictor of cardiovascular mortality, macrovascular events, and microvascular events in patients with T2DM.

Cultural and linguistic adaptability of the Rorschach Performance Assessment System as a measure of psychotic characteristics and severity of mental disturbance in Taiwan.

This study investigated the cultural and linguistic adaptability of the Rorschach Performance Assessment System (R-PAS), a new Rorschach administration, scoring, and interpretation system that minimizes psychometric weaknesses of the Comprehensive System (CS). This investigation addressed the validity of R-PAS measures of psychotic characteristics and psychopathology severity in Taiwan, including the incremental validity of the R-PAS relative to the CS variables measuring the same constructs. Ninety Taiwanese individuals (75 psychiatric patients and 15 nonpatients) were tested with standard R-PAS administration and scoring. Two non-Rorschach severity of disturbance measures and 2 psychosis measures served as independent criterion measures. The R-PAS measures were found to be valid in Taiwan in assessing psychotic symptoms and psychopathology severity, thus demonstrating cultural and linguistic adaptability. Moreover, hierarchical regression analyses demonstrated incremental validity for the R-PAS variables over their CS counterparts, providing support that the R-PAS revisions enhance the test psychometrically. These research findings also demonstrate the viability of the R-PAS as a Rorschach system that can be effectively employed outside the U.S. in a different language and culture.

Assessing bioequivalence of generic antiepilepsy drugs.

OBJECTIVE: Patients with epilepsy are often concerned that switching between brand-name and generic formulations of antiepilepsy drugs (AEDs) may cause clinically significant changes in plasma drug concentrations. We assessed bioequivalence (BE) studies for approved generic AEDs to evaluate US Food and Drug Administration claims that: (1) generic AEDs are accurate copies of reference formulations; (2) delivery of reference formulations may be as variable as generic AEDs and so provide no increased benefit; and (3) switches between generic AED formulations are safe and effective. METHODS: We determined differences in 90% confidence interval limits for total drug exposure (AUC(0-t) ) and peak concentration (Cmax) ratios of generic and reference formulations during fasting and fed BE studies. We simulated BE between generic formulations after adjusting for reference values. RESULTS: AUC(0-t) values of approved reference and generic formulations differed by <15% in 99% of BE studies; Cmax differed by <15% in 89% of studies. Food affected variability of Cmax but not AUC(0-t) . Intersubject variability in Cmax and AUC(0-t) was small and similar for reference and generic products. In simulated switches between 595 pairs of generic AED formulations, estimated AUC(0-t) differed by >15% for 17% of pairs; estimated Cmax differed by >15% for 39%. AEDs with low bioavailability and solubility (eg, oxcarbazepine) had the greatest variability in BE. INTERPRETATION: Most generic AED products provide total drug delivery (AUC) similar to reference products; differences in peak concentrations between formulations are more common. Switches between generic AED products may cause greater changes in plasma drug concentrations than generic substitutions of reference products.

Effect of problem-solving-based diabetes self-management training on diabetes control in a low income patient sample.

BACKGROUND: Lower socioeconomic status is associated with excess disease burden from diabetes. Diabetes self-management support interventions are needed that are effective in engaging lower income patients, addressing competing life priorities and barriers to self-care, and facilitating behavior change. OBJECTIVE: To pilot test feasibility, acceptability, and effect on disease control of a problem-based diabetes self-management training adapted for low literacy and accessibility. DESIGN: Two-arm randomized controlled trial powered to detect a 0.50% change in A1C at follow-up with a 2-sided alpha of 0.05 in a pooled analysis. PARTICIPANTS: Fifty-six urban African-American patients with type 2 diabetes and suboptimal blood sugar, blood pressure, or cholesterol control recruited from a diabetes registry within a university-affiliated managed care organization. INTERVENTIONS: A group, problem-based diabetes self-management training designed for delivery in an intensive and a condensed program format. Three intensive and three condensed program groups were conducted during the trial. MAIN MEASURES: Clinical (A1C, systolic blood pressure [SBP], diastolic blood pressure [DBP], LDL and HDL cholesterol) and behavioral (knowledge, problem solving, self-management behavior) data were measured at baseline, post-intervention, and 3 months post-intervention (corresponding with 6-9 months following baseline). RESULTS: Adoption of both programs was high (>85% attendance rates, 95% retention). At 3 months post-intervention, the between-group difference in A1C change was -0.72% (p = 0.02), in favor of the intensive program. A1C reduction was partially mediated by problem-solving skill at follow-up (ß = -0.13, p = 0.04). Intensive program patients demonstrated within-group improvements in knowledge (p < 0.001), problem-solving (p = 0.01), and self-management behaviors (p = 0.04). Among the subsets of patients with suboptimal blood pressure or lipids at baseline, the intensive program yielded clinically significant individual improvements in SBP, DBP, and LDL cholesterol. Patient satisfaction and usability ratings were high for both programs. CONCLUSIONS: A literacy-adapted, intensive, problem-solving-based diabetes self-management training was effective for key clinical and behavioral outcomes in a lower income patient sample.