Non-standard diagnostic assessment reliability in psychiatry: a study in a Brazilian outpatient setting using Kappa.

The use of Structured Diagnostic Assessments (SDAs) is a solution for unreliability in psychiatry and the gold standard for diagnosis. However, except for studies between the 50 s and 70 s, reliability without the use of Non-SDAs (NSDA) is seldom tested, especially in non-Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. We aim to measure reliability between examiners with NSDAs for psychiatric disorders. We compared diagnostic agreement after clinician change, in an outpatient academic setting. We used inter-rater Kappa measuring 8 diagnostic groups: Depression (DD: F32, F33), Anxiety Related Disorders (ARD: F40-F49, F50-F59), Personality Disorders (PD: F60-F69), Bipolar Disorder (BD: F30, F31, F34.0, F38.1), Organic Mental Disorders (Org: F00-F09), Neurodevelopment Disorders (ND: F70-F99) and Schizophrenia Spectrum Disorders (SSD: F20-F29). Cohen's Kappa measured agreement between groups, and Baphkar's test assessed if any diagnostic group have a higher tendency to change after a new diagnostic assessment. We analyzed 739 reevaluation pairs, from 99 subjects who attended IPUB's outpatient clinic. Overall inter-rater Kappa was moderate, and none of the groups had a different tendency to change. NSDA evaluation was moderately reliable, but the lack of some prevalent hypothesis inside the pairs raised concerns about NSDA sensitivity to some diagnoses. Diagnostic momentum bias (that is, a tendency to keep the last diagnosis observed) may have inflated the observed agreement. This research was approved by IPUB's ethical committee, registered under the CAAE33603220.1.0000.5263, and the UTN-U1111-1260-1212.

Psychoeducation and Problem-Solving Therapy as an Integrative Model of Mutual-Help Groups for People with Severe Mental Disorders: A Report from Brazil.

This case study describes the "Entrelaços" Peer Support Program, a psychoeducational program of a psychiatric institution in the city of Rio de Janeiro that admitted, between 2011 and 2019, 246 people comprising family members and patients to participate in eight educational seminars followed by multifamily problem-solving groups in cycles that were 18 months in duration. Ninety percent of the participants who completed the program decided to create 7 mutual-help groups in the community independent of technicians and the institution. Community groups have already served spontaneously more than 214 families. They have organized scientific, social and anti-stigma events, expanded their social support network and demonstrated empowerment by switching from service users to peer providers to receive new families. This work is based on a pioneering model in Brazil that integrates psychoeducation with problem-solving therapy, spreading the benefits of education and peer-support with lower cost and greater representativeness.

Operational criteria application does not change clinicians' opinion on the diagnosis of mental disorder: a pre- and post-intervention validity study.

Objective: Our objective was to check if the ICD-10 operational criteria application changes non-operational, prototype-based diagnoses obtained in a real-life scenario. Methods: Psychiatry residents applied the diagnostic criteria of the ICD-10 as a "diagnostic test" to five outpatient patients they were already following who had a prototype-based diagnosis. Tests were used to ascertain whether changes in opinion were significant and if any of the diagnostic groups were more prone to change than others. The present paper is part of the study with UTN U1111-1260-1212. Results: Seventeen residents reviewed their last five case files, retrieving 85 diagnostic pairs of non-operational-based vs. operational-based diagnoses. The Stuart-Maxwell test did not indicate a significant opinion change (χ2 = 5.25, p = 0.39; power = 0.94) besides 30% of diagnostic changes. Despite not being statistically significant, 20.2% of all evaluations resulted in a change that would affect treatment choices. Using ICD-10 operational criteria slightly increased the number of observed diagnoses, but probably without clinical relevance. None of the non-operational diagnoses have a higher tendency to change with operational criteria application (χ2 = 11.6, p = 0.07). The female gender was associated with a higher diagnostic change tendency. Conclusion: Applying ICD-10 operational criteria as a diagnostic test does not induce a statistically significant diagnostic opinion change in residents and no diagnostic group seems more sensible to diagnostic change. Gender-related differences in diagnostic opinion changes might be evidence of sunk cost bias. Although not statistically significant, using operational criteria after diagnostic elaboration might help to deal with subjects without adequate treatment response.

Association between motivation and engagement with changes in cognition and symptoms after digital cognitive training in schizophrenia.

BACKGROUND: Digital cognitive training can remediate cognitive deficits present in schizophrenia. However, limited motivation and engagement may impact adherence to training. Therefore, identifying factors that may enhance (facilitators) or decrease (barriers) engagement in digital cognitive training and possibly modulate its effects are of great clinical relevance. METHODS: We measured cognition, symptom severity, motivation (semi-structured interview), and engagement (adapted Utrecht Work Engagement Scale - UWES) of 27 patients with schizophrenia after a 40-h digital cognitive training. The interview transcript quotes were coded and categorized into facilitators and barriers. Thereafter, we tested the association of motivation and engagement with changes in cognition and symptoms after training. RESULTS: The facilitator 'good performance' and the barrier 'difficult exercise' were associated with larger gains in attention (p = 0.03) and reasoning and problem solving (p = 0.02), respectively. 'Poor performance' was associated with smaller gains in global cognition (p < 0.01), attention (p = 0.03), and working memory (p = 0.02). The facilitator 'welcoming setting' was associated with larger reductions in the negative (p = 0.01) and total (p = 0.01) symptoms measured by the Positive and Negative Syndrome Scale. The UWES engagement scale was associated with different facilitators and barriers that emerged from the interview, an indication of consistency among both qualitative and quantitative assessments. DISCUSSION: Using a mixed quantitative and qualitative research design, we showed associations between motivation and engagement and the response to digital cognitive training in schizophrenia. Facilitators and barriers were associated with engagement, gains in cognition, and reduced symptoms after the intervention, providing insights on how to increase engagement in the digital cognitive training delivered to subjects with schizophrenia.

Intra-rater Kappa Accuracy of Prototype and ICD-10 Operational Criteria-Based Diagnoses for Mental Disorders: A Brief Report of a Cross-Sectional Study in an Outpatient Setting.

Background and Objectives: The use of "operational criteria" is a solution for low reliability, contrasting with a prototypical classification that is used in clinics. We aim to measure the reliability of prototypical and ICD-10 diagnoses. Methods: This is a retrospective study, with a convenience sample of subjects treated in a university clinic. Residents reviewed their diagnosis using ICD-10 criteria, and Cohen's kappa statistic was performed on operational and prototype diagnoses. Results: Three out of 30 residents participated, reviewing 146 subjects under their care. Diagnoses were grouped in eight classes: organic (diagnoses from F00 to F09), substance disorders (F10-F19), schizophrenia spectrum disorders (F20-F29), bipolar affective disorder (F30, F31, F34.0, F38.1), depression (F32, F33), anxiety-related disorders (F40-F49), personality disorders (F60-F69), and neurodevelopmental disorders (F70-F99). Overall, agreement was high [K = 0.77, 95% confidence interval (CI) = 0.69-0.85], with a lower agreement related to personality disorders (K = 0.58, 95% CI = 0.38-0.76) and higher with schizophrenia spectrum disorders (K = 0.91, 95% CI = 0.82-0.99). Discussion: Use of ICD-10 criteria did not significantly increase the number of diagnoses. It changed few diagnoses, implying that operational criteria were irrelevant to clinical opinion. This suggests that reliability among interviewers is more related to information gathering than diagnostic definitions. Also, it suggests an incorporation of diagnostic criteria according to training, which then became part of the clinician's prototypes. Residents should be trained in the use of diagnostic categories, but presence/absence checking is not needed to achieve operational compatible diagnoses.

Auditory versus visual neuroscience-informed cognitive training in schizophrenia: Effects on cognition, symptoms and quality of life.

BACKGROUND: Cognitive impairments are related to deficits in primary auditory and visual sensory processes in schizophrenia. These impairments can be remediated by neuroscience-informed computerized cognitive trainings that target auditory and visual processes. However, it is not clear which modality results in greater improvements in cognition, symptoms and quality of life. We aimed to investigate the impact of training auditory versus visual cognitive processes in global cognition in patients with schizophrenia. METHODS: Seventy-nine schizophrenia participants were randomly assigned to either 40 h of auditory or visual computerized training. Auditory and visual exercises were chosen to be dynamically equivalent and difficulties increased progressively during the training. We evaluated cognition, symptoms and quality of life before, after 20 h, and after 40 h of training. ClinicalTrials.gov (1R03TW009002-01). RESULTS: Participants who received the visual training showed significant improvements in global cognition compared to the auditory training group. The visual training significantly improved attention and reasoning and problem-solving, while the auditory training improved reasoning and problem-solving only. Schizophrenia symptoms improved after training in both groups, whereas quality of life remained unchanged. Interestingly, there was a significant and positive correlation between improvements in attention and symptoms in the visual training group. CONCLUSIONS: We conclude that the visual training and the auditory training are differentially efficient at remediating cognitive deficits and symptoms of clinically stable schizophrenia patients. Ongoing follow-up of participants will evaluate the durability of training effects on cognition and symptoms, as well as the potential impact on quality of life over time.

Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system.

OBJECTIVE: Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers. METHODS: The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services' needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions. RESULTS: HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions. CONCLUSION: Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step. CLINICAL TRIAL REGISTRATION: NCT00881699.

Prevalence of depression among patients with presumptive pulmonary tuberculosis in Rio de Janeiro, Brazil.

OBJECTIVE: To estimate the prevalence of major depressive episode (MDE) in patients with presumptive pulmonary tuberculosis (pre-PTB, defined by cough lasting ≥ 3 weeks) and compare it between patients with pulmonary tuberculosis (PTB) and without PTB. METHODS: Patients with pre-PTB (n=260) were screened for depression using the Patient Health Questionnaire (PHQ-9). Those individuals with scores ≥ 10 were subsequently assessed with the depression module of the Mini International Neuropsychiatric Interview (MINI-Plus) to confirm diagnosis. Associations of categorical variables with PTB and MDE were calculated using the chi-square test and OR. RESULTS: PTB was confirmed in 98 patients (37.7%). A high proportion of both groups (active PTB and no PTB) screened positive for depression (60.2 vs. 62.1%, respectively). Among 159 patients who screened positive for depression, a subset of 97 (61.0%) were further evaluated with the MINI-Plus; current MDE was confirmed in 54.6% (53/97). On univariate and multivariate analysis, female sex was the only factor associated with the diagnosis of current MDE (p = 0.04). CONCLUSION: The prevalence of MDE was high among individuals with prolonged respiratory symptoms, independent of PTB diagnosis. This is consistent with other studies of depression in primary care in Brazil.

Kinetic and thermodynamic investigation on ascorbate oxidase activity and stability of a Cucurbita maxima extract.

The kinetic and thermodynamic properties of ascorbate oxidase (AO) activity and stability of a Cucurbita maxima extract were investigated. Activity tests performed at 25 degrees C using initial ascorbic acid concentration in the range 50-750 M allowed estimating the Michaelis constant for this substrate (Km = 126 microM) and the maximum initial rate of ascorbic acid oxidation (A0,max = 1.57 mM min-1). The main thermodynamic parameters of the enzyme reaction (DeltaH* = 10.3 kJ mol-1; DeltaG* = 87.2 kJ mol-1; DeltaS* = -258 J mol-1 K-1) were estimated through activity tests performed at 25-48 C. Within such a temperature range, no decrease in the initial reaction rate was detected. The long-term thermostability of the raw extract was then investigated by means of residual activity tests carried out at 10-70 degrees C, which allowed estimating the thermodynamic parameters of the irreversible enzyme inactivation as well (DeltaH*D = 51.7 kJ mol-1; DeltaG*D = 103 kJ mol-1; S*D = -160 J mol-1 K-1). Taking into account the specific rate of AO inactivation determined at different temperatures, we also estimated the enzyme half-life (1047 min at 10 degrees C and 21.2 min at 70 degrees C) and predicted the integral activity of a continuous system using this enzyme preparation. This work should be considered as a preliminary attempt to characterize the AO activity of a C. maxima extract before its concentration by liquid-liquid extraction techniques.

Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system

Objective: Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers. Methods: The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services' needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions. Results: HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions. Conclusion: Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step. Clinical trial registration: NCT00881699

Prevalence of depression among patients with presumptive pulmonary tuberculosis in Rio de Janeiro, Brazil

Objective: To estimate the prevalence of major depressive episode (MDE) in patients with presumptive pulmonary tuberculosis (pre-PTB, defined by cough lasting ≥ 3 weeks) and compare it between patients with pulmonary tuberculosis (PTB) and without PTB. Methods: Patients with pre-PTB (n=260) were screened for depression using the Patient Health Questionnaire (PHQ-9). Those individuals with scores ≥ 10 were subsequently assessed with the depression module of the Mini International Neuropsychiatric Interview (MINI-Plus) to confirm diagnosis. Associations of categorical variables with PTB and MDE were calculated using the chi-square test and OR. Results: PTB was confirmed in 98 patients (37.7%). A high proportion of both groups (active PTB and no PTB) screened positive for depression (60.2 vs. 62.1%, respectively). Among 159 patients who screened positive for depression, a subset of 97 (61.0%) were further evaluated with the MINI-Plus; current MDE was confirmed in 54.6% (53/97). On univariate and multivariate analysis, female sex was the only factor associated with the diagnosis of current MDE (p = 0.04). Conclusion: The prevalence of MDE was high among individuals with prolonged respiratory symptoms, independent of PTB diagnosis. This is consistent with other studies of depression in primary care in Brazil.

Podem as bactérias ácido lácticas probióticas apresentarem efeito antitumoral em modelo animal de câncer de cólon? Uma revisão da literatura / Can probiotic acid lactic bacteria submit antitumor effect in animal model of colon cancer? A review of the literature

O Câncer de cólon é um dos tipos mais comuns de câncer no mundo e a segunda principal causa de morte relacionada a esta doença em países desenvolvidos. Até 75% dos casos estão associados com a alimentação, indicando que uma pessoa pode reduzir o seu risco simplesmente através de modificação na dieta. Estudos em animais demonstram que várias cepas de bactérias ácido lácticas protegem contra o câncer de cólon em roedores, embora os dados em humanos sejam limitados e conflitantes. O objetivo deste estudo foi investigar a eficácia das bactérias ácido lácticas no tratamento e redução do câncer de cólon em modelo animal. Foram realizadas buscas sistemáticas em bases de dados eletrônicas alcançando 1079 artigos relacionados, entretanto apenas 6 artigos foram eleitos de acordo com os critérios de elegibilidade para análise. Todos os artigos avaliados apresentaram resultados satisfatórios quanto à inibição do câncer de cólon em ratos e camundongos ao utilizarem cepas predominantemente do gênero Lactobacillus. Este estudo pode responder a hipótese de que as bactérias ácido lácticas apresentam efeito preventivo e antitumoral contra o câncer de cólon.(AU)

Colon cancer is one of the most common types of cancer in the world and the second leading cause of death related to the disease in developed countries. Up to 75% of cases are associated with eating, indicating that a person can reduce their risk simply through dietary modification. Studies in animals show that various strains of lactic acid bacteria protect against colon cancer in rodents although data in humans are limited and conflicting. The aim of this study was to investigate the efficacy of acid lactic bacteria in the treatment and reduction of colon cancer in animal models. Systematic searches were conducted in electronic databases reaching 1079 related articles, only six articles were elected according instead of to the eligibility criteria for analysis. All reviewed articles showed satisfactory results on the inhibition of colon cancer in rats and mice when using predominantly Lactobacillus strains. This study can answer hypothesis that acid lactic bacteria has antitumor effect against colon cancer.(AU)