Effects of extreme weather events on child mood and behavior.

Extreme weather events (EWEs) are increasing in frequency and severity as the planet continues to become warmer. Resulting disasters have the potential to wreak havoc on the economy, infrastructure, family unit, and human health. Global estimates project that children will be disproportionately impacted by the changing climate - shouldering 88% of the related burdens. Exposure to EWEs in childhood is traumatic, with ramifications for mental health specifically. Symptoms of posttraumatic stress, depression, and anxiety have all been associated with childhood EWE exposure and have the potential to persist under certain circumstances. Conversely, many childhood survivors of EWE also demonstrate resilience and experience only transient symptoms. While the majority of studies are focused on the effects resulting from one specific type of disaster (hurricanes), we have synthesized the literature across the various types of EWEs. We describe psychological symptoms and behavior, the potential for long-term effects, and potential protective factors and risk factors. What this paper adds Climate change-related phenomena such as extreme weather events (EWEs) have the potential to impact mood and behavior in children. Posttraumatic stress (PTS) is the most common mental health consequence in child survivors of EWEs. PTS is often comorbid with depression and/or anxiety in this group.

Colon Cancer and Diverticular Disease Association: a Case-Control Study.

PURPOSE: To determine if there is an association between diverticular disease and colon cancer diagnoses with a secondary outcome of assessing other known risk factors for colon cancer. Colon cancer and diverticular disease have many shared symptoms and risk factors; the association between the two has been debated for many years. METHODS: 36 cases of colon cancer and 144 age- and sex-matched controls were identified from records at an outpatient endoscopy center in Georgia. These cases and controls then were subject to a retrospective chart review to obtain any known risk factor data points for both diverticular disease and colon cancer. A traditional conditional logistic regression and a stepwise conditional logistic regression model were used to analyze the data using significant data points (P < 0.05). RESULTS: The final stepwise model found that systolic blood pressure (aOR = 1.027, 95% CI = 1.001 to 1.053), history of polyps (aOR = 0.106, 95% CI = 0.029 to 0.387), exercise (aOR = 0.311, 95% CI = 0.029 to 0.387), and history of diverticular disease (aOR = 0.269, 95% CI = 0.091 to 0.795) were protective factors significantly associated with colon cancer. CONCLUSIONS: Presence and history of the removal of colorectal polyps, presence or history of diverticular disease, and exercise pose as protective factors against development of colon cancer.

Accuracy of Signs and Symptoms for the Diagnosis of Community-acquired Pneumonia: A Meta-analysis.

BACKGROUND: Community-acquired pneumonia (CAP) is an important source of morbidity and mortality. However, overtreatment of acute cough illness with antibiotics is an important problem, so improved diagnosis of CAP could help reduce inappropriate antibiotic use. METHODS: This was a meta-analysis of prospective cohort studies of patients with clinically suspected pneumonia or acute cough that used imaging as the reference standard. All studies were reviewed in parallel by two researchers and quality was assessed using the QUADAS-2 criteria. Summary measures of accuracy included sensitivity, specificity, likelihood ratios, the diagnostic odds ratio, and the area under the receiver operating characteristic curve (AUROCC) and were calculated using bivariate meta-analysis. RESULTS: We identified 17 studies, of which 12 were judged to be at low risk of bias and the remainder at moderate risk of bias. The prevalence of CAP was 10% in nine primary care studies and was 20% in seven emergency department studies. The probability of CAP is increased most by an abnormal overall clinical impression suggesting CAP (positive likelihood ratio [LR+] = 6.32, 95% CI = 3.58 to 10.5), egophony (LR+ = 6.17, 95% CI = 1.34 to 18.0), dullness to percussion (LR+ = 2.62, 95% CI = 1.14 to 5.30), and measured temperature (LR+ = 2.52, 95% CI = 2.02 to 3.20), while it is decreased most by the absence of abnormal vital signs (LR- = 0.25, 95% CI = 0.11 to 0.48). The overall clinical impression also had the highest AUROCC at 0.741. CONCLUSIONS: While most individual signs and symptoms were unhelpful, selected signs and symptoms are of value for diagnosing CAP. Teaching and performing these high value elements of the physical examination should be prioritized, with the goal of better targeting chest radiographs and ultimately antibiotics.

Accuracy of Biomarkers for the Diagnosis of Adult Community-acquired Pneumonia: A Meta-analysis.

BACKGROUND: Biomarkers such as C-reactive protein (CRP) and procalcitonin may help distinguish community-acquired pneumonia (CAP) from other causes of lower respiratory tract infection. METHODS: We performed a systematic review of the literature to identify prospective studies evaluating the accuracy of a biomarker in patients with acute cough or suspected CAP. We performed parallel abstraction of data regarding study inclusion, characteristics, quality, and test accuracy. Study quality was evaluated using QUADAS-2. Bivariate meta-analysis was performed using the mada package in R, and summary receiver operating characteristic (ROC) curves were created. RESULTS: Fourteen studies met our inclusion and exclusion criteria; three were at low risk of bias and four at moderate risk of bias, largely due to failure to prespecify diagnostic thresholds. Considering all studies regardless of the cutoff used, CRP was most accurate (area under the ROC curve = 0.802), followed by leukocytosis (0.777) and procalcitonin (0.771). Lipopolysaccharide-binding protein and fibrinogen are promising, but were only studied in a single report. For CRP and procalcitonin, the positive and negative likelihood ratios (LR+ and LR-, respectively) varied inversely based on the cutoff. For CRP, LR+ and LR- were 2.08 and 0.32 for a cutoff of 20 mg/L, 3.64 and 0.36 for a cutoff of 50 mg/L, and 5.89 and 0.47 for a cutoff of 100 mg/L. For procalcitonin, LR+ and LR- were 2.50 and 0.39 for a cutoff of 0.10 µg/L, 5.43 and 0.62 for a cutoff of 0.25 µg/L, and 8.25 and 0.76 for a cutoff of 0.50 µg/L. The combination of CRP >49.5 mg/L and procalcitonin >0.1 µg/L had LR+ of 2.24 and LR- of 0.44. CONCLUSIONS: The best evidence supports CRP as the preferred biomarker for diagnosis of outpatient CAP given its accuracy, low cost, and point-of-care availability.

Meta-analysis of Calibration, Discrimination, and Stratum-Specific Likelihood Ratios for the CRB-65 Score.

BACKGROUND: The CRB-65 score is recommended as a decision support tool to help identify patients with community-acquired pneumonia (CAP) who can safely be treated as outpatients. OBJECTIVE: To perform an updated meta-analysis of the accuracy, discrimination, and calibration of the CRB-65 score using a novel approach to calculation of stratum-specific likelihood ratios. DESIGN: Meta-analysis of accuracy, discrimination, and calibration. METHODS: We searched PubMed, Google, previous systematic reviews, and reference lists of included studies. Data was abstracted and quality assessed in parallel by two investigators. The quality assessment used an adaptation of the TRIPOD and PROBAST criteria. Measures of discrimination, calibration, and stratum-specific likelihood ratios are reported. KEY RESULTS: Twenty-nine studies met our inclusion criteria and provided usable data. Most studies were set in Europe, none in North America, and 12 were judged to be at low risk of bias. The pooled estimate of area under the receiver operating characteristic curve was 0.74 (95% CI 0.71-0.77) for all studies. Calibration was good although there was significant heterogeneity; the pooled estimate of the ratio of observed to expected mortality for all studies was 1.04 (95% CI 0.91-1.19). The corresponding values for studies at low risk of bias where patients could be treated as outpatients or inpatients were 0.76 (0.70-0.81) and 0.88 (0.69-1.13). Summary estimates of stratum-specific likelihood ratios for all studies were 0.19 for the low-risk group, 1.1 for the moderate-risk group, and 4.5 for the high-risk group, and 0.13, 1.3, and 5.6 for studies at low risk of bias where patients could be treated as outpatients or inpatients. CONCLUSIONS: The CRB-65 is useful for identifying low-risk patients for outpatient therapy. Given a 4% overall mortality risk, patients classified as low risk by the CRB-65 had an outpatient mortality risk of no more than 0.5%.