Alcohol use disorder as a moderator of the relationship between posttraumatic stress disorder and suicidality among military personnel.

BACKGROUND: Alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and suicide are substantial public health concerns among military service members, yet the nature of their relationships is not well understood. Here, we tested the hypothesis that AUD moderates the relationship between PTSD symptom severity and suicidal ideation. METHODS: This secondary analysis uses data collected at baseline for a randomized clinical trial. The sample consists of 160 active-duty service members from three service branches (Army, Air Force, and Navy). All participants met diagnostic criteria for PTSD and were not engaged in evidence-based PTSD treatment at the time of enrollment. Zero-inflated Poisson generalized linear regression models were used to test the associations of PTSD and AUD symptom severity with the presence and severity of suicidal ideation. RESULTS: Findings suggest that AUD symptom severity moderates (i.e., amplifies) the relationship between PTSD symptoms and severity of suicidal ideation among military personnel with untreated PTSD. Among service members with mild or absent AUD, we found no significant association between PTSD symptoms and the severity of suicidal ideation. However, when AUD severity was average (i.e., sample mean) or high (mean + 1SD), PTSD symptoms were significantly positively associated with the severity of suicidal ideation. CONCLUSIONS: This study highlights the importance of assessing AUD and PTSD as a part of suicide risk evaluations of veterans. The results also provide strong support for the maintenance and further development in the military health system of treatment programs that simultaneously address AUD and PTSD comorbidity.

Hip and knee replacement in lower limb amputees: a scoping review.

BACKGROUND: There are many consequences of lower limb amputation, including altered biomechanics of gait. It has previously been shown that these can lead to increased rates of osteoarthritis (OA). A common and successful treatment for severe OA is joint replacement. However, it is unclear whether amputees undergoing this surgery can expect the same outcomes or complication profile compared with non-amputees. Furthermore, there are key technical challenges associated with hip or knee replacement in lower limb amputees. This scoping review aimed to identify and summarise the existing evidence base. METHODS: This was a systematic scoping review performed according to PRISMA guidelines. An electronic database search of MEDLINE (PubMed), Cochrane Library, EMBASE and CINAHL was completed from the date of inception to 1st April 2023. All peer reviewed literature related to hip or knee replacement among lower limb amputees was included. RESULTS: Of the 931 records identified, 40 studies were included in this study. The available literature consisted primarily of case reports and case series, with generally low level of evidence. In total, there were 265 patients of which 195 received total hip replacement (THR), 51 received total knee replacement (TKR) and 21 received hip hemiarthroplasty. The most common reason for amputation was trauma (34.2%), and the main indication for joint replacement was OA (77.1%), occurring more frequently in the contralateral limb (66.7%). The outcomes reported varied widely between studies, with most suggesting good functional status post-operatively. A variety of technical tips were reported, primarily concerned with intra-operative control of the residual limb. CONCLUSION: There is a need for more observational studies to clearly define the association between amputation and subsequent need for joint replacement. Furthermore, comparative studies are needed to identify whether amputees can be expected to achieve similar functional outcomes after surgery, and if they are at higher risk of certain complications.

Improving voluntary engagement for posttraumatic stress disorder treatment among active-duty service members using motivational enhancement therapy.

OBJECTIVE: Posttraumatic stress disorder (PTSD) prevalence in the military is high and effective treatments are underutilized. Motivational enhancement therapy (MET) "check-ups" are brief interventions to elicit treatment uptake for those who are nontreatment seeking. The aim of the current study was to test the efficacy of a novel MET intervention designed to promote treatment engagement among active-duty U.S. military personnel with untreated PTSD. METHOD: One hundred and sixty-one active-duty service members who met the criteria for PTSD were randomized to MET or treatment as usual (TAU, treatment resource and referral). MET participants (n = 82) received up to three 30-90 min telephone sessions. TAU participants (n = 79) were mailed PTSD resources and referrals. Follow-up assessments were conducted 6-week, 3- and 6-month postbaseline. RESULTS: Mixed effect model results indicated treatment uptake significantly increased over time but there were no significant differences between conditions or interactions. PTSD symptom severity significantly decreased for both conditions. There was also a significant three-way interaction with baseline readiness-to-change confidence. Those low in baseline readiness-to-change saw more favorable effects of MET (relative to TAU) at 6-month follow-up. CONCLUSIONS: Results suggest both MET and high-quality referral options have promise as a means of increasing evidence-based treatment uptake and decreasing PTSD for service members with PTSD. MET may be particularly useful for individuals with low confidence in their ability to address PTSD. Given the individual and societal costs of PTSD, there is a need for interventions facilitating treatment uptake. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Intraoperative cell salvage in revision hip arthroplasty.

Aims: The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods: An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results: Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion: We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity.

Social support and treatment utilization for posttraumatic stress disorder: Examining reciprocal relations among active duty service members.

Evidence-based treatments for posttraumatic stress disorder (PTSD) are underutilized by active duty service members in the United States. Social support may help service members overcome avoidance and facilitate treatment utilization. In turn, treatment utilization may improve social support. To evaluate these possibilities, the aim of the current study was to examine potential reciprocal associations between social support and treatment utilization among service members. Secondary analyses were conducted on a randomized controlled trial of 161 U.S. military service members with PTSD. Participants completed assessments of perceived social support and attendance at individual therapy sessions at baseline and 3- and 6-month follow-ups. To determine reciprocal relations between social support and treatment utilization, a Bayesian approach was used to estimate a random-intercept cross-lagged panel model with a two-part variable for treatment utilization (i.e., any therapy, and if so, dose). There were no between-person associations between average social support and treatment utilization. One prospective cross-lagged within-person association emerged as significant: social support at 3 months was negatively associated with any therapy use at 6 months; the model explained 26.1% of the variance in this observed variable. The findings revealed that low social support promoted subsequent treatment utilization, but such treatment did not lead to changes in social support. This suggests service members with PTSD may have been motivated to attend individual therapy in pursuit of social connection and support. Future research is needed to determine if reciprocal associations between various forms of social support and therapy utilization differ by treatment modality.

What's In It for Me? Motivating the Untreated Abuser to Consider Treatment.

This paper presents findings of a second trial evaluating telephone-based motivational enhancement therapy (MET) to motivate untreated and unadjudicated men who abuse their intimate partners to explore treatment options. Participants' perceptions of how their abuse is negatively affecting them personally are a highlight of the paper. One hundred forty-one adult men were recruited through social marketing and randomly assigned to the intervention (MET) or comparison (Mail) group. The MET condition consisted of two feedback sessions guided by a personalized feedback report on participants' intimate partner violence (IPV) and substance use. The Mail condition included a mailed educational brochure on IPV and substance use. Results supported the likely effectiveness of MET in short-term reduction of IPV behavior, marijuana use, and increasing motivation for treatment seeking particularly for participants who reported more adverse consequences of IPV to themselves. Findings emphasize the importance of including a focus in interventions on IPV's impact on the abusers themselves. The study's virtual participation and success in reaching and retaining a diverse population of male abusers can contribute to transformative justice and communities looking for alternative early interventions for men of color prior to encountering the criminal justice system.

Does Effectiveness of a Brief Substance Use Treatment Depend on PTSD? An Evaluation of Motivational Enhancement Therapy for Active-Duty Army Personnel.

OBJECTIVE: Posttraumatic stress disorder (PTSD) with comorbid substance use disorders (SUDs) has been associated with poorer treatment outcomes. The present study examined associations between provisional PTSD at baseline and 3 months with 6-month treatment outcomes from either a one-session motivational enhancement therapy (MET) or education intervention addressing substance use. METHOD: Secondary analyses were conducted on a randomized clinical trial comparing a novel MET intervention to an educational intervention for Army personnel with SUD who were not engaged in SUD treatment (n = 242; 92.1% male). We compared three groups with complete data on baseline and 3-month provisional PTSD: individuals without provisional PTSD at baseline (n = 98), those with provisional PTSD remitted by 3 months (n = 42), and those with provisional PTSD unremitted at 3 months (n = 53) on alcohol use frequency, quantity, consequences, and related diagnoses. RESULTS: Individuals with unremitted provisional PTSD were at increased risk for moderate/severe alcohol use disorder at 6 months relative to those without baseline provisional PTSD (odds ratio = 4.53, p = .007). The effect of MET on drinks per week at 6 months (controlling for baseline) differed with a significant effect of MET for individuals with remitted provisional PTSD (count ratio = 0.41, p = .005). CONCLUSIONS: Both interventions were effective in reducing drinking even for those with provisional PTSD, although, compared with education, MET had slightly better effects on reducing drinking quantity for those with remitted PTSD. Findings suggest that PTSD remission may serve as an early prognostic indicator of long-term alcohol use changes, or alternatively, delivery of MET during heightened transitory distress may be most effective for reducing alcohol use.

Development of StressCheck: A telehealth motivational enhancement therapy to improve voluntary engagement for PTSD treatment among active-duty service members.

BACKGROUND: Rates of PTSD in active-duty military are high relative to the general population. Although efficacious treatments exist, they are underutilized. Many service members with PTSD do not present for treatment and, of those who do, many do not receive sufficient doses of the interventions to receive full benefits. Motivational Enhancement Therapy (MET) "check-ups", are brief interventions designed to elicit treatment engagement for those who are not treatment-seeking. METHODS: StressCheck is an MET for nontreatment seeking Army and Air Force personnel. StressCheck aims to improve PTSD and increase treatment engagement, especially around evidence-based interventions, as well as to decrease stigma about seeking mental health services and improve knowledge about treatment options. This paper describes the intervention components and process of treatment development. The paper also describes next steps in testing the effectiveness of the intervention. CONCLUSION: PTSD is associated with deleterious health, occupational, and psychological effects. If effective, this innovative intervention will bridge the gap between those who are not treatment seeking and existing services, thereby enhancing reach and impact of existing services. GOV IDENTIFIER: NCT03423394.

Predicting 30-day mortality after hip fracture: the G4A calibrated prognostic tool.

INTRODUCTION: Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. MATERIALS AND METHODS: We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters' relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. RESULTS: The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow 'goodness of fit' test showed good concordance between observed and predicted mortality rates. CONCLUSIONS: We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.

Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study.

PURPOSE: The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture. METHODS: A multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for "fragility hip fractures" were included in the study. Patients' 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27. RESULTS: A total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865-3.978). CONCLUSION: Hip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of "long-COVID" and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.

Discussing substance use with clients during the COVID-19 pandemic: A motivational interviewing approach.

During the COVID-19 pandemic, trauma-exposed individuals may have heightened risk for substance use. Using substances to cope may contribute to the development of problematic substance use over time. It is imperative to initiate conversations about substance use with clients during this time and motivational interviewing offers an ideal framework for doing so. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Surgeon-Team Separation in Robotic Theaters: A Qualitative Observational and Interview Study.

BACKGROUND: The rapid uptake of robotic surgery has largely been driven by the improved technical aspects of minimally invasive surgery including improved ergonomics, wristed instruments, and 3-dimensional vision. However, little attention has been given to the effect of physical separation of the surgeon from the rest of the operating team. PURPOSE: The aim of this study was to examine in depth how this separation affected team dynamics and staff emotions. METHODS: Robotic procedures were observed in 2 tertiary hospitals, and laparoscopic/open procedures were added for comparison; field notes were taken instantaneously. One-to-one interviews with theater team members were audio recorded and transcribed verbatim. Qualitative analysis was conducted via grounded theory approach using NVIVO11. RESULTS: Twenty-nine participants (26 interviewed) were recruited to the study (11 females) and 134 (109 robotic) hours of observation were completed across gynecology, urology, and colorectal surgery.The following 3 main themes emerged with compounding factors identified: (a) communication challenge, (b) immersion versus distraction, and (c) emotional impact. Compounding factors included the following: individual and team experience, staffing levels, and the physical theater environment. CONCLUSIONS: Our emergent theory is that "surgeon-team separation in robotic theaters poses communication challenges which impacts on situational awareness and staff emotions." These can be ameliorated by staff training, increased experience, and team/procedure consistency.

Mechanisms and moderators of intervention efficacy for soldiers with untreated alcohol use disorder.

OBJECTIVE: This research evaluates changes in perceived military and civilian drinking norms as mechanisms of the effects of a motivational enhancement therapy (MET) intervention on changes in alcohol consumption among active-duty military personnel with a substance use disorder. We also evaluate the value of providing tolerance and family history risk-related personalized feedback by testing whether those receiving feedback indicating higher risk reduce their drinking more than those receiving feedback indicating lower risk or receiving no feedback. METHOD: Participants (N = 242; Mage = 28 years; 92% male; 59% Caucasian) completed a baseline questionnaire and were randomly assigned to a MET or educational control condition. Both conditions were single session and took place over the telephone. Outcomes were assessed 3 and 6 months later. The study was preregistered at ClinicalTrials.gov (NCT01128140). RESULTS: We found evidence that reductions in perceived norms for other military personnel, but not for civilians, mediated intervention efficacy on reductions in alcohol use. Further, the MET intervention was successful at reducing drinking among soldiers who reported higher levels of baseline tolerance and family history risk, but not succuessful at reducing drinking among those who reported low or medium levels of risk. CONCLUSIONS: Systematic evaluation of whether and how individual intervention components contribute to efficacy is a promising approach for refining and improving interventions. This research suggests that MET interventions may wish to target focal perceived norms and provides support for discussion of feedback indicating elevated risks due to tolerance and family history. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Firearm Retailers and Suicide: Results from a Survey Assessing Willingness to Engage in Prevention Efforts.

OBJECTIVE: Firearms are a highly lethal and commonly used means of suicide. Firearm retailers may be an important group of community members to train as they guide sales and have conversations about firearm-related laws and safety issues with customers. This study presents findings from the largest survey to date of independently owned firearm retailers (n = 178) in Washington State with the goal of ascertaining the extent of willingness to engage in suicide prevention efforts and factors that may underlie willingness. METHODS: Descriptive analyses and logistic regressions assess factors related to self-reported willingness to engage in suicide prevention activities guided by a well-tested theoretical model. RESULTS: Respondents are unaware that suicide is the leading type of firearm fatality and have high levels of exposure to suicide in their personal and professional lives. The majority endorse a willingness to learn and engage in suicide prevention activities. Knowledge about warning signs of suicide and beliefs about the preventability of suicide are predictive of a willingness to engage in prevention efforts. Reluctance to discuss personal issues with customers is negatively associated with willingness to engage in prevention efforts. CONCLUSIONS: Suggestions for how to improve outreach to firearm retailers to enhance suicide prevention efforts are discussed.

One-year follow-up of a sit-stand workstation intervention to decrease sedentary time in office workers.

BACKGROUND: Prolonged sedentary time is associated with adverse health outcomes, after controlling for the role of moderate-to-vigorous physical activity. We previously reported on a four-week randomized trial using a sit-stand desk (SSD) intervention that decreased sedentary time at work without changing activity level during non-work hours. PURPOSE: The purpose of this study was to measure the impact of the SSD on sitting time and activity level one year after the original intervention. METHODS: A pre-post design was used where the control period from the original study was regarded as "pre" and the measurements made in the follow-up study as "post." The follow-up study was conducted in the same office workers over a two-week period in June 2013. RESULTS: Fifteen out of the 23 participants took part in the follow-up study. Self-reported sitting time during work-hours was decreased by 22% (95% CI: 15% to 29%; p < 0.001), replaced almost entirely by standing. Activity measured by Gruve accelerometer during work-hours were significantly higher in the one-year follow-up period compared to baseline (+24,748 AU/h; 95% CI: 7150 to 42,347; p < 0.01). Sedentary time during work-hours was decreased by 0.77 min per work-hour (95% CI: -1.88 to 0.33 min/h; p = 0.17). Qualitative findings through focus group sessions suggested the workers had overall favorable experiences with the SSDs without negatively impacting productivity. CONCLUSION: One year following the original intervention, participants continue to have increased activity and decreased sedentary time at work with the use of SSDs.

A Single Center Evaluation of the Diagnostic Accuracy of Multiparametric Magnetic Resonance Imaging against Transperineal Prostate Mapping Biopsy: An Analysis of Men with Benign Histology and Insignificant Cancer following Transrectal Ultrasound Biopsy.

PURPOSE: In this study we evaluated the diagnostic performance of transrectal ultrasound guided biopsy and multiparametric magnetic resonance imaging to detect prostate cancer against transperineal prostate mapping biopsy as the reference test. MATERIALS AND METHODS: Transrectal ultrasound guided biopsy, multiparametric magnetic resonance imaging and transperineal prostate mapping biopsy were performed in 426 patients between April 2012 and January 2016. Patients initially underwent systematic 12 core transrectal ultrasound guided biopsy followed 3 months later by 1.5 Tesla, high resolution T2, diffusion-weighted, dynamic contrast enhanced multiparametric magnetic resonance imaging. Two specialist uroradiologists blinded to the results of transperineal prostate mapping biopsy allocated a PI-RADS™ (Prostate Imaging-Reporting and Data System) score to each multiparametric magnetic resonance imaging study. Transperineal prostate mapping biopsy with 5 mm interval sampling, which was performed within 6 months of multiparametric magnetic resonance imaging, served as the reference test. RESULTS: Transrectal ultrasound guided biopsy identified 247 of 426 patients with prostate cancer and 179 of 426 with benign histology. Transperineal prostate mapping biopsy detected prostate cancer in 321 of 426 patients. On transperineal prostate mapping biopsy 94 of 179 patients with benign transrectal ultrasound guided biopsy had prostate cancer and 95 of 247 with prostate cancer on transrectal ultrasound guided biopsy were identified with cancer of higher grade. Using a multiparametric magnetic resonance imaging PI-RADS score of 3 or greater to detect significant prostate cancer, defined as any core containing Gleason 4 + 3 or greater prostate cancer on transperineal prostate mapping biopsy, the ROC AUC was 0.754 (95% CI 0.677-0.819) with 87.0% sensitivity (95% CI 77.3-97.0), 55.3% specificity (95% CI 50.2-60.4) and 97.1% negative predictive value (95% CI 94.8-99.4). CONCLUSIONS: Multiparametric magnetic resonance imaging is a more accurate diagnostic test than transrectal ultrasound guided biopsy. However, a significant proportion of ISUP (International Society of Urological Pathology) Grade Group 2 prostate cancer remained undetected following multiparametric magnetic resonance imaging. Although multiparametric magnetic resonance imaging could avoid unnecessary biopsy in many patients with ISUP Grade Group 3 or greater prostate cancer, at less stringent definitions of significant cancer a substantial proportion of prostate cancer would remain undetected after multiparametric magnetic resonance imaging.

Utility of early transperineal template-guided prostate biopsy for risk stratification in men undergoing active surveillance for prostate cancer.

OBJECTIVE: To assess the accuracy and utility of routine multiparametric magnetic resonance imaging (mpMRI) and transperineal template-guided prostate biopsy (TPB) after enrolment in active surveillance (AS). PATIENTS AND METHODS: From April 2012 to December 2016 consecutive men from our single institution, diagnosed with low- or intermediate-risk prostate cancer on transrectal ultrasonography-guided biopsy, were offered further staging with early mpMRI and TPB within 12 months of diagnosis. Data were collected prospectively. Eligibility criteria comprised: age ≤77 years; Gleason score ≤3 + 4; clinical stage T1-T2; PSA ≤15 ng/mL; and <50% positive biopsy cores. RESULTS: A total of 208 men were enrolled, including 196 with Gleason score 3 + 3 and 12 with Gleason score 3 + 4 disease. The median (range) number of TPB cores was 50 (17-161), with a mean TPB core density of 1.2 cores/cm3 prostate volume. A total of 83 men (39.9%) underwent histopathological upgrading after TPB, including 76 men (38.8%) with Gleason score 3 + 3 disease and seven men (58.3%) with Gleason score 3 + 4 disease. Of these, 26 (31.3%) were found to harbour primary pattern Gleason grade ≥4 disease. In all, 24 (28.9%) upgraded cases had Prostate Imaging Reporting and Data System (PI-RADS) score 1 or 2 lesions on mpMRI, including five men with Gleason score ≥4 + 3 disease. Of these, 14 (58.3%) had a prostate-specific antigen (PSA) density of ≥0.15, including four out of the five men with Gleason ≥4 + 3 disease. Overall there was a change in prostate cancer management in 77 men (37.0%) after TPB. CONCLUSIONS: Early TPB during AS is associated with significant upgrading and a change in treatment plan in over a third of men. If TPB was omitted in men with a PI-RADS score <3 and a PSA density <0.15, 12% of those harbouring more significant disease would have been misclassified.