Alternative scoring of the Patient Health Questionnaire-9 in neurological populations: an approach based on a predictive algorithm deriving from individual item scores.

OBJECTIVE: The study objective was to assess whether machine learning methods could improve predictive performance of the PHQ-9 for depression in patients with neurological disease. Specifically, we assessed whether a predictive algorithm deriving from all nine items could outperform the tradition of summing the items and applying a cut-point. METHOD: Data from the NEEDS Study was used (n = 825). Demographic data, PHQ-9 scores, and MDD diagnoses (via the SCID) were obtained. Logistic LASSO, logistic regression, and non-parametric ROC analyses were performed. The ROC curve was used to identify the optimal cut-point for regression-derived predictive algorithms using the Youden method. RESULTS: The traditional approach to PHQ-9 scoring had a classification accuracy of 85.1% (sensitivity: 84.5%; specificity: 85.2%). The logistic LASSO regression model had a classification accuracy of 85.6% (sensitivity: 83.3%; specificity: 86.1%). The logistic regression model had a classification accuracy of 85.8% (sensitivity: 91.4%; specificity: 84.8%). Both models had similar areas under the curve values (logistic LASSO: 0.9097; logistic regression: 0.9026). CONCLUSIONS: The current cut-off threshold approach to PHQ-9 scoring and interpretation remains clinically appropriate.

White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.

Background and Purpose- Acute minor neurological deficits are a common complaint in the emergency department and differentiation of transient ischemic attack/minor stroke from a stroke mimic is difficult. We sought to assess the ability of white matter hyperintensity (WMH) volume to aid the diagnosis in such patients. Methods- This is a post hoc analysis of the previously published SpecTRA study (Spectrometry in TIA Rapid Assessment) of adult patients that presented to the emergency department with acute minor neurological deficits between December 2013 and March 2017. WMH volumes were measured if fluid-attenuated inversion recovery imaging was available. Outcomes of interest were final diagnosis, symptoms at presentation, and 90-day stroke recurrence. Results- WMH volume was available for 1485 patients. Median age was 70 years (interquartile range, 59-80), and 46.7% were female. Mean WMH volume was higher in transient ischemic attack/minor strokes compared with stroke mimics (1.71 ln mL [95% CI, 1.63-1.79 ln mL] versus 1.15 ln mL [95% CI, 1.02-1.27 ln mL], P<0.001). In multivariable-adjusted logistic regression analysis, WMH volume was not associated with final diagnosis. However, the combination of both diffusion-weighted imaging positivity and high WMH volume led to lower odds of focal symptoms at presentation (P=0.035). Conclusions- The combination of diffusion-weighted imaging positivity and high WMH volume was associated with lower odds of focal symptoms at presentation in patients seen with minor neurological deficits in the emergency department. This suggests that WMH volume might be an important consideration and the absence of focal symptoms at presentation should not discourage clinicians from further investigating patients with suspected cerebral ischemia.

Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event.

IMPORTANCE: Sex differences have been described in the presentation, care, and outcomes among people with acute ischemic strokes, but these differences are less understood for minor ischemic cerebrovascular events. The present study hypothesized that, compared with men, women are more likely to report nonfocal symptoms and to receive a stroke mimic diagnosis. OBJECTIVE: To evaluate sex differences in the symptoms, diagnoses, and outcomes of patients with acute transient or minor neurologic events. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study of patients with minor ischemic cerebrovascular events or stroke mimics enrolled at multicenter academic emergency departments in Canada between December 2013 and March 2017 and followed up for 90 days is a substudy of SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment). In total, 1729 consecutive consenting patients with acute transient or minor neurologic symptoms were referred for neurologic evaluation; 66 patients were excluded for protocol violation (n = 46) or diagnosis of transient global amnesia (n = 20). EXPOSURES: The main exposure was female or male sex. MAIN OUTCOMES AND MEASURES: The main outcome was the clinical diagnosis (cerebral ischemia vs stroke mimic). Secondary outcomes were 90-day stroke recurrence and 90-day composite outcome of stroke, myocardial infarction, or death. The association between presenting symptoms (focal vs nonfocal) and clinical diagnosis was also assessed. Research hypotheses were formulated after data collection. RESULTS: Of 1648 patients included, 770 (46.7%) were women, the median (interquartile range) age was 70 (59-80) years, 1509 patients (91.6%) underwent brain magnetic resonance imaging, and 1582 patients (96.0%) completed the 90-day follow-up. Women (522 of 770 [67.8%]) were less likely than men (674 of 878 [76.8%]) to receive a diagnosis of cerebral ischemia (adjusted risk ratio [aRR], 0.88; 95% CI, 0.82-0.95), but the 90-day stroke recurrence outcome (aRR, 0.90; 95% CI, 0.48-1.66) and 90-day composite outcome (aRR, 0.86; 95% CI, 0.54-1.32) were similar for men and women. No significant sex differences were found for presenting symptoms. Compared with patients with no focal neurologic symptoms, those with focal and nonfocal symptoms were more likely to receive a diagnosis of cerebral ischemia (aRR, 1.28; 95% CI, 1.15-1.39), but the risk was highest among patients with focal symptoms only (aRR, 1.45; 95% CI, 1.34-1.53). Sex did not modify these associations. CONCLUSIONS AND RELEVANCE: The results of the present study suggest that, despite similar presenting symptoms among men and women, women may be more likely to receive a diagnosis of stroke mimic, but they may not have a lower risk than men of subsequent vascular events, indicating potentially missed opportunities for prevention of vascular events among women.