Evaluating Clinical Outcomes in Patients Being Treated Exclusively via Telepsychiatry: Retrospective Data Analysis.

BACKGROUND: Depression and anxiety are highly prevalent conditions in the United States. Despite the availability of suitable therapeutic options, limited access to high-quality psychiatrists represents a major barrier to treatment. Although telepsychiatry has the potential to improve access to psychiatrists, treatment efficacy in the telepsychiatry model remains unclear. OBJECTIVE: Our primary objective was to determine whether there was a clinically meaningful change in 1 of 2 validated outcome measures of depression and anxiety-the Patient Health Questionnaire-8 (PHQ-8) or the Generalized Anxiety Disorder-7 (GAD-7)-after receiving at least 8 weeks of treatment in an outpatient telepsychiatry setting. METHODS: We included treatment-seeking patients enrolled in a large outpatient telepsychiatry service that accepts commercial insurance. All analyzed patients completed the GAD-7 and PHQ-8 prior to their first appointment and at least once after 8 weeks of treatment. Treatments included comprehensive diagnostic evaluation, supportive psychotherapy, and medication management. RESULTS: In total, 1826 treatment-seeking patients were evaluated for clinically meaningful changes in GAD-7 and PHQ-8 scores during treatment. Mean treatment duration was 103 (SD 34) days. At baseline, 58.8% (1074/1826) and 60.1% (1097/1826) of patients exhibited at least moderate anxiety and depression, respectively. In response to treatment, mean change for GAD-7 was -6.71 (95% CI -7.03 to -6.40) and for PHQ-8 was -6.85 (95% CI -7.18 to -6.52). Patients with at least moderate symptoms at baseline showed a 45.7% reduction in GAD-7 scores and a 43.1% reduction in PHQ-8 scores. Effect sizes for GAD-7 and PHQ-8, as measured by Cohen d for paired samples, were d=1.30 (P<.001) and d=1.23 (P<.001), respectively. Changes in GAD-7 and PHQ-8 scores correlated with the type of insurance held by the patients. Greatest reductions in scores were observed among patients with commercial insurance (45% and 43.9% reductions in GAD-7 and PHQ-8 scores, respectively). Although patients with Medicare did exhibit statistically significant reductions in GAD-7 and PHQ-8 scores from baseline (P<.001), these improvements were attenuated compared to those in patients with commercial insurance (29.2% and 27.6% reduction in GAD-7 and PHQ-8 scores, respectively). Pairwise comparison tests revealed significant differences in treatment responses in patients with Medicare versus commercial insurance (P<.001). Responses were independent of patient geographic classification (urban vs rural; P=.48 for GAD-7 and P=.07 for PHQ-8). The finding that treatment efficacy was comparable among rural and urban patients indicated that telepsychiatry is a promising approach to overcome treatment disparities that stem from geographical constraints. CONCLUSIONS: In this large retrospective data analysis of treatment-seeking patients using a telepsychiatry platform, we found robust and clinically significant improvement in depression and anxiety symptoms during treatment. The results provide further evidence that telepsychiatry is highly effective and has the potential to improve access to psychiatric care.

The Healthy Hearts Project: Development and evaluation of a website for cardiovascular risk assessment and visualisation and self-management through healthy lifestyle goal-setting.

Materially deprived communities in the UK have excess morbidity and mortality from cardiovascular disease (CVD) but are less likely to engage with formal care pathways. Community engagement and e-health may be more effective ways to promote risk-reducing lifestyle change. The "Healthy Hearts Project" website was designed for use by community health workers (CHWs) for cardiovascular risk assessment and lifestyle goal setting, or for independent use by community members. This paper describes the website's development and evaluation. The website was developed using interactive wire frame prototypes in a user-led approach. Qualitative evaluation of the completed website's usability and acceptability was conducted using the "Thinking Aloud" method in a purposive sample of 10 participants (one voluntary sector employee, three CHWs, two community members and four healthcare professionals). Thinking Aloud interview transcripts were thematically analysed using an inductive approach. A separate quantitative evaluation of usability and the effect of using the website on CVD knowledge and beliefs was conducted. A random sample of 134 participants, recruited using the online platform Prolific, completed the "Attitudes and Beliefs About Cardiovascular Disease" (ABCD) questionnaire before and after using the website, along with the System Usability Scale (SUS). Qualitative evaluation-Four key themes were identified: 1) Website functionality and design-participants generally found the website easy to use and understood the risk communication graphics and the feedback and goal-setting features,; 2) Inclusivity and representation-most participants considered the website inclusive of a range of users/cultures; 3) Language and comprehension-participants found the language used easy to understand but suggested reducing the amount of text; 4) Motivation and barriers to change-participants liked the personalized feedback and empowerment offered by goal-setting but commented on the need for self-motivation. Quantitative evaluation-The mean score across all domains of the ABCD questionnaire (from 2.99 to 3.11, p<0.001) and in the sub-domains relating to attitudes and beliefs around healthy eating and exercise increased after using the website. The mean(sd) score on the SUS was 77.5 (13.5). The website's usability was generally rated well by both quantitative and qualitative measures, and measures of CVD knowledge improved after use. A number of general recommendations for the design of eHealth behaviour change tools are made based on participants' suggestions to improve the website.

Outcomes After Positive Syphilis Screening.

BACKGROUND: Syphilis screening during pregnancy helps prevent congenital syphilis. The harms associated with false positive (FP) screens and whether screening leads to correct treatments has not been well determined. METHODS: The population included mothers and infants from 75 056 pregnancies. Using laboratory-based criteria we classified initial positive syphilis screens as FP or true positive (TP) and calculated false discovery rates. For mothers and infants we determined treatments, clinical characteristics, and syphilis classifications. RESULTS: There were 221 positive screens: 183 FP and 38 TP. The false discovery rate was 0.83 (95% confidence interval [CI], 0.78-0.88). False discovery rates were similar for traditional 0.83 [95% CI, 0.72-0.94] and reverse algorithms 0.83 (95% CI, 0.77-0.88), and for syphilis Immunoglobin (Ig) G 0.79 (95% CI, 0.71-0.86) and total 0.90 (95% CI, 0.82-0.97) assays. FP screens led to treatment in 2 women and 1 infant. Two high-risk women were not rescreened at delivery and were diagnosed after hospital discharge; 1 infant developed congenital syphilis. Among 15 TP women with new syphilis, the diagnosis was before the late third trimester in 14 (93%). In one-half of these women, there was concern for reinfection, treatment failure, inadequate treatment or follow-up care, or late treatment, and their infants did not achieve an optimal syphilis classification. CONCLUSIONS: Syphilis screening identifies maternal syphilis, but limitations include FP screens, which occasionally lead to unnecessary treatment, inconsistent risk-based rescreening, and among TP mothers failure to optimize care to prevent birth of infants at higher risk for congenital syphilis.

Congenital syphilis: Missed opportunities and the case for rescreening during pregnancy and at delivery.

Two infants treated for syphilis born to at risk mothers who screened negative at their first prenatal visit but were not rescreened at delivery are described. The first presented with classic, but unrecognized, features of congenital syphilis. In the second case, possible early maternal syphilis was diagnosed soon after delivery using the treponemal first reverse-screening algorithm. Although the child's physical exam was normal and the maternal rapid plasma reagin (RPR) negative, the child was treated for syphilis because maternal confirmatory treponemal tests suggested recent seroconversion. Given the re-emergence of congenital syphilis, our report aims to demonstrate the importance of rescreening women at increased risk and improve awareness of common manifestations of the syphilis disease in the newborn. For women at increased risk, repeat syphilis testing early in the third trimester and again at delivery in communities and populations with a high prevalence of syphilis is recommended.

Genome-wide transcriptional analysis of the phosphate starvation stimulon of Bacillus subtilis.

Bacillus subtilis responds to phosphate starvation stress by inducing the PhoP and SigB regulons. While the PhoP regulon provides a specific response to phosphate starvation stress, maximizing the acquisition of phosphate (P(i)) from the environment and reducing the cellular requirement for this essential nutrient, the SigB regulon provides nonspecific resistance to stress by protecting essential cellular components, such as DNA and membranes. We have characterized the phosphate starvation stress response of B. subtilis at a genome-wide level using DNA macroarrays. A combination of outlier and cluster analyses identified putative new members of the PhoP regulon, namely, yfkN (2',3' cyclic nucleotide 2'-phosphodiesterase), yurI (RNase), yjdB (unknown), and vpr (extracellular serine protease). YurI is thought to be responsible for the nonspecific degradation of RNA, while the activity of YfkN on various nucleotide phosphates suggests that it could act on substrates liberated by YurI, which produces 3' or 5' phosphoribonucleotides. The putative new PhoP regulon members are either known or predicted to be secreted and are likely to be important for the recovery of inorganic phosphate from a variety of organic sources of phosphate in the environment.

Post-transcriptional regulation of the Bacillus subtilis pst operon encoding a phosphate-specific ABC transporter.

During phosphate starvation, Bacillus subtilis regulates genes in the PhoP regulon to reduce the cell's requirement for this essential substrate and to facilitate the recovery of inorganic phosphate from organic sources such as teichoic and nucleic acids. Among the proteins that are highly induced under these conditions is PstS, the phosphate-binding lipoprotein component of a high-affinity ABC-type phosphate transporter. PstS is encoded by the first gene in the pst operon, the other four members of which encode the integral membrane and cytoplasmic components of the transporter. The transcription of the pst operon was analysed using a combination of methods, including transcriptional reporter gene technology, Northern blotting and DNA arrays. It is shown that the primary transcript of the pst operon is processed differentially to maintain higher concentrations of PstS relative to other components of the transporter. The comparative studies have revealed limitations in the use of reporter gene technology for analysing the transcription of operons in which the messenger RNA transcript is differentially processed.

Transcriptional regulation of the phoPR operon in Bacillus subtilis.

When Bacillus subtilis is subjected to phosphate starvation, the Pho regulon is activated by the PhoP-PhoR two-component signal transduction system to elicit specific responses to this nutrient limitation. The response regulator, PhoP, and its cognate histidine sensor kinase, PhoR, are encoded by the phoPR operon that is transcribed as a 2.7-kb bicistronic mRNA. The phoPR operon is transcribed from two sigma(A)-dependent promoters, P(1) and P(2). Under conditions where the Pho regulon was not induced (i.e., phosphate-replete conditions or phoR-null mutant), a low level of phoPR transcription was detected only from promoter P(1). During phosphate starvation-induced transition from exponential to stationary phase, the expression of the phoPR operon was up-regulated in a phosphorylated PhoP (PhoP approximately P)-dependent manner; in addition to P(1), the P(2) promoter becomes active. In vitro gel shift assays and DNase I footprinting experiments showed that both PhoP and PhoP approximately P could bind to the control region of the phoPR operon. The data indicate that while low-level constitutive expression of phoPR is required under phosphate-replete conditions for signal perception and transduction, autoinduction is required to provide sufficient PhoP approximately P to induce other members of the Pho regulon. The extent to which promoters P(1) and P(2) are activated appears to be influenced by the presence of other sigma factors, possibly the result of sigma factor competition. For example, phoPR is hyperinduced in a sigB mutant and, later in stationary phase, in sigH, sigF, and sigE mutants. The data point to a complex regulatory network in which other stress responses and post-exponential-phase processes influence the expression of phoPR and, thereby, the magnitude of the Pho regulon response.