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1.
Clin J Sport Med ; 2020 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-32032160

RESUMO

OBJECTIVE: To describe injury rates and injury patterns in the Canadian Football League (CFL) according to time during the season, player position, injury type, and injury location. DESIGN: Prospective, cohort study. SETTING AND PARTICIPANTS: Eight seasons from CFL injury surveillance database. INDEPENDENT VARIABLES: Depending on the analysis, time of season (preseason, regular, and playoffs), player position, injury type, and injury location. MAIN OUTCOME MEASURES: Medical attention and time-loss injury rates per 100 athletes at risk (AAR), and prevalence of time-loss injuries per week. RESULTS: The average game injury rate was 45.2/100 AAR medical attention injuries and 30.7/100 AAR time-loss injuries. Injury rates declined by 1% per week over the season for both medical attention (rate ratio = 0.99) and time-loss (rate ratio = 0.99) injuries, with a substantial decline during the playoffs compared with preseason (rate ratio = 0.70-0.77). The number of ongoing time-loss injuries increased over the course of the regular season. Quarterbacks, offensive backs, and linebackers had the highest game injury rates. Joint/ligament and muscle/tendon injuries were the most common injury types for games and practices, respectively. The lower extremity was the most commonly affected area, specifically the lower leg/ankle/foot and hip/groin/thigh. CONCLUSIONS: There was a 1% decline in injury rate per week during the season and a 30% decline during the playoffs. The number of ongoing time-loss injuries increased over the regular season. Current results can aid league officials and medical staff in making evidence-based decisions concerning player safety and health.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31535689

RESUMO

OBJECTIVE: Interstitial lung disease (ILD) is a leading cause of mortality in SSc. Little is known about the benefits of immunosuppressive drugs in mild ILD. Our aim was to determine whether use of CYC or MMF was associated with an improved ILD course in patients with normal or mildly impaired lung function. METHODS: A retrospective cohort of SSc subjects with ILD, disease duration below seven years and no exposure to CYC or MMF prior to the baseline visit was constructed from the Canadian Scleroderma Research Group registry. Subjects were categorized as having mild ILD if baseline forced vital capacity (FVC % predicted) was >85%. The primary exposure was any use of CYC or MMF at the baseline visit. FVC at one year was compared between exposed and unexposed subjects, using multivariate linear regression. RESULTS: Out of 294 eligible SSc-ILD subjects, 116 met criteria for mild ILD. In this subgroup, mean (s.d.) disease duration was 3.7 (2.0) years. Thirteen (11.2%) subjects were exposed to CYC or MMF at baseline. The one-year FVC was higher in exposed subjects compared with unexposed subjects, by a difference of 8.49% (95% CI: 0.01-16.98%). None of the exposed subjects experienced clinically meaningful progression over two years, whereas 24.6% of unexposed subjects did. CONCLUSION: In this real-world setting, CYC/MMF exposure at baseline was associated with higher FVC values and a lower risk of progression among subjects with mild ILD. These data suggest a window of opportunity to preserve lung function in SSc-ILD.

3.
BMJ Evid Based Med ; 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31439540

RESUMO

Properly interpreting research results is the foundation of evidence-based medicine. Most observational studies use multiple regression and report adjusted effects. In randomised trials, adjusted effects are often provided when there are chance baseline imbalances. The estimates for the exposure of interest (eg, treatment) from these adjusted analyses are usually interpreted as population average causal effects (PACEs); for example, what would be the difference in the mean outcome if everyone in the population was treated versus untreated? In this paper, we show this interpretation is incorrect when there is an interaction between treatment and other variables with respect to the outcome. We provide the appropriate methods to calculate the PACE from regression analyses and also introduce alternative methods that have gained popularity over the last 20 years. Finally, we explain why researchers should be cautious when excluding interaction terms based on p values.

4.
Patient Educ Couns ; 102(4): 735-741, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30545649

RESUMO

OBJECTIVE: Bibliotherapy refers to psychological self-help interventions that utilize treatment books to improve psychological well-being. Research supports bibliotherapy as an efficacious intervention for a variety of mental health problems. Yet, few studies have investigated bibliotherapy in psychosocial oncology. The objective of this randomized controlled trial was to examine the efficacy of the NuCare intervention, delivered as a self-directed workbook, for enhancing empowerment, coping, and quality of life and reducing distress in patients with cancer. METHODS: Eighty-nine adult patients with cancer were randomized to receive the workbook for 6 weeks or the control condition, usual care. Participants completed questionnaires at baseline, 6 weeks post-baseline, and 10 weeks post-baseline. RESULTS: The increase of empowerment (main outcome) and quality of life and the decrease of distress in the NuCare group from pre-intervention to follow-up assessment differed significantly from the respective difference scores in the control group. CONCLUSIONS: The self-administered NuCare workbook is a potentially cost-effective, minimal intervention addressing psychosocial needs of patients with cancer. PRACTICE IMPLICATIONS: Evidence-based bibliotherapy can empower patients and has the promise of reducing the burden on the healthcare system while enhancing the immediacy of psychosocial support.


Assuntos
Biblioterapia , Neoplasias/psicologia , Neoplasias/terapia , Qualidade de Vida/psicologia , Adaptação Psicológica , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autocuidado , Autoeficácia , Autogestão , Estresse Psicológico/terapia , Resultado do Tratamento , Adulto Jovem
6.
Br J Psychiatry ; 212(6): 377-385, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29717691

RESUMO

BACKGROUND: Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics. METHOD: Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit. RESULTS: A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15-3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98-10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7-15) (OR = 0.96; 95% CI = 0.56-1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26-0.97). CONCLUSIONS: The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.


Assuntos
Depressão/diagnóstico , Transtorno Depressivo Maior/diagnóstico , Entrevista Psicológica/métodos , Escalas de Graduação Psiquiátrica , Adulto , Depressão/classificação , Transtorno Depressivo Maior/classificação , Feminino , Humanos , Entrevista Psicológica/normas , Masculino , Metanálise como Assunto , Probabilidade , Escalas de Graduação Psiquiátrica/normas
7.
Epidemiology ; 29(4): 533-535, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29537993

RESUMO

Although meta-analyses provide summary effect estimates that help advise patient care, patients often want to compare their overall health to the general population. The Harvard Cancer Risk Index was published in 2004 and uses risk ratio estimates and prevalence estimates from original studies across many risk factors to provide an answer to this question. However, the published version of the formula only uses dichotomous risk factors and its derivation was not provided. The objective of this brief report was to provide the derivation of a more general form of the equation that allows the incorporation of risk factors with three or more levels.


Assuntos
Metanálise como Assunto , Medição de Risco/métodos , Algoritmos , Fatores de Risco
8.
Res Synth Methods ; 9(1): 25-40, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28741808

RESUMO

While the systematic review process is intended to maximize objectivity and limit researchers' biases, examples remain of discordant recommendations from meta-analyses. Current guidelines to explore discrepancies assume the variation is produced by methodological differences and thus focus only on the study process. Because heterogeneity of interpretation also occurs when experts examine the same data, our purpose was to examine if there are reasoning differences, ie, in how information is processed and valued. We created simulated meta-analyses based on idealized randomized studies (ie, perfect studies with no bias) to ensure differences in interpretations could only be due to reasoning. We recruited published meta-analysts using purposeful variables. We conducted 3 audio-recorded interviews per participant using structured and semi-structured interviews, with paraphrasing and reflective listening to enhance and verify responses. Recruitment and analysis of transcripts and field notes followed the principles of grounded theory (eg, theoretical saturation, constant comparative analysis). Results show the complexity of meta-analytic reasoning. At each step of the process, participants attempted to reconcile disparate forms of knowledge to determine a right answer (moral concern) and accurately draw a treatment effect (epistemological concern). The reasoning processes often shifted between considering the meta-analysis as if the data were whole, and as if the data were discrete components (individual studies). These findings highlight paradigmatic tensions regarding the epistemological premises of meta-analysis, resembling previous historical investigations of the functioning of scientific communities. In understanding why different meta-analysts interpret data differently, it may be unrealistic to expect objective homogenous recommendations based on meta-analyses.


Assuntos
Teoria Fundamentada , Metanálise como Assunto , Projetos de Pesquisa , Artrite Reumatoide/terapia , Viés , Simulação por Computador , Coleta de Dados , Medicina Baseada em Evidências , Humanos , Doença de Parkinson/terapia , Doença Pulmonar Obstrutiva Crônica/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Literatura de Revisão como Assunto , Escleroderma Sistêmico/terapia
9.
Epidemiology ; 29(1): 78-86, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29023241

RESUMO

The intention-to-treat analysis evaluates the causal effect of treatment assignment in a randomized controlled trial; however, participants do not always adhere to assigned treatment and the intention-to-treat effect may differ from the effect of treatment receipt. Although more recent adherence-based methods assess a well-defined causal effect of receiving treatment, adherence is assumed to be dichotomized as all or none. This approach can lack precision in the real world because adherence is a complex and heterogeneous phenomenon. In this article, we illustrate a simple method that provides estimates of bounds on the causal effect of full adherence to treatment in the presence of partial adherence. We first define three types of partial adherence (delayed, partial-dose, posttreatment). We then use casual diagrams to show that categorizing partial adherence as nonadherence in a sensitivity analysis can lead to a violation of the exclusion restriction principle. Finally, we apply recently published sensitivity analyses related to principal stratification that allow for creating bound estimates around the causal effect of treatment in the presence of partial adherence.


Assuntos
Causalidade , Análise de Intenção de Tratamento , Cooperação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Estatística como Assunto , Humanos
10.
Am J Epidemiol ; 185(10): 954-964, 2017 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-28419203

RESUMO

In studies of diagnostic test accuracy, authors sometimes report results only for a range of cutoff points around data-driven "optimal" cutoffs. We assessed selective cutoff reporting in studies of the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) depression screening tool. We compared conventional meta-analysis of published results only with individual-patient-data meta-analysis of results derived from all cutoff points, using data from 13 of 16 studies published during 2004-2009 that were included in a published conventional meta-analysis. For the "standard" PHQ-9 cutoff of 10, accuracy results had been published by 11 of the studies. For all other relevant cutoffs, 3-6 studies published accuracy results. For all cutoffs examined, specificity estimates in conventional and individual-patient-data meta-analyses were within 1% of each other. Sensitivity estimates were similar for the cutoff of 10 but differed by 5%-15% for other cutoffs. In samples where the PHQ-9 was poorly sensitive at the standard cutoff, authors tended to report results for lower cutoffs that yielded optimal results. When the PHQ-9 was highly sensitive, authors more often reported results for higher cutoffs. Consequently, in the conventional meta-analysis, sensitivity increased as cutoff severity increased across part of the cutoff range-an impossibility if all data are analyzed. In sum, selective reporting by primary study authors of only results from cutoffs that perform well in their study can bias accuracy estimates in meta-analyses of published results.


Assuntos
Técnicas e Procedimentos Diagnósticos/normas , Métodos Epidemiológicos , Metanálise como Assunto , Viés , Confiabilidade dos Dados , Depressão/diagnóstico , Humanos , Sensibilidade e Especificidade
11.
Br J Sports Med ; 51(8): 630-635, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28219942

RESUMO

Previous injury is a well-established predictor of subsequent injury in sports medicine. Some have interpreted this to mean that either our current methods of rehabilitation are inadequate or there is some permanent damage to the tissue and 100% rehabilitation is not possible. In 2011, we illustrated that these analyses and interpretations failed to account for the fact that some athletes are more prone to get injured, either physiologically, or because of their role/type of play. We suggested that the appropriate analysis would simply require using statistical methods that measured how each individual athlete's risk changed from preinjury to postinjury.In this paper, we revisit our recommendation and illustrate that it too would be flawed if the risk of injury changed over time independent of an injury ever occurring. This might be expected if general fitness were to decline over the season, or if the style of play changed between early season games and postseason championship games. Acknowledging that risk may change regardless of whether an injury occurred or not leads to three different general definitions of 100% rehabilitation: (1) a return to the baseline state, (2) a return to the immediate preinjury state and (3) a return to the state that would have been present had the initial injury never occurred. We guide the reader on how to estimate the risks for each definition and the assumptions that must be acknowledged.


Assuntos
Traumatismos em Atletas/diagnóstico , Traumatismos em Atletas/reabilitação , Atletas , Tomada de Decisão Clínica , Humanos , Recidiva , Volta ao Esporte , Fatores de Risco , Esportes , Medicina Esportiva
12.
J Sci Med Sport ; 20(3): 255-260, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27720127

RESUMO

OBJECTIVES: Different individuals may make different return to play (RTP) decisions due to different risk assessments or risk tolerances. Our objectives were to determine the feasibility of eliciting reinjury risk assessments with Bayesian methods, and risk tolerance with questionnaires, from clinicians and athletes in a real-world RTP setting. DESIGN: Feasibility study with a descriptive prospective case-series. METHODS: We recruited the athlete, sport physician and physiotherapist caring for an athlete ("triplet") within on-going groin and hamstring injury studies. We applied Bayesian methods to elicit estimates for reinjury risk over the next 2 months, based on the available clinical knowledge, and projected activity level. We used a standardized questionnaire to elicit factors affecting risk tolerance. RESULTS: Although our methods appeared feasible in general, there were important challenges that included language, time availability of practicing clinicians, and general work-flow issues related to embedding our study within an on-going larger study. We did obtain valuable data from more than one person on 10 of the 15 eligible athletes recruited. Despite the limited number of cases, there were clinically meaningful differences in risk estimates in some cases. In one triplet, participants estimated the reinjury risk between 1-10%, 20-50% and 30-40% for the same athlete. The most common factors modifying risk tolerance were "timing and season", "pressure from athlete", and "external pressure". CONCLUSIONS: Bayesian methods for risk elicitation in clinical sport medicine are feasible, and large differences in both risk estimation and risk tolerance sometimes occur.


Assuntos
Volta ao Esporte/normas , Medição de Risco/estatística & dados numéricos , Adulto , Teorema de Bayes , Estudos de Viabilidade , Feminino , Humanos , Masculino , Adulto Jovem
13.
PLoS One ; 11(4): e0153220, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27058355

RESUMO

BACKGROUND: A large proportion of mindfulness-based therapy trials report statistically significant results, even in the context of very low statistical power. The objective of the present study was to characterize the reporting of "positive" results in randomized controlled trials of mindfulness-based therapy. We also assessed mindfulness-based therapy trial registrations for indications of possible reporting bias and reviewed recent systematic reviews and meta-analyses to determine whether reporting biases were identified. METHODS: CINAHL, Cochrane CENTRAL, EMBASE, ISI, MEDLINE, PsycInfo, and SCOPUS databases were searched for randomized controlled trials of mindfulness-based therapy. The number of positive trials was described and compared to the number that might be expected if mindfulness-based therapy were similarly effective compared to individual therapy for depression. Trial registries were searched for mindfulness-based therapy registrations. CINAHL, Cochrane CENTRAL, EMBASE, ISI, MEDLINE, PsycInfo, and SCOPUS were also searched for mindfulness-based therapy systematic reviews and meta-analyses. RESULTS: 108 (87%) of 124 published trials reported ≥1 positive outcome in the abstract, and 109 (88%) concluded that mindfulness-based therapy was effective, 1.6 times greater than the expected number of positive trials based on effect size d = 0.55 (expected number positive trials = 65.7). Of 21 trial registrations, 13 (62%) remained unpublished 30 months post-trial completion. No trial registrations adequately specified a single primary outcome measure with time of assessment. None of 36 systematic reviews and meta-analyses concluded that effect estimates were overestimated due to reporting biases. CONCLUSIONS: The proportion of mindfulness-based therapy trials with statistically significant results may overstate what would occur in practice.


Assuntos
Atenção Plena/métodos , Viés de Publicação , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Viés , Terapia Cognitivo-Comportamental/métodos , Bases de Dados Factuais/estatística & dados numéricos , Humanos , Metanálise como Assunto , Literatura de Revisão como Assunto , Estresse Psicológico/terapia
14.
BMJ Open ; 6(4): e011913, 2016 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-27075844

RESUMO

INTRODUCTION: The Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) has been recommended for depression screening in medically ill patients. Many existing HADS-D studies have used exploratory methods to select optimal cut-offs. Often, these studies report results from a small range of cut-off thresholds; cut-offs with more favourable accuracy results are more likely to be reported than others with worse accuracy estimates. When published data are combined in meta-analyses, selective reporting may generate biased summary estimates. Individual patient data (IPD) meta-analyses can address this problem by estimating accuracy with data from all studies for all relevant cut-off scores. In addition, a predictive algorithm can be generated to estimate the probability that a patient has depression based on a HADS-D score and clinical characteristics rather than dichotomous screening classification alone. The primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the HADS-D to detect major depression among adults across all potentially relevant cut-off scores and to generate a predictive algorithm for individual patients. We are already aware of over 100 eligible studies, and more may be identified with our comprehensive search. METHODS AND ANALYSIS: Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO and Web of Science. Eligible studies will have datasets where patients are assessed for major depression based on a validated structured or semistructured clinical interview and complete the HADS-D within 2 weeks (before or after). Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values, and a predictive algorithm for individual patients will be generated. ETHICS AND DISSEMINATION: The findings of this study will be of interest to stakeholders involved in research, clinical practice and policy.


Assuntos
Depressão/diagnóstico , Transtorno Depressivo Maior/diagnóstico , Programas de Rastreamento/normas , Adulto , Idoso , Ansiedade/diagnóstico , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Valores de Referência , Projetos de Pesquisa , Revisão Sistemática como Assunto
15.
Arthritis Care Res (Hoboken) ; 68(8): 1158-65, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26663624

RESUMO

OBJECTIVE: Body concealment is a component of social avoidance among people with visible differences from disfiguring conditions, including systemic sclerosis (SSc). The study objective was to develop a measure of body concealment related to avoidance behaviors in SSc. METHODS: Initial items for the Body Concealment Scale for Scleroderma (BCSS) were selected using item analysis in a development sample of 93 American SSc patients. The factor structure of the BCSS was evaluated in 742 Canadian patients with single-factor, 2-factor, and bifactor confirmatory factor analysis models. Convergent and divergent validity were assessed by comparing the BCSS total score with the Brief-Satisfaction with Appearance Scale (Brief-SWAP) and measures of depressive symptoms and pain. RESULTS: A 2-factor model (Comparative Fit Index [CFI] 0.99, Tucker-Lewis Index [TLI] 0.98, Root Mean Square Error of Approximation [RMSEA] 0.08) fit substantially better than a 1-factor model (CFI 0.95, TLI 0.94, RMSEA 0.15) for the 9-item BCSS, but the Concealment with Clothing and Concealment of Hands factors were highly correlated (α = 0.79). The bifactor model (CFI 0.99, TLI 0.99, RMSEA 0.08) also fit well. In the bifactor model, the omega coefficient was high for the general factor (ω = 0.80), but low for the Concealment with Clothing (ω = 0.01) and Concealment of Hands (ω = 0.33) factors. The BCSS total score correlated more strongly with the Brief-SWAP Social Discomfort (r = 0.59) and Dissatisfaction with Appearance (r = 0.53) subscales than with measures of depressive symptoms and pain. CONCLUSION: The BCSS sum score is a valid indicator of body concealment in SSc that extends the concepts of body concealment and avoidance beyond the realms of body shape and weight to concerns of individuals with visible differences from SSc.


Assuntos
Imagem Corporal/psicologia , Psicometria/métodos , Escleroderma Sistêmico/psicologia , Comportamento Social , Inquéritos e Questionários , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
16.
Arthritis Care Res (Hoboken) ; 68(8): 1143-9, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26605870

RESUMO

OBJECTIVE: Married persons have, on average, better mental health than nonmarried persons. Among married persons, marital satisfaction is associated with better mental health. Studies on mental health in married and nonmarried persons that consider marital satisfaction have categorized patients as satisfied versus unsatisfied, which reduces statistical power and does not generate clinically useful information on mental health across the satisfaction spectrum. Our objective was to demonstrate a novel regression approach to evaluate mental health in women with systemic sclerosis (SSc), comparing married and unmarried women, accounting for continuously measured marital satisfaction. METHODS: Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) and marital satisfaction with the Dyadic Adjustment Scale-7. A single multiple linear regression model was used to predict CES-D scores from marital status and, among married women, continuously measured marital satisfaction, controlling for demographic and clinical characteristics. RESULTS: Of 725 women, 494 (68%) were married or living as married. On average, married women had mean CES-D scores that were 2.0 points (0.19 SDs) lower than unmarried women (P = 0.013). Among married women, a 1.0 SD increase in marital satisfaction was associated with a 2.2 point (0.21 SDs) decrease in CES-D scores (P < 0.001). Married women whose marital satisfaction scores were below the 19th percentile had greater predicted depressive symptoms than unmarried women. Married women's predicted CES-D scores ranged from 6.7 points lower to 6.9 points higher than those of unmarried women, depending on marital satisfaction. CONCLUSION: Comparisons of mental health in married and unmarried patients with rheumatic diseases should include continuously measured marital satisfaction.


Assuntos
Depressão/psicologia , Escleroderma Sistêmico/psicologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Conflito Familiar/psicologia , Feminino , Humanos , Estado Civil , Pessoa de Meia-Idade , Satisfação Pessoal , Adulto Jovem
17.
BMJ Open ; 5(10): e009742, 2015 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-26486977

RESUMO

INTRODUCTION: Studies of the diagnostic accuracy of depression screening tools often used data-driven methods to select optimal cut-offs. Typically, these studies report results from a small range of cut-off points around whatever cut-off score is identified as most accurate. When published data are combined in meta-analyses, estimates of accuracy for different cut-off points may be based on data from different studies, rather than data from all studies for each cut-off point. Thus, traditional meta-analyses may exaggerate accuracy estimates. Individual patient data (IPD) meta-analyses synthesise data from all studies for each cut-off score to obtain accuracy estimates. The 10-item Edinburgh Postnatal Depression Scale (EPDS) is commonly recommended for depression screening in the perinatal period. The primary objective of this IPD meta-analysis is to determine the diagnostic accuracy of the EPDS to detect major depression among women during pregnancy and in the postpartum period across all potentially relevant cut-off scores, accounting for patient factors that may influence accuracy (age, pregnancy vs postpartum). METHODS AND ANALYSIS: Data sources will include Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. Studies that include a diagnosis of major depression based on a validated structured or semistructured clinical interview administered within 2 weeks of (before or after) the administration of the EPDS will be included. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values. Analyses will evaluate data from pregnancy and the postpartum period separately, as well as combining data from all women in a single model. ETHICS AND DISSEMINATION: This study does not require ethics approval. Dissemination will include journal articles and presentations to policymakers, healthcare providers and researchers. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2015:CRD42015024785.


Assuntos
Depressão Pós-Parto/diagnóstico , Transtorno Depressivo Maior/diagnóstico , Programas de Rastreamento/normas , Complicações na Gravidez/diagnóstico , Projetos de Pesquisa , Feminino , Humanos , Saúde Mental , Metanálise como Assunto , Gravidez , Escalas de Graduação Psiquiátrica , Autorrelato , Revisão Sistemática como Assunto
18.
Am J Epidemiol ; 182(6): 557-66, 2015 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-26283090

RESUMO

In randomized controlled trials, the intention-to-treat estimator provides an unbiased estimate of the causal effect of treatment assignment on the outcome. However, patients often want to know what the effect would be if they were to take the treatment as prescribed (the patient-oriented effect), and several researchers have suggested that the more relevant causal effect for this question is the complier average causal effect (CACE), also referred to as the local average treatment effect. Sophisticated approaches to estimating the CACE include Bayesian and frequentist methods for principal stratification, inverse-probability-of-treatment-weighted estimators, and instrumental-variable (IV) analysis. All of these approaches exploit information about adherence to assigned treatment to improve upon the intention-to-treat estimator, but they are rarely used in practice, probably because of their complexity. The IV principal stratification estimator is simple to implement but has had limited use in practice, possibly due to lack of familiarity. Here, we show that the IV principal stratification estimator is a modified per-protocol estimator that should be obtainable from any randomized controlled trial, and we provide a closed form for its robust variance (and its uncertainty). Finally, we illustrate sensitivity analyses we conducted to assess inference in light of potential violations of the exclusion restriction assumption.


Assuntos
Análise de Intenção de Tratamento/métodos , Modelos Teóricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Fatores Socioeconômicos
19.
Prehosp Emerg Care ; 19(1): 116-125, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25076192

RESUMO

Abstract Objectives. To compare paramedics' ability to minimize cervical spine motion during patient transfer onto a vacuum mattress with two stabilization techniques (head squeeze vs. trap squeeze) and two transfer methods (log roll with one assistant (LR2) vs. 3 assistants (LR4)). Methods. We used a crossover design to minimize bias. Each lead paramedic performed 10 LR2 transfers and 10 LR4 transfers. For each of the 10 LR2 and 10 LR4 transfers, the lead paramedic stabilized the cervical spine using the head squeeze technique five times and the trap squeeze technique five times. We randomized the order of the stabilization techniques and LR2/LR4 across lead paramedics to avoid a practice or fatigue effect with repeated trials. We measured relative cervical spine motion between the head and trunk using inertial measurement units placed on the forehead and sternum. Results. On average, total motion was 3.9° less with three assistants compared to one assistant (p = 0.0002), and 2.8° less with the trap squeeze compared to the head squeeze (p = 0.002). There was no interaction between the transfer method and stabilization technique. When examining specific motions in the six directions, the trap squeeze generally produced less lateral flexion and rotation motion but allowed more extension. Examining within paramedic differences, some paramedics were clearly more proficient with the trap squeeze technique and others were clearly more proficient with the head squeeze technique. Conclusion. Paramedics performing a log roll with three assistants created less motion compared to a log roll with only one assistant, and using the trap squeeze stabilization technique resulted in less motion than the head squeeze technique but the clinical relevance of the magnitude remains unclear. However, large individual differences suggest future paramedic training should incorporate both best evidence practice as well as recognition that there may be individual differences between paramedics.

20.
Syst Rev ; 3: 124, 2014 Oct 27.
Artigo em Inglês | MEDLINE | ID: mdl-25348422

RESUMO

BACKGROUND: Major depressive disorder (MDD) may be present in 10%-20% of patients in medical settings. Routine depression screening is sometimes recommended to improve depression management. However, studies of the diagnostic accuracy of depression screening tools have typically used data-driven, exploratory methods to select optimal cutoffs. Often, these studies report results from a small range of cutoff points around whatever cutoff score is most accurate in that given study. When published data are combined in meta-analyses, estimates of accuracy for different cutoff points may be based on data from different studies, rather than data from all studies for each possible cutoff point. As a result, traditional meta-analyses may generate exaggerated estimates of accuracy. Individual patient data (IPD) meta-analyses can address this problem by synthesizing data from all studies for each cutoff score to obtain diagnostic accuracy estimates. The nine-item Patient Health Questionnaire-9 (PHQ-9) and the shorter PHQ-2 and PHQ-8 are commonly recommended for depression screening. Thus, the primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2 to detect MDD among adults across all potentially relevant cutoff scores. Secondary analyses involve assessing accuracy accounting for patient factors that may influence accuracy (age, sex, medical comorbidity). METHODS/DESIGN: Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. We will include studies that included a Diagnostic and Statistical Manual or International Classification of Diseases diagnosis of MDD based on a validated structured or semi-structured clinical interview administered within 2 weeks of the administration of the PHQ. Two reviewers will independently screen titles and abstracts, perform full article review, and extract study data. Disagreements will be resolved by consensus. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cutoff values. DISCUSSION: The proposed IPD meta-analyses will allow us to obtain estimates of the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014010673.


Assuntos
Transtorno Depressivo Maior/diagnóstico , Projetos de Pesquisa , Inquéritos e Questionários , Conjuntos de Dados como Assunto , Humanos , Valor Preditivo dos Testes , Revisão Sistemática como Assunto
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