Generalized propensity score for estimating the average treatment effect of multiple treatments.

The propensity score method is widely used in clinical studies to estimate the effect of a treatment with two levels on patient's outcomes. However, due to the complexity of many diseases, an effective treatment often involves multiple components. For example, in the practice of Traditional Chinese Medicine (TCM), an effective treatment may include multiple components, e.g. Chinese herbs, acupuncture, and massage therapy. In clinical trials involving TCM, patients could be randomly assigned to either the treatment or control group, but they or their doctors may make different choices about which treatment component to use. As a result, treatment components are not randomly assigned. Rosenbaum and Rubin proposed the propensity score method for binary treatments, and Imbens extended their work to multiple treatments. These authors defined the generalized propensity score as the conditional probability of receiving a particular level of the treatment given the pre-treatment variables. In the present work, we adopted this approach and developed a statistical methodology based on the generalized propensity score in order to estimate treatment effects in the case of multiple treatments. Two methods were discussed and compared: propensity score regression adjustment and propensity score weighting. We used these methods to assess the relative effectiveness of individual treatments in the multiple-treatment IMPACT clinical trial. The results reveal that both methods perform well when the sample size is moderate or large.

Activity scheduling as a core component of effective care management for late-life depression.

BACKGROUND: Activity scheduling is an established component of evidenced-based treatment for late-life depression in primary care. We examined participant records from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self-reported activity engagement, and depression outcomes. METHODS: This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Logistic regression was used to evaluate associations between activity scheduling, activity engagement, and depression outcomes at 12 months. All relevant institutional review boards approved the research protocol. RESULTS: Seventeen distinct activity categories were generated. Most patients worked on at least one social and one solitary activity during their course of treatment. Common activity categories included physical activity (32%), medication management (22%), active-non-physical (19%), and passive (14%) activities. We found significant, positive associations between activity scheduling, self-reported engagement in activities at 12 months, and depression outcomes at 12 months. CONCLUSION: Older primary care patients in CM for depression worked on a wide range of activities. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities. Care managers should encourage patients to balance instrumental activities (e.g., attending to medical problems) with social activities targeting direct interpersonal engagement.

Efficiency influence of exogenous betaine on anaerobic sequencing batch biofilm reactor treating high salinity mustard tuber wastewater.

When treating a composite mustard tuber wastewater with high concentrations of salt (about 20 g Cl(-) L(-1)) and organics (about 8000 mg L(-1) COD) by an anaerobic sequencing batch biofilm reactor (ASBBR) in winter, both high salinity and low temperature will inhibit the activity of anaerobic microorganisms and lead to low treatment efficiency. To solve this problem, betaine was added to the influent to improve the activity of the anaerobic sludge, and an experimental study was carried to investigate the influence of betaine on treating high salinity mustard tuber wastewater by the ASBBR. The results show that, when using anaerobic acclimated sludge in the ASBBR, and controlling biofilm density at 50% and water temperature at 8-12 degrees C, the treatment efficiency of the reactor could be improved by adding the betaine at different concentrations. The efficiency reached the highest when the optimal dosage ofbetaine was 0.5 mmol L(-1). The average effluent COD, after stable acclimation, was 4461 mg L(-1). Relative to ASBBR without adding betaine, the activity of the sludge increased significantly. Meanwhile, the dehydrogenase activity of anaerobic microorganisms and the COD removal efficiency were increased by 18.6% and 18.1%, respectively.

Long-term chronic opioid therapy discontinuation rates from the TROUP study.

OBJECTIVE: To report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation. METHODS: Medical and pharmacy claims records from January 2000 through December 2005 from a national private health network (HealthCore), and Arkansas (AR) Medicaid were used to identify ambulatory adult enrollees who had 90 days of opioids supplied. Recipients were followed until they discontinued opioid prescription fills or disenrolled. Kaplan Meier survival models and Cox proportional hazards models were estimated to identify factors associated with time until opioid discontinuation. RESULTS: There were 23,419 and 6,848 chronic opioid recipients followed for a mean of 1.9 and 2.3 years in the HealthCore and AR Medicaid samples. Over a maximum follow up of 4.8 years, 67.0% of HealthCore and 64.9% AR Medicaid recipients remained on opioids. Recipients on high daily opioid dose (greater than 120 milligrams morphine equivalent (MED)) were less likely to discontinue than recipients taking lower doses: HealthCore hazard ratio (HR) = 0.66 (95%CI: 0.57-0.76), AR Medicaid HR = 0.66 (95%CI: 0.50-0.82). Recipients with possible opioid misuse were also less likely to discontinue: HealthCore HR = 0.83 (95%CI: 0.78-0.89), AR Medicaid HR = 0.78 (95%CI: 0.67-0.90). CONCLUSIONS: Over half of persons receiving 90 days of continuous opioid therapy remain on opioids years later. Factors most strongly associated with continuation were intermittent prior opioid exposure, daily opioid dose ≥ 120 mg MED, and possible opioid misuse. Since high dose and opioid misuse have been shown to increase the risk of adverse outcomes special caution is warranted when prescribing more than 90 days of opioid therapy in these patients.

Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms.

OBJECTIVE: Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults. METHODS: Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs. RESULTS: Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) (p = 0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms. CONCLUSION: Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms.

Psychosocial stress during pregnancy.

OBJECTIVE: We sought to identify factors associated with high antenatal psychosocial stress and describe the course of psychosocial stress during pregnancy. STUDY DESIGN: We performed a cross-sectional analysis of data from an ongoing registry. Study participants were 1522 women receiving prenatal care at a university obstetric clinic from January 2004 through March 2008. Multiple logistic regression identified factors associated with high stress as measured by the Prenatal Psychosocial Profile stress scale. RESULTS: The majority of participants reported antenatal psychosocial stress (78% low-moderate, 6% high). Depression (odds ratios [OR], 9.6; 95% confidence interval [CI], 5.5-17.0), panic disorder (OR, 6.8; 95% CI, 2.9-16.2), drug use (OR, 3.8; 95% CI, 1.2-12.5), domestic violence (OR, 3.3; 95% CI, 1.4-8.3), and having > or =2 medical comorbidities (OR, 3.1; 95% CI, 1.8-5.5) were significantly associated with high psychosocial stress. For women who screened twice during pregnancy, mean stress scores declined during pregnancy (14.8 +/- 3.9 vs 14.2 +/- 3.8; P < .001). CONCLUSION: Antenatal psychosocial stress is common, and high levels are associated with maternal factors known to contribute to poor pregnancy outcomes.

Age and sex trends in long-term opioid use in two large American health systems between 2000 and 2005.

OBJECTIVE: To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems. DESIGN: Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18-44, 45-64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2). PATIENTS: Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000). RESULTS: Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35-50% increase). Per-patient daily doses did not increase. CONCLUSIONS: No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.

Healthcare costs associated with mild traumatic brain injury and psychological distress in children and adolescents.

PRIMARY OBJECTIVE: Comparison of healthcare costs for youth with mild traumatic brain injuries (TBIs) to costs in a matched cohort of children without TBI in the 3 years following injury. RESEARCH DESIGN: This study used a prospective cohort design with 3-year follow-up. Costs were examined using the well-established two-step model and controlling for potential confounding variables. METHODS AND PROCEDURES: Four-hundred and ninety subjects from a large health maintenance organization, 14 years old or younger, who sustained a mild TBI in 1993, were identified using computerized records. For each youth with mild TBI, three control subjects were selected (n = 1470), matched on age, sex and enrolment at the time of injury. EXPERIMENTAL INTERVENTIONS: Not applicable. MAIN OUTCOMES AND RESULTS: TBI exposure was associated with an increase in the proportion of subjects who had non-zero medical costs in all categories examined and a 75% increase in mean total costs. Presence of psychological distress was also associated with increased proportion of subjects with costs in all categories examined and was associated with an approximate doubling of mean total costs. CONCLUSIONS: Mild TBI and psychological distress were each associated with significant increases in healthcare costs in an HMO setting.

Improving primary care for older adults with cancer and depression.

BACKGROUND: Depression is common among older cancer patients, but little is known about the optimal approach to caring for this population. This analysis evaluates the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program, a stepped care management program for depression in primary care patients who had an ICD-9 cancer diagnosis. METHODS: Two hundred fifteen cancer patients were identified from the 1,801 participants in the parent study. Subjects were 60 years or older with major depression (18%), dysthymic disorder (33%), or both (49%), recruited from 18 primary care clinics belonging to 8 health-care organizations in 5 states. Patients were randomly assigned to the IMPACT intervention (n = 112) or usual care (n = 103). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care provider and who offered education, care management, support of antidepressant management, and brief, structured psychosocial interventions including behavioral activation and problem-solving treatment. RESULTS: At 6 and 12 months, 55% and 39% of intervention patients had a 50% or greater reduction in depressive symptoms (SCL-20) from baseline compared to 34% and 20% of usual care participants (P = 0.003 and P = 0.029). Intervention patients also experienced greater remission rates (P = 0.031), more depression-free days (P < 0.001), less functional impairment (P = 0.011), and greater quality of life (P = 0.039) at 12 months than usual care participants. CONCLUSIONS: The IMPACT collaborative care program appears to be feasible and effective for depression among older cancer patients in diverse primary care settings.

Major depression and urinary incontinence in women: temporal associations in an epidemiologic sample.

OBJECTIVE: To determine whether: (1) major depression is associated with increased risk for onset of urinary incontinence, and (2) urinary incontinence is associated with increased risk for onset of depression. STUDY DESIGN: Longitudinal cohort study of female Health and Retirement Study participants completing baseline interviews at Wave 3 (1996-1997) and follow-up interviews at Waves 4-6 (1998-2003). RESULTS: In a cohort of 5820 women with a mean age 59.3 (+/- 0.5) years, 6-year cumulative incidences of depression and incontinence were 11% and 21%, respectively. Major depression was associated with increased odds of incident incontinence (adjusted odds ratio, 1.46; 95% confidence interval, 1.08-1.97) during follow-up compared with those without major depression at baseline. Conversely, incontinence was not associated with increased odds of incident depression (adjusted odds ratio, 1.03; 95% confidence interval, 0.75-1.42) compared with those without incontinence at baseline. CONCLUSION: Major depression predicted onset of urinary incontinence in a population-based sample of at-risk, community-dwelling women. Incontinence did not predict onset of depression.

A single-blind placebo run-in study of venlafaxine XR for activity-limiting osteoarthritis pain.

OBJECTIVE: Osteoarthritis pain is a significant problem for our aging population. Non-steroidal anti-inflammatory drugs and opioids are effective treatments, but have significant adverse effects, so there is a need for alternative treatments. Selective norepinephrine-serotonin reuptake inhibitor antidepressants may provide a new treatment option for osteoarthritis pain. METHODS: We performed a single-blind placebo run-in trial of 150-225 mg of venlafaxine in 18 subjects with activity-limiting osteoarthritis pain. Each subject received 2 weeks of placebo followed by 10 weeks of venlafaxine. The primary outcome was reduction in average pain intensity between 2 and 12 weeks. For subjects not completing the trial, their last observation was carried forward as an imputed outcome. RESULTS: Average pain on the Brief Pain Inventory (BPI) was 4.7 at baseline, 4.4 after the 2-week placebo run-in, and 3.3 at 12 weeks (25% decrease, P = 0.03). Nine subjects (50%) reported at least 30% pain reduction between weeks 2 and 12. The Western Ontario and McMasters University Osteoarthritis Index (WOMAC) pain score at baseline was 2.0, 1.8 after 2 weeks, and 1.7 after 12 weeks. This represented a 6% decrease in pain between weeks 2 and 12 (P = 0.42), with two subjects (11%) reported at least 30% pain relief between weeks 2 and 12 on the WOMAC. Effects on self-reported physical and role function and depression were marginal or non-significant, and observed physical function did not improve. CONCLUSION: Venlafaxine significantly reduced pain intensity on the BPI and marginally improved self-reported function. Venlafaxine should be investigated further in a larger randomized trial for the treatment of osteoarthritis pain.

A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury.

OBJECTIVE: To examine factors other than injury severity that are likely to influence functional outcomes after hospitalization for injury. SUMMARY BACKGROUND DATA: This study used data from the National Study on the Costs and Outcomes of Trauma investigation to examine the association between posttraumatic stress disorder (PTSD), depression, and return to work and the development of functional impairments after injury. METHOD: A total of 2707 surgical inpatients who were representative of 9374 injured patients were recruited from 69 hospitals across the US. PTSD and depression were assessed at 12 months postinjury, as were the following functional outcomes: activities of daily living, health status, and return to usual major activities and work. Regression analyses assessed the associations between PTSD and depression and functional outcomes while adjusting for clinical and demographic characteristics. RESULTS: At 12 months after injury, 20.7% of patients had PTSD and 6.6% had depression. Both disorders were independently associated with significant impairments across all functional outcomes. A dose-response relationship was observed, such that previously working patients with 1 disorder had a 3-fold increased odds of not returning to work 12 months after injury odds ratio = 3.20 95% (95% confidence interval = 2.46, 4.16), and patients with both disorders had a 5-6 fold increased odds of not returning to work after injury odds ratio = 5.57 (95% confidence interval = 2.51, 12.37) when compared with previously working patients without PTSD or depression. CONCLUSIONS: PTSD and depression occur frequently and are independently associated with enduring impairments after injury hospitalization. Early acute care interventions targeting these disorders have the potential to improve functional recovery after injury.

Bullying and school safety.

OBJECTIVE: To identify an association between involvement in bullying and problems in school. STUDY DESIGN: This was a cross-sectional study of 5391 students in grades 7, 9, and 11 in an urban public school district. The main outcome measure was involvement in bullying. Secondary outcomes included attendance, grade point average, psychosocial distress, and perceived acceptability of carrying guns to school. RESULTS: Of the 5391 children surveyed, 26% were involved in bullying either as victim, bully, or both (bully-victim). All 3 groups were significantly more likely than bystanders to feel unsafe at school and sad most days. Victims and bully-victims were more likely to say they are "no good." Victims were more likely to feel that they "do not belong" in their school. The odds of being a victim (vs a bystander) were 10% lower for every 1 point increase in grade point average. Bully-victims were more likely to say that it is "not wrong" to take a gun to school. CONCLUSIONS: Associations between involvement in bullying and academic achievement, psychological distress, and the belief that it is not wrong to take a gun to school reinforce the notion that school environment is interrelated with mental health and school success.

Is insomnia a perpetuating factor for late-life depression in the IMPACT cohort?

STUDY OBJECTIVES: Insomnia and depressive disorders are significant health problems in the elderly. Persistent insomnia is a risk factor for the development of new-onset and recurrent major depressive disorder (MDD). Less clear is whether persistent insomnia may perpetuate MDD andlor dysthymia. The present longitudinal study examines the relationship of insomnia to the continuation of depression in the context of an intervention study in elderly subjects. DESIGN: Data were drawn from Project IMPACT, a multisite intervention study, which enrolled 1801 elderly patients with MDD and/or dysthymia. In the current study, subjects were assigned to an insomnia-status group (Persistent, Intermediate, and No Insomnia) based on insomnia scores at both baseline and 3-month time points. Logistic regressions were conducted to determine whether Persistent Insomnia was prospectively associated with increased risk of remaining depressed and/or achieving a less than 50% clinical improvement at 6 and at 12 months compared with the No Insomnia reference group. The Intermediate Insomnia group was compared with the other 2 groups to determine whether a dose-response relationship existed between insomnia type and subsequent depression. SETTING: Eighteen primary clinics in 5 states. PARTICIPANTS: Older adults (60+) with depression. MEASUREMENTS AND RESULTS: Overall, patients with persistent insomnia were 1.8 to 3.5 times more likely to remain depressed, compared with patients with no insomnia. The findings were more robust in patients receiving usual care for depression than in patients receiving enhanced care. Findings were also more robust in subjects who had MDD as opposed to those with dysthymia alone. CONCLUSIONS: These findings suggest that, in addition to being a risk factor for a depressive episode, persistent insomnia may serve to perpetuate the illness in some elderly patients and especially in those receiving standard care for depression in primary care settings. Enhanced depression care may partially mitigate the perpetuating effects of insomnia on depression.

Depression and diabetes: a potentially lethal combination.

OBJECTIVE: To assess whether Medicare fee-for-service beneficiaries with depression and diabetes had a higher mortality rate over a 2-year period compared with beneficiaries with diabetes alone. DESIGN: Evidence of depression was based on a physician diagnosis or self-reported prescription of an antidepressant in the year prior to screening, or a score of > or = 3 on the Patient Health Questionnaire two-item questionnaire. Mortality was assessed bi-monthly by checking Medicare claims and eligibility files or from information from telephone contact with the participant's family. Cox proportional hazard regression models were used to calculate adjusted hazard ratios of death in depressed versus nondepressed beneficiaries with diabetes. PARTICIPANTS: A total of 10,704 beneficiaries with diabetes enrolled in a disease management program were surveyed with a health assessment questionnaire and followed over a two-year period. MAIN RESULTS: Comorbid depression in Medicare beneficiaries with diabetes participating in a disease management program was associated with an increased risk for all-cause mortality over a two-year period of approximately 36% to 38%, depending on the definition of depression that was used. No significant increase in rates of cause-specific mortality from macrovascular disease were found in depressed versus nondepressed beneficiaries. CONCLUSION: Among a large Medicare cohort of fee-for-service beneficiaries with diabetes, comorbid depression was associated with an increase in all-cause mortality over a two-year period. Future research will be required to determine whether the increase in mortality associated with depression is due to potential behavioral mediators (i.e., smoking, poor adherence to diet) or physiologic abnormalities (i.e., hypothalamic-pituitary axis dysregulation) associated with depression.

Care management for depression and osteoarthritis pain in older primary care patients: a pilot study.

OBJECTIVE: To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis. METHODS: Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months. RESULTS: Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests. CONCLUSION: The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.

Effectiveness of problem-solving therapy for older, primary care patients with depression: results from the IMPACT project.

PURPOSE: We compared a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia. DESIGN AND METHODS: The data here are from the IMPACT study, which compared collaborative care within a primary care clinic to care as usual in the treatment of 1,801 primary care patients, 60 years of age or older, with major depression or dysthymia. This study is a secondary data analysis (n = 433) of participants who received either PST-PC (by means of collaborative care) or community-based psychotherapy (by means of usual care). RESULTS: Older adults who received PST-PC had more depression-free days at both 12 and between 12 and 24 months (beta = 47.5, p <.001; beta = 47.0, p <.001), and they had fewer depressive symptoms and better functioning at 12 months (beta(dep) = -0.36, p <.001; beta(func) = -0.94, p <.001), than those who received community-based psychotherapy. We found no differences at 24 months. IMPLICATIONS: Results suggest that PST-PC as delivered in primary care settings is an effective method for treating late-life depression.

Predicting adolescent alcohol drinking patterns after major injury.

BACKGROUND: Bedside alcohol counseling provided to injured adolescents during their acute medical care reduces subsequent alcohol consumption and reinjury. This counseling would be even more effective if extended beyond hospitalization to help injured youth return to normal functioning. To enhance this counseling, we first need to know the natural course of adolescent drinking during the year after injury, as well as the predictors of problem drinking during that year. METHODS: Prospective cohort study that described the natural history of adolescent drinking during the year after traumatic injury and identified predictors of increased alcohol use. Randomly sampled injured adolescents 12 years to 18 years of age, admitted to the surgical services of a Level I trauma center were interviewed to assess alcohol consumption at baseline and 2 months, 5 months, and 12 months after injury admission. RESULTS: Drinking increased steadily over the year, with this increase beginning in the months immediately after injury. Greater preinjury alcohol consumption, greater number of cumulative preinjury traumatic life experiences, and increasing age were independent positive predictors of increased drinking during the year after injury. Increased injury severity was a negative predictor such that the more severe the injury was, the less the adolescent drank during the year after injury. CONCLUSIONS: This documented postinjury drinking pattern and its predictors can now identify for the purposes of extended counseling those adolescents most likely to drink heavily during the year after injury.

Adolescents' and parents' agreement on posttraumatic stress disorder symptoms and functioning after adolescent injury.

Few investigations have simultaneously assessed concordance between youth and parent ratings of posttraumatic stress disorder (PTSD) symptoms and functioning. Randomly sampled adolescent injury survivors ages 12-18 and their parents were assessed on the inpatient ward and again at 2, 5, and 12-months postinjury (N = 99). Adolescent PTSD symptoms and functioning were rated by both adolescents and parents. Parent PTSD was also assessed; 27% of parents endorsed symptoms consistent with a diagnosis of PTSD over the course of the year after adolescent injury. The PTSD positive parents demonstrated significantly greater discordance in ratings of adolescent PTSD symptoms, family cohesion, and mental health functioning. These findings suggest caution in clinical and policy applications of parental ratings of adolescent symptomatic and functional outcomes after injury.

Influence of vitamin D deficiency on T cell subsets and related indices during spinal tuberculosis.

The present study investigated the effects of vitamin D deficiency on T cell subsets in patients with spinal tuberculosis. In addition, the influence of vitamin D deficiency was investigated on the expression of cytokines IL-1ß, IL-6 and TNF-α in intervertebral disc lesions of patients. One hundred and seventeen patients with spinal tuberculosis who received operative treatment in the Department of Orthopedics in Wuhan City Third Hospital from March 2012 to March 2015 were collected. The patients were divided depending upon vitamin D content into the control group (64 cases, vitamin D content <25 nmol/l) and experimental group (53 cases, vitamin D content >50 nmol/l). Immunofluorescence method was applied to determine the content of T cell subsets in both groups of patients. Intervertebral disc lesion tissues of two groups of patients were obtained during surgery then treated with HE staining and immunohistochemical staining. The values of average optical density obtained under light microscope were observed as the expression quantities of IL-1ß, IL-6 and TNF-α, to explore the relationship between vitamin D and the expression of cytokines. When vitamin D is lacking, the expression of T lymphocyte subsets in patients with spinal tuberculosis significantly decreased. Compared with experimental group, the difference was statistically significant (P<0.05). Further, the expression of cytokines IL-1ß, IL-6 and TNF-α in intervertebral disc lesion tissues of patients with spinal tuberculosis were significantly higher than those of patients with spinal tuberculosis whose vitamin D content was normal (P<0.05). In the control group, vitamin D content was negatively correlated with the expression of IL-1ß, IL-6 and TNF-α. The expression of T lymphocyte subsets in patients with vitamin D deficiency was significantly reduced, and the immune function decreased. The expression of IL-1ß, IL-6 and TNF-α in lesions were significantly higher than those of patients with normal vitamin D content. In addition, the lower the content of vitamin D was, the more active the expression of inflammatory factors were, which was not conducive to the recovery of tuberculosis lesions.