Convergent and criterion validity of PROMIS anxiety measures relative to six legacy measures and a structured diagnostic interview for anxiety in cancer patients.

BACKGROUND: Detecting anxiety in oncology patients is important, requiring valid yet brief measures. One increasingly popular approach is the Patient Reported Outcomes Measurement Information System (PROMIS); however, its validity is not well established in oncology. We assessed the convergent and criterion validity of PROMIS anxiety measures in an oncology sample. METHODS: 132 oncology/haematology outpatients completed the PROMIS Anxiety Computer Adaptive Test (PROMIS-A-CAT) and the 7 item (original) PROMIS Anxiety Short Form (PROMIS-A-SF) along with six well-established measures: Hospital Anxiety and Depression Scale-Anxiety (HADS-A); Generalised Anxiety Disorder-7 (GAD-7); Depression, Anxiety and Stress Scale-Anxiety (DASS-A) and Stress (DASS-S); Distress Thermometer (DT) and PSYCH-6. Correlations, area under the curve (AUC) and diagnostic accuracy statistics were calculated with Structured Clinical Interview as the reference standard. RESULTS: Both PROMIS measures correlated with all legacy measures at p < .001 (Rho = .56-.83). AUCs (> .80) were good for both PROMIS measures and comparable to or better than all legacy measures. At the recommended mild cut-point (55), PROMIS-A-SF had sensitivity (.67) comparable to or better than all the legacy measures, whereas PROMIS-A-CAT sensitivity (.59) was lower than GAD-7 (.67) and HADS-A (.62), but comparable to PSYCH-6 and higher than DASS-A, DASS-S and DT. Sensitivity for both was .79. A reduced cut-point of 51 on both PROMIS measures improved sensitivity (.83-.84) although specificity was only adequate (.61-.62). CONCLUSIONS: The convergent and criterion validity of the PROMIS anxiety measures in cancer populations was confirmed as equivalent, but not superior to, established measures (GAD-7 and HADS-A). The PROMIS-A-CAT did not demonstrate clear advantages over PROMIS-A-SF.

Is fidelity to a complex behaviour change intervention associated with patient outcomes? Exploring the relationship between dietitian adherence and competence and the nutritional status of intervention patients in a successful stepped-wedge randomised clinical trial of eating as treatment (EAT).

BACKGROUND: Behavioural medicine is characterised by findings for the effectiveness and efficacy of complex behaviour change interventions. Comparatively, scant attention has been paid to key intervention components or mechanisms of action. Evaluating relationships between process variables (fidelity) and intervention effects is central to addressing this imbalance. Accordingly, in the current study, we sought to explore the magnitude and direction of effect between fidelity predictors (dietitian adherence and competence) and intervention effects (patient nutritional status) during the intervention phase of a real-world, stepped-wedge evaluation of 'EAT: Eating As Treatment'. METHODS: The EAT clinical trial was conducted within five major Australian hospitals located in Queensland, Western Australia, Victoria and South Australia between 2013 and 2016. EAT is a dietitian-delivered health behaviour change intervention designed to reduce malnutrition in head and neck cancer (HNC) patients undergoing radiotherapy. Dietitian adherence and competence ratings were derived from a 20% random sample of audio-recorded dietetic consultations (n=194) conducted after dietitians (n=18) were trained in EAT. Sessions were coded by trained, independent, coders using a study checklist, the Behaviour Change Counselling Index (BECCI) and items from the Cognitive Therapy Scale-Revised (CTS-R). Patient nutritional status was measured using the Patient-Generated Subjective Global Assessment (PGSGA). RESULTS: Dietitian adherence to a written nutrition plan (ß=7.62, 95% CI=0.65 to 14.58, p=0.032), dietitian adherence to behaviour change counselling (ß=0.69, 95% CI =0.02 to 1.38, p=0.045) and competence in delivering behaviour change counselling (ß=3.50, 95% CI =0.47 to 6.53, p=0.024) were significant predictors of patient nutritional status. Dietitian adherence and competence ratings were higher during consultations with intervention patients at greater risk of malnutrition. CONCLUSIONS: This study contributes new insights into the relationship between fidelity and treatment outcome by demonstrating that dietitian adherence and competence is greater when working with more challenging patients. This is likely central to the demonstrated success of the EAT intervention in reducing malnutrition and highlights the importance of ensuring that providers are adequately equipped to flexibly integrate intervention elements according to patient need. TRIAL REGISTRATION: This study is a process analysis of a stepped-wedge randomised controlled trial prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12613000320752 ; Date of registration 21/03/2013).

Performance and stability comparison of Aemion™ and Aemion+™ membranes for vanadium redox flow batteries.

Anion exchange membranes (AEMs) have shown a significant rise in performance and durability within recent years for applications such as electrolysis and fuel cells. However, in vanadium redox-flow batteries, their use is of particular interest to lower costs and self-discharge rates compared to conventional perfluorinated sulfonic acid-based ionomers such as Nafion. In this work we evaluate the properties of two commercial AEMs, Aemion™ and Aemion+™, based on ex situ characterizations, an accelerated stress test degradation study (>1000 hours storage in highly oxidizing VO2 + electrolyte at 35 °C) and electrochemical battery cycle tests. All membranes feature low ionic resistances of below 320 mΩ cm2, enabling battery cycling at 100 mA cm-2. Aemion shows considerable VO2+ formation within a VO2 + stress test, whereas Aemion+ remains almost unaffected in the 1058 h stress test. Evaluating self-discharge data, cycling performance and durability data, Aemion+™ (50 µm thickness) features the best properties for vanadium redox-flow battery operation.

Can't leave it at home? The effects of personal stress on burnout and salesperson performance.

Personal stress is a prevalent problem in a connected world. For salespeople, demands of a connected workplace have largely eliminated boundaries between personal and work life, allowing stress from personal issues to spill over into their work. Thus, problems of health, relationships, and finances are no longer "left at home" for salespeople. Rather, a less central workplace model (e.g., remote workplaces and mobile platforms) and 24/7 work expectations expand the workplace, which comingles personal and work demands. Utilizing a sample of 331 salespeople, we study personal stressors that cross boundaries into the workplace and find that they play a critical role in the formation of burnout across its dimensions, which leads to reduced salesperson performance. Our research contributes to the sales literature by investigating individual personal stressors via Job Demands and Conservation of Resources theories and offers insights for managers of salespeople that face both personal and work stress.

Improving the water management in anion-exchange membrane fuel cells via ultra-thin, directly deposited solid polymer electrolyte.

Thin ionomer membranes are considered key to achieve high performances in anion exchange membrane fuel cells. However, the handling of unsupported anion exchange membranes with thicknesses below 15 µm is challenging. Typical pre-treatments of KOH-soaking, DI-water rinsing and/or wet assembly with sub-15 µm thin films are particularly problematic. In this work, we report configurations of membrane electrode assemblies with solid polymer electrolyte thicknesses equivalent to 3, 5 and 10 µm, made possible by direct coating of the ionomer onto gas diffusion electrodes (direct membrane deposition). The anion-conducting solid polymer electrolyte employed is hexamethyl-p-terphenyl poly(benzimidazolium) (HMT-PMBI), which is known for its high mechanical stability and low rate of gas crossover. By fabricating membrane-electrode-assemblies with PtRu/C anodes and Pt/C cathodes with a low precious metal loading of <0.3 mg cm-2, reproducible performances beyond 1 W cm-2 in H2/O2 atmosphere are achieved. The thin membranes enable excellent performance robustness towards changes in relative humidity, as well as low ionic resistances (<40 mOhm cm2).

Sulfophenylated Terphenylene Copolymer Membranes and Ionomers.

The copolymerization of a prefunctionalized, tetrasulfonated oligophenylene monomer was investigated. The corresponding physical and electrochemical properties of the polymers were tuned by varying the ratio of hydrophobic to hydrophilic units within the polymers. Membranes prepared from these polymers possessed ion exchange capacities ranging from 1.86 to 3.50 meq g-1 and exhibited proton conductivities of up to 338 mS cm-1 (80 °C, 95 % relative humidity). Small-angle X-ray scattering and small-angle neutron scattering were used to elucidate the effect of the monomer ratios on the polymer morphology. The utility of these materials as low gas crossover, highly conductive membranes was demonstrated in fuel cell devices. Gas crossover currents through the membranes of as low as 4 % (0.16±0.03 mA cm-2 ) for a perfluorosulfonic acid reference membrane were demonstrated. As ionomers in the catalyst layer, the copolymers yielded highly active porous electrodes and overcame kinetic losses typically observed for hydrocarbon-based catalyst layers. Fully hydrocarbon, nonfluorous, solid polymer electrolyte fuel cells are demonstrated with peak power densities of 770 mW cm-2 with oxygen and 456 mW cm-2 with air.

Smoking, drinking, and depression: comorbidity in head and neck cancer patients undergoing radiotherapy.

We aimed to determine the prevalence and co-occurrence of tobacco smoking, alcohol consumption, and depressive symptoms among a sample of head and neck cancer (HNC) patients undergoing radiotherapy. A total of 307 HNC patients participated in a multi-site stepped-wedge randomized controlled trial (RCT) evaluating the effectiveness of a dietitian-delivered health behavior intervention in patients with HNC undergoing radiotherapy. During week one of radiotherapy patients completed measures of smoking, alcohol consumption, and level of depression. Approximately one-fifth (21%) of patients had two or more co-occurring problems: current smoking, hazardous alcohol use, and/or likely presence of a major depressive episode (MDE). Approximately one-third (34%) of the sample were current smokers, one-third (31%) were drinking hazardously and almost one-fifth (19%) had likely cases of depression. Comorbidity of smoking, hazardous alcohol use, and MDE is high in HNC patients, and interventions need to address this cluster of cancer risk factors.

PROMIS depression measures perform similarly to legacy measures relative to a structured diagnostic interview for depression in cancer patients.

PURPOSE: To assess the convergent validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) depression measures relative to legacy measures and criterion validity against a structured diagnostic interview for depression in an oncology sample. METHODS: 132 oncology/haematology outpatients completed the PROMIS Depression Computer Adaptive Test (PROMIS-D-CAT) and PROMIS Depression Short Form (PROMIS-D-SF) along with seven legacy measures: Beck Depression Inventory (BDI); Centre for Epidemiological Studies Depression (CES-D); Depression, Anxiety and Stress Scale; Hospital Anxiety and Depression Scale; Patient Health Questionnaire; Distress Thermometer and PSYCH-6. Correlations, area under the curve (AUC) and diagnostic accuracy statistics were calculated with Structured Clinical Interview as the gold standard. RESULTS: Both PROMIS measures correlated with all legacy measures at p < .001 (ρ = 0.589-0.810) and all AUCs (> 0.800) were comparable. At the cut-off points for mild depression of 53, the PROMIS measures had sensitivity (0.83 for PROMIS-D-CAT and 0.80 for PROMIS-D-SF) similar to or better than 6/7 legacy measures with high negative predictive value (> 90%). At cut-off points of 60 for moderate depression, PROMIS measures had specificity > 90%, similar to or better than all legacy measures and positive predictive value ≥ 0.50 (similar to 5/7 legacy measures). CONCLUSIONS: The convergent and criterion validity of the PROMIS depression measures in cancer populations was confirmed, although the optimal cut-off points are not established. PROMIS measures were briefer than BDI-II and CES-D but do not offer any advance in terms of diagnostic accuracy, reduced response burden or cost over other legacy measures of depression in oncology patients.

Highly Stable, Low Gas Crossover, Proton-Conducting Phenylated Polyphenylenes.

Two classes of novel sulfonated phenylated polyphenylene ionomers are investigated as polyaromatic-based proton exchange membranes. Both types of ionomer possess high ion exchange capacities yet are insoluble in water at elevated temperatures. They exhibit high proton conductivity under both fully hydrated conditions and reduced relative humidity, and are markedly resilient to free radical attack. Fuel cells constructed with membrane-electrode assemblies containing each ionomer membrane yield high in situ proton conductivity and peak power densities that are greater than obtained using Nafion reference membranes. In situ chemical stability accelerated stress tests reveal that this class of the polyaromatic membranes allow significantly lower gas crossover and lower rates of degradation than Nafion benchmark systems. These results point to a promising future for molecularly designed sulfonated phenylated polyphenylenes as proton-conducting media in electrochemical technologies.

Cationic Polyelectrolytes, Stable in 10 M KOHaq at 100 °C.

We report on poly(arylene-imidazoliums), which were synthesized by microwave polycondensation of dialdehyde with bisbenzil and quantitatively functionalized by alkylation. This cationic polyelectrolyte is sterically protected around the C2-position and is stable in 10 M KOHaq at 100 °C (t1/2 of >5000 h). Alkaline stability is rationalized through analyses of model compounds, single crystal X-ray diffraction, and density functional theory. The polyelectrolytes form tough, pliable, transparent, ionically conductive films.

Study Protocol: Evaluation of a DVD intervention designed to meet the informaton needs of patients with head and neck cancer and their partner, carer and families.

BACKGROUND: Patients who undergo surgery for cancer of the head and neck and their families face complex and difficult challenges and are at risk of anxiety and depression and inability to cope with symptom and treatment burden. Information available to support them is not flexible enough to adjust to individual need. DESIGN/METHODS: A randomised clinical trial pre and post intervention design, comparing the use of a tailored DVD intervention, provided preoperatively and used throughout the post- operative period, with usual treatment. One hundred fifty-six individuals or partner couples will be randomly recruited into either the intervention or control group. A survey will be administered at three time points, preoperatively, post operatively and 3 months post-surgery. Anxiety and empowerment are the primary outcome measures. Qualitative data about use of the resource will be gathered by phone interview. DISCUSSION: This is the first study to rigorously evaluate the impact of a DVD intervention for this group of patients and their family members. The study will help to understand the impact of information usage on patient and family well- being and test a means by which to evaluate information and education resources for this and other cancer patient groups. TRIAL REGISTRATION: ACTRN12614001104640 . Date registered: 17/10/2014.

Making Sense of Variations in Prevalence Estimates of Depression in Cancer: A Co-Calibration of Commonly Used Depression Scales Using Rasch Analysis.

BACKGROUND: The use of different depression self-report scales warrants co-calibration studies to establish relationships between scores from 2 or more scales. The goal of this study was to examine variations in measurement across 5 commonly used scales to measure depression among patients with cancer: Hospital Anxiety and Depression Scale-Depression subscale (HADS-D), Centre for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire-9 (PHQ-9), Beck Depression Inventory-II (BDI-II), and Depression Anxiety and Stress Scale-Depression subscale (DASS-D). METHODS: The depression scales were completed by 162 patients with cancer. Participants were also assessed by the major depressive episode module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Rasch analysis and receiver operating characteristic curves were performed. RESULTS: Rasch analysis of the 5 scales indicated that these all measured depression. The HADS and BDI-II had the widest measurement range, whereas the DASS-D had the narrowest range. Co-calibration revealed that the cutoff scores across the scales were not equivalent. The mild cutoff score on the PHQ-9 was easier to meet than the mild cutoff score on the CES-D, BDI-II, and DASS-D. The HADS-D possible cutoff score was equivalent to cutoff scores for major to severe depression on the other scales. Optimal cutoff scores for clinical assessment of depression were in the mild to moderate depression range for most scales. CONCLUSIONS: The labels of depression associated with the different scales are not equivalent. Most markedly, the HADS-D possible case cutoff score represents a much higher level of depression than equivalent scores on other scales. Therefore, use of different scales will lead to different estimates of prevalence of depression when used in the same sample.

Structurally-defined, sulfo-phenylated, oligophenylenes and polyphenylenes.

We report the synthesis and molecular characterization of structurally defined, sulfo-phenylated, oligo- and polyphenylenes that incorporate a novel tetra-sulfonic acid bistetracyclone monomer. The utility of this monomer in the [4 + 2] Diels-Alder cycloaddition to produce well-defined, sulfonated oligophenylenes and pre-functionalized polyphenylene homopolymers is demonstrated. Characterization of the oligophenylenes indicates formation of the meta-meta and para-para adducts in a ∼ 1:1 ratio. These functionalized monomers and their subsequent coupling provide a route to prepare novel, sterically encumbered, sulfonated polyphenylenes possessing unprecedented structural control.

Using Rasch analysis to examine the distress thermometer's cut-off scores among a mixed group of patients with cancer.

PURPOSE: The distress thermometer (DT) is commonly used in cancer care to improve detection of distress. The DT's recommended cut-off score of 4 or 5 has typically been established using the Hospital Anxiety and Depression Scale (HADS) by receiver operating characteristic curve analysis. The present analysis complements these studies by critically examining the use of the HADS to identify the DT's cut-off score and corroborating the DT's cut-off scores using item response theory (Rasch analysis). METHODS: The DT and HADS were completed by 340 patients with cancer. Rasch dimensionality analysis was performed on the HADS-Total, and test characteristic curves were examined to equate the DT and the HADS subscales. Identified DT cut-off scores were then examined for their sensitivity and specificity. RESULTS: Rasch analysis did not support the unidimensionality of HADS-Total. The test characteristic curves indicated that a cut-off score of ≥8 on the HADS-Anxiety and HADS-Depression subscales was equivalent to a score of 6 and 7 on the DT, respectively. However, a DT cut-off score of 5 resulted in the best balance between sensitivity and specificity across the HADS-Anxiety and HADS-Depression subscales. CONCLUSIONS: Despite being a popular practice, the present findings did not support combining the HADS-Anxiety and HADS-Depression subscales to identify the DT's cut-off score. Furthermore, these results inform the use of the DT as a preliminary screening tool and suggest that when a single screen is used, a DT cut-off score of 6 or 7 might be more appropriate than the typical cut-off score of 4.

Early screening in patients with head and neck cancer identified high levels of pain and distress.

PURPOSE: Pain and distress are recognized as the fifth and sixth vital signs in cancer care, respectively, as debilitating symptoms that are frequently under-recognized. The aim of this study was to document, using touch-screen technology, levels of pain and distress in patients with head and neck cancer before their assessment at a head and neck multidisciplinary referral clinic. MATERIALS AND METHODS: A cross-sectional study over a 4-year period (2008 through 2011) was conducted for patients attending a head and neck oncology multidisciplinary team clinic in the Hunter New England referral district of Australia. Predictor variables were cancer stage and site. Cancer sites divided into 8 different regions, with distinction made for cutaneous versus noncutaneous sites. Outcome variables consisted of pain and distress levels. Pain was assessed using a Numerical Rating Scale of 0 to 10, and distress was assessed using the Distress Thermometer and PSYCH-6 scales. In the context of a screening study and for statistically comparing pain with other variables, pain was regarded as any score higher than 0. Clinically significant distress represented a Distress Thermometer score higher than 3 and a PSYCH-6 score of at least 3. Data analysis consisted of descriptive statistics, variance contrasts, and 2-tailed Pearson correlations. RESULTS: Four hundred thirty-six patients were included in the study, with an equal number of cutaneous and noncutaneous cancer sites. Thirty-four percent of patients reported having pain, and 13% had clinically significant distress. Tumor stage did not significantly affect pain or distress scores. CONCLUSIONS: There is a high level of pain and distress reported by patients with head and neck cancer before their assessment and management is discussed.

A Rasch analysis of the Hospital Anxiety and Depression Scale (HADS) among cancer survivors.

OBJECTIVE: The Hospital Anxiety and Depression Scale (HADS) is commonly used to assess distress among individuals with cancer. However, previous studies cast doubt on the most appropriate dimensional structure for the HADS, suggesting that 1- or 3-dimensional structures might offer superior fit to the original 2-dimensional one. This article is the first to use Rasch analysis to examine the psychometric properties of the subscales corresponding to each of these alternative structures. METHOD: The HADS was completed by 1,360 cancer survivors. Rasch analyses were conducted to examine summary and individual model fit statistics, person separation index, response format, item bias, redundancy, and dimensionality. RESULTS: The HADS-Total scale was found to be multidimensional, and it was necessary to remove almost half of the items to achieve fit. Analyses only partially supported the original structure, as both HADS-Anxiety and HADS-Depression showed initial model misfit and item deletion was necessary to achieve fit. Within the 3-dimensional structures, the Rasch statistics for the anxiety subscales were within acceptable range and no adjustment was needed. Analyses did not support adding Item 7 to HADS-Depression. CONCLUSIONS: Results supported modified versions of the HADS-Anxiety and HADS-Depression; however, combining all items to form HADS-Total is not recommended. Numerous studies using classical test theory and Rasch analyses have corroborated the exclusion of some items (e.g., Item 7) and appropriateness of the subscales defined by a 3-dimensional structure. Further research is required to identify the incremental validity of potential revised subscales.