Psychiatric vulnerability and the risk for unintended pregnancies, a systematic review and meta-analysis.

BACKGROUND: Unintended pregnancies (UPs) are a global health problem as they contribute to adverse maternal and offspring outcomes, which underscores the need for prevention. As psychiatric vulnerability has previously been linked to sexual risk behavior, planning capacities and compliance with contraception methods, we aim to explore whether it is a risk factor for UPs. METHODS: Electronic databases were searched in November 2020. All articles in English language with data on women with age ≥ 18 with a psychiatric diagnosis at time of conception and reported pregnancy intention were included, irrespective of obstetric outcome (fetal loss, livebirth, or abortion). Studies on women with intellectual disabilities were excluded. We used the National Institutes of Health tool for assessment of bias in individual studies and the Grading of Recommendations Assessment, Development and Evaluation method for assessment of quality of the primary outcome. FINDINGS: Eleven studies reporting on psychiatric vulnerability and UPs were included. The participants of these studies were diagnosed with mood, anxiety, psychotic, substance use, conduct and eating disorders. The studies that have been conducted show that women with a psychiatric vulnerability (n = 2650) have an overall higher risk of UPs compared to women without a psychiatric vulnerability (n = 16,031) (OR 1.34, CI 1.08-1.67) and an overall weighed prevalence of UPs of 65% (CI 0.43-0.82) (n = 3881). INTERPRETATION: Studies conducted on psychiatric vulnerability and UPs are sparse and many (common) psychiatric vulnerabilities have not yet been studied in relation to UPs. The quality of the included studies was rated fair to poor due to difficulties with measuring the outcome pregnancy intention (use of various methods of assessment and use of retrospective study designs with risk of bias) and absence of a control group in most of the studies. The findings suggest an increased risk of UPs in women with psychiatric vulnerability. As UPs have important consequences for mother and child, discussing family planning in women with psychiatric vulnerabilities is of utmost importance.

[The use and appreciation of the mental status examination in the Netherlands]. / Gebruik en waardering van het status-mentalisonderzoek in Nederland.

BACKGROUND: The mental status examination (MSE) is part of everyday psychiatric practice. However, it is unknown which items of the MSE are considered important and how the MSE is appreciated in the Netherlands.
AIM: To gain insight in the importance of the MSE, and to investigate which items are used in everyday practice.
METHOD: Dutch psychiatrists and residents filled in a questionnaire, using a 5-point Likert scale, where they rated frequency of use and importance of 24 different items of the Dutch MSE. They also reported which items, in their opinion, should be rated 'always', 'on indication only' or 'never'. Finally, the respondents were asked about their need of education and training in the MSE. The data were collected through an online questionnaire, which was distributed through email and the website of the Dutch psychiatric association.
RESULTS: A total of 402 respondents filled in the questionnaire, of which 60.4% were psychiatrists and 39.6% were residents. The MSE was seen as an essential part of the everyday psychiatric practice. The current format was appreciated strongly. In current practice, 10 items of the MSE were 'always' rated by more than 50% of the respondents. Ten items were rated very rarely, if ever. Respondents thought these items should only be rated on specific indication. There was a need for extra training in the MSE amongst residents and psychiatrists.
CONCLUSION: The Dutch MSE, consisting of 24 items, is strongly appreciated by psychiatrists and residents as an essential part of the psychiatric diagnostic process. In the everyday practice only a part of the items are used frequently.

Dress and address in hospital psychiatry: an issue?

Background and aims: To assess the preferences of Dutch psychiatric patients in three general hospital psychiatric settings for the dress of psychiatrists and patients preference to be addressed by psychiatrists. To assess the associations concerning different clothing styles and the attributes of the patient-doctor relationship.Methods: One hundred and seventy-three adults, in and outpatients (aged 18-89 years) attending the psychiatry departments of three general hospitals, were included during the period June 2015 to May 2016. In these hospitals, the psychiatrist staff has different clothing policies. Data were analyzed with SPSS21.Results: Divided over the three hospitals, 173 patients were included, 96 inpatients and 77 outpatients. The patients' opinions on the psychiatrists' dress differed significantly between the hospitals in line with the local hospital clothing policy (p = 0.002 for the male psychiatrists, p = 0.000 for the female psychiatrists). The patients' ethnicity significantly influenced their preferences for dress and address, as a majority of the patients with a non-Dutch ethnic background expressed a preference for white coats, and address by surname (RR = 2.0, p = 0.003 for male and RR = 2.1 p = 0.002 for female psychiatrists). A significant difference in preference for being addressed by their first names by the psychiatrist was found between Dutch and non-native Dutch patients (RR = 2.6, p = 0.005). According to patients, the male psychiatrist in trousers and a long sleeve shirt and female psychiatrist in casual clothing were most often associated as being the friendliest, a white coat as being the most competent, and wearing smart attire as being the most accessible.Conclusion: Patients' preferences are in line with current local clothing habits. Ethnicity, setting and country influence a patient's preferences. Casual clothing for psychiatrists is assessed as being the friendliest but as the least competent, and white coats are assessed as being the most competent but as being less friendly and less accessible.

Factors influencing the admission decision for Medical Psychiatry Units: A concept mapping approach.

OBJECTIVE: Medical Psychiatry Units (MPUs), also known as Complexity Intervention Units (CIUs), provide care for complex patients suffering from both psychiatric and physical disorders. Because there is no consensus on the indications for admission to an MPU, daily practice and effectiveness research are hampered. This study therefore used a concept mapping approach to investigate which organizational and medical factors determine the decision to admit a patient to an MPU. METHODS: The first step of the concept mapping approach was to create a list of factors determining MPU admission from literature. Secondly, clinical experts sorted and ranked these factors. The sorted and ranked data were then analyzed, and a draft conceptual framework was created. A final conceptual MPU admission framework was then drawn during an expert consensus meeting and recommendations for implementation were suggested. RESULTS: Thirteen clinical experts defined 90 factors from literature, which were sorted and ranked by 40 experts from 21 Dutch hospitals. This concept mapping approach resulted in a five-cluster solution for an MPU admission framework based on: 1. Staff competencies and organizational pre-requisites; 2. Patient context; 3. Patient characteristics; 4. Medical needs and capabilities; and 5. Psychiatric symptoms and behavioral problems. Furthermore, three inclusion and two exclusion criteria were formulated to help the clinicians decide whether or not to admit patients to an MPU. These criteria can be implemented in daily practice. CONCLUSION: Implementing the five criteria derived from this conceptual framework will help make the admission decision for complex patients with psychiatric and physical disorders to an MPU more correct, consistent, and transparent.

Measuring outcomes on a Medical Psychiatric Unit: HoNOS,, CANSAS and costs.

OBJECTIVE: To study the course of the functional status and healthcare needs of patients on a Medical Psychiatric Unit (MPU). METHODS: In a single-centre observational prospective design the Health of the Nation Outcome Scales (HoNOS) and Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) instruments were administered at admission and discharge. Functional status and healthcare needs were assessed utilizing the HoNOS and CANSAS respectively. The total costs of healthcare claims related to the admission were calculated based on claims data. RESULTS: In total 50 patients were included with a mean improvement of 4.6 on the HoNOS and an effect size of 0.6.The total number of unmet needs fell from 208 to 115. The median costs per decreased HoNOS point were €2.842 and €6.880 per unmet need. DISCUSSION: Many patients improved, but due to a large standard deviation at baseline and a low Cronbach's alpha, only 4 patients showed a reliable improvement on functional status. That substantial remission was achieved was shown by the decrease in unmet needs of 93 (44.7%) for the whole group. These observations support the implementation of MPUs, although more research is warranted to ensure cost-effectiveness.

Health-related quality of life among adult HIV positive patients: assessing comprehensive themes and interrelated associations.

PURPOSE: We selected and evaluated a comprehensive set of themes that encompass health-related quality of life (HRQOL) among HIV patients, which enables clinicians to tailor care to individual needs, follow changes over time and quantify returns on health care investments and interventions. METHODS: HIV patients (N = 250) of two Dutch HIV clinics were invited to complete an online survey comprised of a set of (adaptations of) validated questionnaires measuring eight themes, including general health (SF-12), stigma (short stigma scale), social support (SSL12-I), self-esteem (SISE), sexuality problems, anxiety and depression (HADS), sleeping difficulties (SCL90-Sleep) and perceived side-effects. RESULTS: Findings from 170 (response rate 68%) patients (Male = 159, 94.1%) showed that questionnaires had high internal consistency, and most themes significantly correlated (r's .21 to - .69, p < .05) in the expected directions. Exploring cut-off scores shows that a significant proportion of patients score outside of the desired range on single themes (between 16.0 and 73.1%), and many patients on multiple themes simultaneously (8.9% on 5 or more themes). Regression analysis showed that social support, self-esteem and sexuality problems were associated with general health (R = .48, R2 = .23, F(4,145) = 10.57, p < .001); adding anxiety and depression, sleeping difficulties and perceived side-effects explained 51.2% of the variance in total (R = .72, ∆R2 = .29, F(3, 142) = 27.82, p < .001). CONCLUSIONS: We succeeded in developing a questionnaire that comprehensively assesses HRQOL. HRQOL of the majority of Dutch HIV patients could be improved. The themes strongly influenced each other, therefore insights into any of the themes could inform interventions to improve HRQOL, and increase attention to these themes in routine consultations between patients and health care professionals.

Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.

AIM: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in a study and to evaluate the general isability of its results. METHODS: The standards for reporting of diagnostic accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, and members of professional organisations shortened this list during a 2 day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. At the consensus meeting, participants shortened the list to a 25-item checklist, by using evidence whenever available. A prototype of a flow diagram provides information about the method of recruitment of patients, the order of test execution and the numbers of patients undergoing the test under evaluation, the reference standard, or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of clinicians, researchers, reviewers, journals, and the public.

[Reporting studies of diagnostic accuracy according to a standard method; the Standards for Reporting of Diagnostic Accuracy (STARD)]. / Verslaglegging van diagnostisch evaluatieonderzoek volgens een standaardmethode; de 'standards for reporting of diagnostic accuracy' (STARD).

The objective of the 'Standards for Reporting of Diagnostic Accuracy' (STARD) initiative is to improve the reporting of studies of diagnostic accuracy, so as to allow readers to assess the potential for bias in a study and to evaluate the generalibility of its results. The group searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies. This was used to draw up a list of potential items. During a consensus meeting, a group of researchers, medical journal editors, and members of professional organisations reduced this list to a usable checklist. Wherever possible, evidence from the literature was used to justify the decisions made. The search for published guidelines about diagnostic research yielded 33 previously published checklists, from which a list of 75 potential items was extracted. At the consensus meeting, participants shortened the list to a 25-item checklist. A generic flow diagram was drawn up to provide guidance on the method for including patients, the order in which tests were to be conducted and the number of patients to undergo the test being evaluated, the reference standard, or both. A scientific publication can only be assessed when the reporting is both correct and complete. Use of the checklist and flow diagram will improve the quality of reports produced, to the advantage of clinicians, researchers, reviewers, journal editors and other interested parties.

Diagnostic accuracy of triage tests to exclude pulmonary embolism.

We performed a study in 403 prospectively included patients with suspected pulmonary embolism to compare the accuracy of a combination of the SimpliRED D-dimer assay and an intuitive clinical probability estimate with either one alone. Based on a conjoint diagnostic refer, ence standard, including ventilation-perfusion lung scintigraphy and pulmonary angiography, the prevalence of pulmonary embolism was 31%. We demonstrated a high sensitivity (98%, 95% CI 95-100) and negative predictive value (94%, 95% CI 79-99) for the combination of the two tests. These figures were more favorable than for either test alone. The specificity of the combination was lower (11%, 95% CI 9-12) and consequently the proportion of patients in whom further diagnostic tests would have been avoided was only 8%. We conclude that the combined use of the SimpliRED test and the clinical probability estimate attains a higher sensitivity than either test alone. However, there remains a risk of false negatives and the exclusion efficiency is limited.

Magnetic resonance angiography for the evaluation of lower extremity arterial disease: a meta-analysis.

CONTEXT: Magnetic resonance angiography (MRA) is a rapidly evolving technique that has been reported to be accurate for assessment of lower extremity arterial disease. OBJECTIVE: To obtain the best available estimates of the diagnostic performance of MRA in patients with lower extremity arterial disease. DATA SOURCES: Studies published from January 1985 through May 2000 in English, German, or French, identified from the MEDLINE, EMBASE, and Current Contents databases. STUDY SELECTION: Studies were included that allowed construction of 2 x 2 contingency tables for detection of stenosis greater than 50% or occlusion with MRA or arteriography in patients with claudication or critical ischemia. DATA EXTRACTION: Two observers graded the following elements of study quality: consecutively enrolled patients, prospective study design, clear cut-off levels, blinded assessment, and clear description of MRA technique. Summary receiver operating characteristic analysis was performed to examine the influence of year of publication, all methodological criteria, arterial tract, number of subdivisions within arterial tracts, and MRA technique on diagnostic performance. DATA SYNTHESIS: Of 3583 studies initially identified, 34 were included that evaluated MRA in 1090 patients (72% men; median age, 65 years). Magnetic resonance angiography was highly accurate for assessment of all lower extremity arteries. Three-dimensional gadolinium-enhanced (3-D Gd) MRA improved diagnostic performance compared with 2-D MRA (relative diagnostic odds ratio, 2.8 [95% confidence interval, 1.2-6.4]), adjusted for number of subdivisions within arterial tracts. The estimated points of equal sensitivity and specificity were 94% and 90% for 3-D Gd MRA and 2-D MRA, respectively. CONCLUSIONS: Magnetic resonance angiography is highly accurate for assessment of the entire lower extremity for arterial disease. Three-dimensional Gd-enhanced MRA improves diagnostic performance compared with 2-D MRA.

Use of a new monoclonal antibody-based enzyme immunoassay for soluble fibrin to exclude pulmonary embolism. ANTELOPE-Study Group.

We prospectively evaluated the diagnostic performance of a new soluble fibrin assay in 303 consecutive patients with suspected pulmonary embolism and examined potentially useful cut-off levels at which this disease can be safely excluded. In addition, the diagnostic accuracy was calculated in the subgroups of in- and outpatients. The ROC curve of the assay in the total study cohort had an area under the curve of 0.69. The cut-off level associated with a sensitivity and negative predictive value of 100% was 20 ng/ml, but the specificity was only 4%. The cut-off level with a sensitivity of 90% was 30 ng/ml, which corresponded with a specificity and negative predictive value of 27% and 86%. respectively. The diagnostic performance was comparable in the subgroups of in- and outpatients. We conclude that the soluble fibrin assay has a low diagnostic accuracy and seems unsuitable as a screening test for the exclusion of pulmonary embolism.

[Sensitive and specific screening for detection of spina bifida by echography in the second trimester; systematic review and meta-analysis]. / Sensitieve én specifieke screening ter detectie van spina bifida door echografie in het tweede trimester; systematische review en meta-analyse.

OBJECTIVE: Evaluation of the diagnostic accuracy of ultrasound in the second trimester for the detection of spina bifida. DESIGN: Systematic review and meta-analysis. METHOD: Medline and Embase were searched to identify prospective studies in a general pregnant population. Also, in the Cochrane Library, references of identified reports and recent reviews were checked for relevant studies. Retrieved abstracts were selected independently by 2 authors using predefined criteria. Assessment of quality and generalizability of the included studies and data extraction were performed by 3 authors independently. The data were tested for heterogeneity and pooled estimates of sensitivity and specificity were calculated for all studies. RESULTS: 13 studies were included. Specificity was approximately 100% in all cases. Sensitivity varied from 40% to 100%. The summary point estimate for sensitivity was 71% with a 95% confidence interval of 59%-81%. CONCLUSION: Ultrasound in the second trimester is a specific investigation to detect spina bifida, which may detect seven out of ten defects. Used as a screening tool, it could contribute to a significant reduction in the number of children born with spina bifida.

Clinical evaluation of a monoclonal antibody-based enzyme immunoassay for fibrin degradation products in patients with clinically suspected pulmonary embolism. ANTELOPE-Study Group.

We prospectively evaluated the diagnostic accuracy of the Fibrinostika FbDP assay in 304 consecutive patients with suspected pulmonary embolism and examined potentially useful cut-off points at which the disease can be excluded. The prevalence of pulmonary embolism was 31%. The assay generated an area under the Receiver Operating Characteristic curve of 0.79 (95% CI 0.73-0.84). A cut-off point of 0.05 microg/ml yielded a sensitivity, specificity, negative predictive value and an exclusion efficiency of 100% (95% CI 96-100), 5% (95% CI 2-9), 100% (95% CI 69-100) and 3% (95% CI 2-6), respectively. A clinically useful cut-off point seems to be 0.11 microg/ml which corresponded with a sensitivity, specificity, negative predictive value and an exclusion efficiency of 96% (95% CI 90-99), 27% (95% CI 24-28), 93% (95% CI 84-98) and 20% (95% CI 16-25), respectively. We conclude that the assay has potential clinical utility for the exclusion of pulmonary embolism, but it cannot be used as a sole test.

Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group.

Recent studies have suggested that both the subjective judgement of a physician and standardized clinical models can be helpful in the estimation of the probability of the disease in patients with suspected pulmonary embolism (PE). We performed a multi-center study in consecutive in- and outpatients with suspected PE to compare the potential diagnostic utility of these methods. Of the 517 study patients, 160 (31%) were classified as having PE. Of these patients, 14% had a low probability as estimated by the treating physician, while 25 to 36% were categorized as having a low clinical probability with the use of two previously described clinical models. The objectively confirmed prevalence of PE in these three low probability categories was 19%, 28% and 28%, respectively. The three methods yielded comparable predictive values for PE in the other probability categories. We conclude that a physician's clinical judgement alone and two standardized clinical models, although comparable, perform disappointingly in categorizing the pre-test probability in patients with suspected PE.

Abdominal symptoms: do they predict gallstones? A systematic review.

BACKGROUND: Our objective was to evaluate the diagnostic accuracy of abdominal symptoms in gallstones in studies using ultrasonography or oral cholecystography as the reference standard and to assess the extent to which variability in diagnostic accuracy is explained by patient selection and other characteristics of study design. METHODS: A Medline search (1966-1998) was conducted in combination with reference checking for further relevant publications. Two independent assessors selected controlled studies that included patients > or =18 years of age. Articles were excluded if sensitivity and specificity could not be extracted or the included patients were at extraordinary risk for gallstones. Seven abdominal symptoms were evaluated. Modification of the diagnostic accuracy by clinical setting, extent of the disease, blinding, age, and sex was analysed by using logistic regression. RESULTS: A total of 24 publications were included. The symptoms 'biliary colic', 'radiating pain', and 'analgesics used' were consistently related to gallstones. The setting of the study had a significant effect on the diagnostic accuracy of these symptoms. The unadjusted, pooled diagnostic odds ratios, however, were low (2.6 (95% confidence interval, 2.4-2.9), 2.8 (2.2-3.7), and 2 (1.6-2.5), respectively). The diagnostic odds ratio of biliary colic increased with the extent of gallstone disease (13.3 (4.2-42). CONCLUSIONS: Although biliary colic was specific for gallstones, 80% of the referred patients with gallstones presented with other abdominal symptoms. There is no current evidence that justifies the use of single abdominal symptoms, other than biliary colic, in the diagnosis of symptomatic gallstones. Further research should focus on the prognosis of patients with non-specific abdominal symptoms and gallstones.

Diagnostic accuracy of myoglobin concentration for the early diagnosis of acute myocardial infarction.

STUDY OBJECTIVE: We evaluated the diagnostic accuracy of myoglobin determination for the early diagnosis of acute myocardial infarction (AMI). METHODS: Consecutive patients with chest pain were included in the study. Receiver operating characteristic (ROC) analysis was used to assess optimal timing of blood sampling and cutoff values. RESULTS: A total of 309 patients were included, of whom 162 patients had a diagnosis of AMI. ROC analysis revealed that the diagnostic accuracy of myoglobin concentration as indicated by the area under the ROC curve (AUC) increased significantly from 3 (0.89+/-0.026) and 4 hours (0.93+/-0.019) to 5 hours after onset of symptoms (0. 96+/-0.014; P=.0040 and.035, respectively). At 5 hours (the earliest time point with maximal AUC), sensitivity was 87% and specificity was 97% using a myoglobin cutoff value of 90 microg/L. With a myoglobin cutoff value of 50 microg/L, sensitivity was 95% (95% confidence interval 90% to 98%), but specificity was 86% (95% confidence interval 80% to 93%). CONCLUSION: Myoglobin has maximal diagnostic accuracy for the diagnosis of AMI at 5 hours after the onset of symptoms, using a cutoff value of 50 microg/L. In combination with the measurement of other biochemical markers, myoglobin determination could be particularly useful for triage of patients with AMI at an early stage.

Effect of study design on the association between nuchal translucency measurement and Down syndrome.

OBJECTIVE: To evaluate the effect of verification bias on the accuracy of first-trimester nuchal translucency measurement for Down syndrome detection. METHODS: We used MEDLINE and EMBASE to identify all papers relating the results of nuchal translucency measurement to fetal karyotype. The detected studies were scored for verification bias. Fifteen studies without and ten with verification bias were included. RESULTS: Sensitivity and specificity were calculated for each study. For studies with verification bias, adjusted estimates of the sensitivity were calculated assuming a fetal loss rate for Down syndrome pregnancies of 48%. The sample size weighted sensitivity was 55% in studies without and 77% in those with verification bias, for specificities of 96% and 97%, respectively. After adjustment for verification bias, the sample size weighted sensitivity changed from 77% to 63%. CONCLUSION: Studies with verification bias reported higher sensitivities, but also slightly higher specificities of nuchal translucency measurement than studies without verification bias. The difference in sensitivity is greater than could be explained by verification bias. We postulate that the experience of the sonographist might be an explanation for the differences.

Empirical evidence of design-related bias in studies of diagnostic tests.

CONTEXT: The literature contains a large number of potential biases in the evaluation of diagnostic tests. Strict application of appropriate methodological criteria would invalidate the clinical application of most study results. OBJECTIVE: To empirically determine the quantitative effect of study design shortcomings on estimates of diagnostic accuracy. DESIGN AND SETTING: Observational study of the methodological features of 184 original studies evaluating 218 diagnostic tests. Meta-analyses on diagnostic tests were identified through a systematic search of the literature using MEDLINE, EMBASE, and DARE databases and the Cochrane Library (1996-1997). Associations between study characteristics and estimates of diagnostic accuracy were evaluated with a regression model. MAIN OUTCOME MEASURES: Relative diagnostic odds ratio (RDOR), which compared the diagnostic odds ratios of studies of a given test that lacked a particular methodological feature with those without the corresponding shortcomings in design. RESULTS: Fifteen (6.8%) of 218 evaluations met all 8 criteria; 64 (30%) met 6 or more. Studies evaluating tests in a diseased population and a separate control group overestimated the diagnostic performance compared with studies that used a clinical population (RDOR, 3.0; 95% confidence interval [CI], 2.0-4.5). Studies in which different reference tests were used for positive and negative results of the test under study overestimated the diagnostic performance compared with studies using a single reference test for all patients (RDOR, 2.2; 95% CI, 1.5-3.3). Diagnostic performance was also overestimated when the reference test was interpreted with knowledge of the test result (RDOR, 1.3; 95% CI, 1.0-1.9), when no criteria for the test were described (RDOR, 1.7; 95% CI, 1.1-2.5), and when no description of the population under study was provided (RDOR, 1.4; 95% CI, 1.1-1.7). CONCLUSION: These data provide empirical evidence that diagnostic studies with methodological shortcomings may overestimate the accuracy of a diagnostic test, particularly those including nonrepresentative patients or applying different reference standards.