Comprehensive and reliable sonographic assessment and scoring system for inflammatory lesions of the paediatric ankle.

OBJECTIVE: The clinical decision-making process in paediatric arthritis lacks an objective, reliable bedside imaging tool. The aim of this study was to develop a US scanning protocol and assess the reliability of B-mode and Doppler scoring systems for inflammatory lesions of the paediatric ankle. METHODS: As part of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) US group, 19 paediatric rheumatologists through a comprehensive literature review developed a set of standardized views and scoring systems to assess inflammatory lesions of the synovial recesses as well as tendons of the paediatric ankle. Three rounds of scoring of still images were followed by one practical exercise. Agreement among raters was assessed using two-way single score intraclass correlation coefficients (ICC). RESULTS: Of the 37 initially identified views to assess the presence of ankle synovitis and tenosynovitis, nine views were chosen for each B-mode and Doppler mode semi-quantitative evaluation. Several scoring exercises and iterative modifications resulted in a final highly reliable scoring system: anterior tibiotalar joint ICC: 0.93 (95% CI 0.92, 0.94), talonavicular joint ICC: 0.86 (95% CI 0.81, 0.90), subtalar joint ICC: 0.91 (95% CI 0.88, 0.93) and tendons ICC: 0.96 (95% CI 0.95, 0.97). CONCLUSION: A comprehensive and reliable paediatric ankle US scanning protocol and scoring system for the assessment of synovitis and tenosynovitis were successfully developed. Further validation of this scoring system may allow its use as an outcome measure for both clinical and research applications.

Reliability of the Pediatric Specific Musculoskeletal Ultrasound Scoring Systems for the Elbow, Wrist, and Finger Joints.

OBJECTIVE: Musculoskeletal ultrasound (MSUS) is increasingly being used in the evaluation of pediatric musculoskeletal diseases. In order to provide objective assessments of arthritis, reliable MSUS scoring systems are needed. Recently, joint-specific scoring systems for arthritis of the pediatric elbow, wrist, and finger joints were proposed by the Childhood Arthritis and Rheumatology Research Alliance (CARRA) MSUS workgroup. This study aimed to assess the reliability of these scoring systems when used by sonographers with different levels of expertise. METHODS: Members of the CARRA MSUS workgroup attended training sessions for scoring the elbow, wrist, and finger. Subsequently, scoring exercises of B mode and power Doppler (PD) mode still images for each joint were performed. Interreader reliability was determined using 2-way single-score intraclass correlation coefficients (ICCs) for synovitis and Cohen [Formula: see text] for tenosynovitis. RESULTS: Seventeen pediatric rheumatologists with different levels of MSUS expertise (1-15 yrs) completed a 2-hour training session and calibration exercise for each joint. Excellent reliability (ICC > 0.75) was found after the first scoring exercise for all the finger and elbow views evaluated on B mode and PD mode, and for all of the wrist views on B mode. After a second training session and a scoring exercise, the wrist PD mode views reached excellent reliability as well. CONCLUSION: The preliminary CARRA MSUS scoring systems for assessing arthritis of the pediatric elbow, wrist, and finger joints demonstrate excellent reliability among pediatric MSUS sonographers with different levels of expertise. With further validation, this reliable joint-specific scoring system could serve as a clinical tool and scientific outcome measure.

Ultrasonography in Pediatric Rheumatology.

This review highlights the increasing evidence from the last few years supporting the use of musculoskeletal ultrasonography (MSUS) in the evaluation and management of patients with pediatric rheumatic diseases, particularly focusing on juvenile idiopathic arthritis. Recently developed definitions for the sonographic appearance of healthy and pathologic joints in children are discussed. Further topics explored include how MSUS enhances the diagnosis of inflammatory joint disease (synovitis, enthesitis, tenosynovitis), including the detection of subclinical synovitis. There is a brief summary on the use of ultrasonography in the evaluations of myositis, Sjögren syndrome, and scleroderma.

A biomarker-guided, prospective, phase 2 trial of pre-emptive graft-versus-host disease therapy using anti-thymocyte globulin.

BACKGROUND AIMS: Intensified immunosuppressive prophylaxis for graft-versus-host disease (GVHD) may be toxic and therefore warranted only in patients at high risk of developing GVHD. In patients who underwent allogeneic hematopoietic cell transplant at the authors' center, high serum soluble IL-2 receptor alpha (sIL-2Rα) and low IL-15 levels on day 7 post-transplant were found to predict a high risk of developing clinically significant GVHD (sGVHD), defined as grade 2-4 acute GVHD or moderate to severe chronic GVHD. METHODS: This was a prospective, phase 2 trial in which high-risk patients (serum sIL-2Rα >4500 ng/L or IL-15 <31 ng/L) received rabbit anti-thymocyte globulin (ATG) 3 mg/kg on day 8 post-transplant. Controls consisted of patients who had their sIL-2Rα/IL-15 levels measured but did not participate in the trial. A total of 68 trial patients and 143 controls were accrued to this study. The primary endpoint was incidence of sGVHD. RESULTS: There was a reduction in sGVHD in high-risk trial patients (received day 8 ATG) compared with high-risk controls (did not receive day 8 ATG) (sub-hazard ratio [SHR] = 0.48, P < 0.05). There was no significant difference between the groups in overall survival or relapse; however, there was a greater incidence of non-GVHD-associated non-relapse mortality in high-risk trial patients (SHR = 3.73, P < 0.05), mostly related to infections. This may be due in part to the biomarkers ineffectively stratifying GVHD risk. CONCLUSIONS: Pre-emptive ATG therapy is both feasible and effective at reducing sGVHD without increasing relapse. Further mitigation strategies are needed to reduce the risk of infection associated with intensified GVHD prophylaxis. This study was registered at ClinicalTrials.gov (NCT01994824).

Acceptability and accuracy of patient-reported outcome measures (PROMs) for surveillance of breathlessness in routine lung cancer care: A mixed-method study.

BACKGROUND: Breathlessness in lung cancer negatively impacts on quality of life but often goes undetected and undertreated in clinical practice. There is a need for routine surveillance for early identification and proactive management of breathlessness using patient reported outcome measures (PROMs) in clinical care but it is unclear what PROMs should be used or are accurate for use in routine care. METHODS: We used mixed-methods (quantitative surveys and qualitative interviews) to examine the predictors of breathlessness in 339 lung cancer participants and acceptability of PROMs. In addition to multivariate analysis to examine predictors of dyspnea, participants completed an acceptability survey and themes were derived for the qualitative data (n = 26) to explore patient experience of PROMs. We also tested the accuracy of PROMs using a Receiver Operating Characteristic and Area Under the Curve analysis. RESULTS: A total of 339 patients completed the breathlessness PROMs and acceptability survey and 26 patients participated in an in-depth interview to investigate their experiences of breathlessness and its PROMs. Prevalence of breathlessness was 51.9 % (n = 176) and 70.5 % of patients preferred the Medical Research Council (MRC) scale followed by the Breathlessness Intensity (BI) scale (63.7 %) among the five measures for breathlessness- Modified Borg Scale (MBS), Cancer Dyspnea Scale (CDS), MRC, BI, and Breathlessness Distress (BD). The finding showed wide variation in the MRC grades across the BI rating even among patients with the same BI score. AUC scores for the Borg scale was 0.71 (using MRC cut-off score of < 2), for CDS, 0.72, for BD, 0.70, and for BI 0.79. For an MRC score of 2, the Borg score cut-off was 0.8 (optimal sensitivity, 50 %; specificity, 93.3 %); the cut-off score of CDS, BD, BI score was 1.4 (optimal sensitivity, 67.1 %; specificity, 70 %), 1.5 (optimal sensitivity, 57.5 %; specificity, 73.3 %), and 1.5 (optimal sensitivity, 72.6 %; specificity, 83.3 %) respectively. AUC by ROC analysis for breathlessness and modest concordance among five PROMs showed important gaps between the individuals' experience and PROMs data. Three main themes from qualitative data included 1) Making sense of symptom reporting, 2) Valuing the reported data, 3) Managing the symptom of breathlessness. CONCLUSION: This study examined measurement of breathlessness using PROMs for routine clinical care and showed that severity measures alone do not accurately detect this symptomnor the experiential dimensions of breathlessness that are critical to guide appropriate intervention.

Borrowing from Peter to pay Paul: managing threatened predators of endangered and declining prey species.

Conservation policy and practice can sometimes run counter to their mutual aims of ensuring species survival. In Kenya, where threatened predators such as lion deplete endangered prey such as Grevy's zebra, conservation practitioners seek to ensure species success through exclusive strategies of protection, population increase and preservation. We found strong selection for the endangered Grevy's zebra by both lion and hyena on two small fenced conservancies in Kenya. Despite abundant diversity of available prey, Grevy's zebra were selected disproportionately more than their availability, while other highly available species such as buffalo were avoided. Lions were therefore not alone in presenting a credible threat to Grevy's zebra survival. Conservation practitioners must consider interlinked characteristics of prey selection, resource availability and quality, the interplay between carnivore guild members and landscape scale population trends performance in wildlife management decisions.

Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013-2016.

Major depression is a common and treatable mental disorder characterized by changes in mood, and cognitive and physical symptoms over a 2-week period (1). It is associated with high societal costs (2) and greater functional impairment than many other chronic diseases, including diabetes and arthritis (3). Depression rates differ by age, sex, income, and health behaviors (4). This report provides the most recent national estimates of depression among adults. Prevalence of depression is based on scores from the Patient Health Questionnaire (PHQ-9), a symptom-screening questionnaire that allows for criteria-based diagnoses of depressive disorders (5). Estimates for non-Hispanic Asian persons are presented for the first time.

Finding some seagrass optimism in Wales, the case of Zostera noltii.

There exists limited understanding of the long-term dynamics of the seagrass Zostera noltii and how this is influenced by anthropogenic pressures. Milford Haven is a heavily industrialised estuary and also one of the important sites for Zostera sp. in the UK. In this study we examine all available long-term spatial variability and abundance data of Zostera noltii within Milford Haven using historic datasets. Results show that Z. noltii in all sites have shown meadow expansion when compared to the first obtainable records. Little change in abundance over the past 10-15years for the two sites confirms certain seagrass populations to be robust and thriving. We hypothesise that these populations are showing a level of resilience to the high nutrient levels, disturbance and high turbidity present within the water column of the Haven.

Antidepressant Use Among Persons Aged 12 and Over:United States,2011-2014.

Antidepressants are one of the three most commonly used therapeutic drug classes in the United States (1). While the majority of antidepressants are taken to treat depression, antidepressants can also be taken to treat other conditions, like anxiety disorders. This Data Brief provides the most recent estimates of antidepressant use in the U.S. noninstitutionalized population, including prevalence of use by age, sex, race and Hispanic origin, and length of use. This report also describes trends in the prevalence of antidepressant use from 1999­2002 to 2011­2014.

Excess mortality among people who report lifetime use of illegal drugs in the United States: A 20-year follow-up of a nationally representative survey.

OBJECTIVE: The purpose of this study was to determine the mortality risks, over 20 years of follow-up in a nationally representative sample, associated with illegal drug use and to describe risk factors for mortality. METHODS: We analyzed data from the 1991 National Health Interview Survey, which is a nationally representative household survey in the United States, linked to the National Death Index through 2011. This study included 20,498 adults, aged 18-44 years in 1991, with 1047 subsequent deaths. A composite variable of self-reported lifetime illegal drug use was created (hierarchical categories of heroin, cocaine, hallucinogens/inhalants, and marijuana use). RESULTS: Mortality risk was significantly elevated among individuals who reported lifetime use of heroin (HR=2.40, 95% CI: 1.65-3.48) and cocaine (HR=1.27, 95% CI: 1.04-1.55), but not for those who used hallucinogens/inhalants or marijuana, when adjusting for demographic characteristics. Baseline health risk factors (smoking, alcohol use, physical activity, and BMI) explained the greatest amount of this mortality risk. After adjusting for all baseline covariates, the association between heroin or cocaine use and mortality approached significance. In models adjusted for demographics, people who reported lifetime use of heroin or cocaine had an elevated mortality risk due to external causes (poisoning, suicide, homicide, and unintentional injury). People who had used heroin, cocaine, or hallucinogens/inhalants had an elevated mortality risk due to infectious diseases. CONCLUSIONS: Heroin and cocaine are associated with considerable excess mortality, particularly due to external causes and infectious diseases. This association can be explained mainly by health risk behaviors.

Testing the effects of perimeter fencing and elephant exclosures on lion predation patterns in a Kenyan wildlife conservancy.

The use of fences to segregate wildlife can change predator and prey behaviour. Predators can learn to incorporate fencing into their hunting strategies and prey can learn to avoid foraging near fences. A twelve-strand electric predator-proof fence surrounds our study site. There are also porous one-strand electric fences used to create exclosures where elephant (and giraffe) cannot enter in order to protect blocs of browse vegetation for two critically endangered species, the black rhinoceros (Diceros bicornis) and the Grevy's zebra (Equus grevyi). The denser vegetation in these exclosures attracts both browsing prey and ambush predators. In this study we examined if lion predation patterns differed near the perimeter fencing and inside the elephant exclosures by mapping the location of kills. We used a spatial analysis to compare the predation patterns near the perimeter fencing and inside the exclosures to predation in the rest of the conservancy. Predation was not over-represented near the perimeter fence but the pattern of predation near the fence suggests that fences may be a contributing factor to predation success. Overall, we found that predation was over-represented inside and within 50 m of the exclosures. However, by examining individual exclosures in greater detail using a hot spot analysis, we found that only a few exclosures contained lion predation hot spots. Although some exclosures provide good hunting grounds for lions, we concluded that exclosures did not necessarily create prey-traps per se and that managers could continue to use this type of exclusionary fencing to protect stands of dense vegetation.

Excess mortality due to depression and anxiety in the United States: results from a nationally representative survey.

OBJECTIVES: We compared the mortality of persons with and without anxiety and depression in a nationally representative survey and examined the role of socioeconomic factors, chronic diseases and health behaviors in explaining excess mortality. METHODS: The 1999 National Health Interview Survey was linked with mortality data through 2011. We calculated the hazard ratio (HR) for mortality by presence or absence of anxiety/depression and evaluated potential mediators. We calculated the population attributable risk of mortality for anxiety/depression. RESULTS: Persons with anxiety/depression died 7.9 years earlier than other persons. At a population level, 3.5% of deaths were attributable to anxiety/depression. Adjusting for demographic factors, anxiety/depression was associated with an elevated risk of mortality [HR=1.61, 95% confidence interval (CI)=1.40, 1.84]. Chronic diseases and health behaviors explained much of the elevated risk. Adjusting for demographic factors, people with past-year contact with a mental health professional did not demonstrate excess mortality associated with anxiety/depression while those without contact did. CONCLUSIONS: Anxiety/depression presents a mortality burden at both individual and population levels. Our findings are consistent with targeting health behaviors and physical illnesses as strategies for reducing this excess mortality among people with anxiety/depression.

Low Counts of B Cells, Natural Killer Cells, Monocytes, Dendritic Cells, Basophils, and Eosinophils are Associated with Postengraftment Infections after Allogeneic Hematopoietic Cell Transplantation.

Hematopoietic cell transplant (HCT) recipients are immunocompromised and thus predisposed to infections. We set out to determine the deficiency of which immune cell subset(s) may predispose to postengraftment infections. We determined day 28, 56, 84, and 180 blood counts of multiple immune cell subsets in 219 allogeneic transplant recipients conditioned with busulfan, fludarabine, and Thymoglobulin. Deficiency of a subset was considered to be associated with infections if the low subset count was significantly associated with subsequent high infection rate per multivariate analysis in both discovery and validation cohorts. Low counts of monocytes (total and inflammatory) and basophils, and low IgA levels were associated with viral infections. Low plasmacytoid dendritic cell (PDC) counts were associated with bacterial infections. Low inflammatory monocyte counts were associated with fungal infections. Low counts of total and naive B cells, total and CD56(high) natural killer (NK) cells, total and inflammatory monocytes, myeloid dendritic cells (MDCs), PDCs, basophils and eosinophils, and low levels of IgA were associated with any infections (due to any pathogen or presumed). In conclusion, deficiencies of B cells, NK cells, monocytes, MDCs, PDCs, basophils, eosinophils, and/or IgA plasma cells appear to predispose to postengraftment infections.

Hospitalization, Readmission, and Death Experience of Noninstitutionalized Medicare Fee-for-service Beneficiaries Aged 65 and Over.

OBJECTIVE: This report provides descriptive measures of hospitalization, readmission, and death among the noninstitutionalized population aged 65 and over using data from a national survey of the noninstitutionalized population linked to Medicare data and the National Death Index. The estimates are presented by self-reported demographic, socioeconomic, heath status, and other characteristics gathered during the interview with the survey participants. METHODS: Data are from the 2000­2005 National Health Interview Survey (NHIS) linked to 2000­2006 Medicare data and the National Center for Health Statistics 2011 Linked Mortality Files. Findings are based on in-home interviews with 25,593 linkage-eligible noninstitutionalized respondents aged 65 and over who were enrolled in fee-for-service (FFS) Medicare during the year following the interview. Among them, 1,100 died during the year following the interview, 5,456 were hospitalized with 3,490 hospitalized once, 1,192 hospitalized twice, and 774 hospitalized three or more times. Among those hospitalized, 1,491 were readmitted to the hospital within 30 days since the discharge. Both population-based and discharge-based measures are used to present the estimates. RESULTS: This is the first report presenting national estimates on hospitalization, readmission, and death using NHIS data linked to the Medicare claims and death data. Among noninstitutionalized Medicare FFS beneficiaries aged 65 and over, 4.5% died in the year following the interview and 21.6% were hospitalized, with a discharge rate of 348.4 per 1,000 population. Among those who were hospitalized and discharged alive, 17.3% were readmitted within 30 days after discharge. About one-quarter of the deceased died in the hospital (including 7.1% who died during a readmission stay).

Serious Psychological Distress Among Adults: United States, 2009-2013.

In every age group, women were more likely to have serious psychological distress than men. Among all adults, as income increased, the percentage with serious psychological distress decreased. Adults aged 18-64 with serious psychological distress were more likely to be uninsured (30.4%) than adults without serious psychological distress (20.5%). More than one-quarter of adults aged 65 and over with serious psychological distress (27.3%) had limitations in activities of daily living. Adults with serious psychological distress were more likely to have chronic obstructive pulmonary disease, heart disease, and diabetes than adults without serious psychological distress.

Depression in the U.S. household population, 2009-2012.

KEY FINDINGS: Data from the National Health and Nutrition Examination Survey, 2009-2012. During 2009-2012, 7.6% of Americans aged 12 and over had depression (moderate or severe depressive symptoms in the past 2 weeks). Depression was more prevalent among females and persons aged 40-59. About 3% of Americans aged 12 and over had severe depressive symptoms, while almost 78% had no symptoms. Persons living below the poverty level were nearly 2½ times more likely to have depression than those at or above the poverty level. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home, and social activities. Of those with severe symptoms, 35% reported having contact with a mental health professional in the past year. Depression is a serious medical illness with mood, cognitive, and physical symptoms (1). Depression is associated with higher rates of chronic disease, increased health care utilization, and impaired functioning (2,3). Rates of treatment remain low, and the treatment received is often inadequate (1). This data brief examines both depression and depressive symptom severity in the past 2 weeks from a symptom-based questionnaire, by demographic characteristics, functioning difficulties, and recent contact with a mental health professional. Severity is categorized as severe, moderate, mild, or no depressive symptoms. Current depression is defined as severe or moderate symptoms; no depression is defined as mild or no symptoms.

Depression and obesity in the U.S. adult household population, 2005-2010.

Forty-three percent of adults with depression were obese as compared with 33% of adults without depression. Women with depression were more likely to be obese than women without depression. The relationship was consistent across all age groups among women and was also seen in men aged 60 and over. Non-Hispanic white women with depression were more likely to be obese than non-Hispanic white women without depression. This relationship was not seen in non-Hispanic black or Hispanic women or among men of any racial or ethnic background. As the severity of depression increased, the percentage of all adults and of women with obesity increased as well. Both moderate to severe depressive symptoms and antidepressant use were associated with increased obesity. Moderate to severe depressive symptoms were associated with a higher rate of obesity both in persons who were taking antidepressant medication and those who were not, and antidepressant use was associated with a higher rate of obesity in persons with moderate to severe depressive symptoms and those with mild or no depressive symptoms. Of the four categories, the highest prevalence of obesity (54.6%) was found in persons who had moderate or severe depressive symptoms and took antidepressant medication. In this study, it is not clear whether depression or obesity occurred first because they were both measured at the same time. Other studies have shown a bidirectional relationship, meaning obesity increases risk of depression and depression increases risk of obesity . Knowledge of these risks may help general medical practitioners and mental health professionals plan prevention and treatment.

Immune cell subset counts associated with graft-versus-host disease.

Graft-versus-host disease (GVHD) is a major transplantation complication. The purpose of this study was to measure immune cell subsets by flow cytometry early after transplantation (before median day of GVHD onset) to identify subsets that may play a role in GVHD pathogenesis. We also measured the subsets later after transplantation to determine which subsets may be influenced by GVHD or its treatment. We studied 219 patients. We found that acute GVHD (aGVHD) was preceded by high counts of CD4 T cells and CD8 T cells. It was followed by low counts of total and naive B cells, total and cytolytic NK cells, and myeloid and plasmacytoid dendritic cells. Chronic GVHD (cGVHD) was preceded by low counts of memory B cells. In conclusion, both CD4 and CD8 T cells appear to play a role in the pathogenesis of aGVHD. Generation of B cells, NK cells, and dendritic cells may be hampered by aGVHD and/or its treatment. Memory B cells may inhibit the development of cGVHD.

Implications of two-stage depression screening for identifying persons with thoughts of self-harm.

OBJECTIVE: Persons with thoughts of self-harm may need evaluation for suicide risk. We examine the prevalence of thoughts of self-harm and whether persons with thoughts of self-harm are identified when two-stage depression screening is used. METHODS: Data are from the 2005-2010 National Health and Nutrition Examination Surveys. Persons responding positively to question nine of the Patient Health Questionnaire-9 (PHQ-9) are identified as having thoughts of self-harm. We compare two depression cutoff scores for the Patient Health Questionnaire-2 (PHQ-2) to see what percentage of persons with thoughts of self-harm would be identified as needing further screening with the PHQ-9. RESULTS: The prevalence of thoughts of self-harm was 3.5%. Persons 12-17 years old, poor and reporting fair or poor health were more likely to report thoughts of self-harm. A cutoff score of three on the PHQ-2 identified 49% of persons with thoughts of self-harm for further screening with the PHQ-9. A cut point of two increased the proportion of persons with thoughts of self-harm continuing for further screening to 76%. CONCLUSIONS: Using a lower cutoff score, two, the PHQ-2 captures more persons with thoughts of self-harm. One quarter of persons with self-harm thoughts may not be identified for further screening when two-stage screening is used.

Characteristics of adults with serious mental illness in the United States household population in 2007.

OBJECTIVE: This study described the epidemiology of serious mental illness in the adult household population. METHODS: Data from the 2007 National Health Interview Survey of 23,393 adult respondents were used. Serious mental illness was defined when respondents reported that a health professional had told them that they had schizophrenia, bipolar disorder, mania, or psychosis. Sociodemographic and health characteristics, health care utilization, and participation in government assistance programs among adults with and without serious mental illness were compared. RESULTS: Over 2% of adults reported having received a diagnosis of serious mental illness. Thirty-five percent of adults with serious mental illness had a history of homelessness or of having been in jail. Fewer than two-thirds of adults with serious mental illness had seen a mental health professional in the past year. CONCLUSIONS: Adults with serious mental illness were socially disadvantaged and had worse health compared with adults without serious mental illness.