Normative Cutoff Values Research Articles

Vitamin D, vitamin B12, folate, homocysteine, and major haemato-chemical parameters in patients with mood disorders

IntroductionThe potential involvement of the immune and inflammatory systems has been extensively studied in mood disorders (MDs). Despite these findings and despite the fact that the pathogenetic role of altered immunologic and metabolic profiles in MDs is being confirmed in many current studies, there is still a lack of consensus about it, due to controversial results.ObjectivesThe present study aimed to appraise peripheral metabolic parameters (blood glucose, lipoproteins, triglycerides, uric acid, blood urea nitroge [BUN], transaminases and others9 and plasma/serum levels of essential nutrients (vitamin D, B12, folate and homocysteine) in a group of inpatients affected by MDs, as compared with healthy controls.MethodsMethods. Ten ml of venous blood was drawn from fasting subjects. The metabolic parameters and vitamins were measured according to common clinical-chemistry methods.Comparisons for continuous variables were performed by the Student’s t-test for variables that follow a normal distribution, and by the Wilcoxon-Mann-Whitney test for variables not normally distributed. The correlations between biological markers were explored by calculating the Pearson’s correlation coefficient or Spearman rank correlation.Results Most patients showed loer circulating vitamin D levels, in respect to both control subjects (P< .0001) and the normative cut-off values. This finding was paralleled by increased serum homocysteine concentrations i (P<.0001), indicating an imbalance in their methionine metabolism. Homocysteine levels were negatively correlated with vitamin D, vitamin B12 and folate in control subjects, but not in patients. In addition, patients displayed higher blood glucose and lower BUN than controls, indicating an impaired protein-to-carbohydrate metabolism and/or altered nutritional/dietary status.ConclusionsWe provide herein further support to the notion that MD patients are a population where vitamin deficits, dysmetabolism and/or dietary defects are common feature, and, s such, they might be more vulnerable to a variety of somatic illnesses than the general population. This cross-sectional investigation, albeit preliminary, might contribute to improve the characterization and the monitoring of the clinical status of mood disorder patients, as well as to identify new molecular targets for more tailored treatments ad of more pointed health-care intervention,Disclosure of InterestNone Declared

Toward Sound Localization Testing in Virtual Reality to Aid in the Screening of Auditory Processing Disorders.

Sound localization testing is key for comprehensive hearing evaluations, particularly in cases of suspected auditory processing disorders. However, sound localization is not commonly assessed in clinical practice, likely due to the complexity and size of conventional measurement systems, which require semicircular loudspeaker arrays in large and acoustically treated rooms. To address this issue, we investigated the feasibility of testing sound localization in virtual reality (VR). Previous research has shown that virtualization can lead to an increase in localization blur. To measure these effects, we conducted a study with a group of normal-hearing adults, comparing sound localization performance in different augmented reality and VR scenarios. We started with a conventional loudspeaker-based measurement setup and gradually moved to a virtual audiovisual environment, testing sound localization in each scenario using a within-participant design. The loudspeaker-based experiment yielded results comparable to those reported in the literature, and the results of the virtual localization test provided new insights into localization performance in state-of-the-art VR environments. By comparing localization performance between the loudspeaker-based and virtual conditions, we were able to estimate the increase in localization blur induced by virtualization relative to a conventional test setup. Notably, our study provides the first proxy normative cutoff values for sound localization testing in VR. As an outlook, we discuss the potential of a VR-based sound localization test as a suitable, accessible, and portable alternative to conventional setups and how it could serve as a time- and resource-saving prescreening tool to avoid unnecessarily extensive and complex laboratory testing.

THU649 PCOS Phenotype In Unselected Populations (P-PUP) Study: Defining And Comparing Hirsutism Across Various Ethnic Groups In Unselected Populations

Abstract Disclosure: S. Kiconco: None. A.E. Joham: None. L.V. Suturina: None. X. Zhao: None. A. Gambineri: None. F.R. Tehrani: None. B.O. Yildiz: None. J. Kim: None. H.J. Teede: None. R. Azziz: None. Introduction Hirsutism is defined as the male pattern distribution of terminal hair in a female. It is one of the diagnostic features of polycystic ovary syndrome (PCOS), reflecting clinical hyperandrogenism, as measured by the modified Ferriman-Gallwey score (mFG). However, whether the mFG scores and the normative cut-off varies by ethnicity is unclear. We aimed to describe and compare the distribution of mFG score in different ethnic groups from eight countries using data from unselected (medically unbiased) populations to determine and compare the normative cut-off values between the different ethnic groups and the prevalence of hirsutism thereby defined. Methods We utilised data of 10,919 participants aged 15 to 80 years. Data were obtained from epidemiologic studies assessing unselected women conducted in different countries including China, Iran, Italy, Nigeria, Russia, South Korea, Turkey, and the United States of America. The distribution of mFG between ethnic groups was determined descriptively as medians. Cluster analysis (k means, k=2) and the receiver operating characteristics curve were used to determine the normative cut-offs for the mFG score. All medians, cut-offs and percentile values were compared between ethnic groups using the Kruskal-Wallis test at a 95% level of significance. Results Our data consisted of 11 ethnic groups from 8 countries. The Persian (4.8±4.7) and Italian (4.8±4.7) populations had higher median mFG scores than the rest of the ethnic groups, whilst Asian populations (Chinese, Korean and Buryat) had the lowest scores. Overall, the median distribution of mFG differed significantly by ethnicity. Using cluster analysis, the mFG cut offs range from 4 to 9, with the Persian ethnic group having the highest, followed by the Italian group, with cut-offs differing by ethnicity overall; however cut offs are similar for Black American, Turkish, Asian and Russian groups. Conclusion The distribution and normal cut off values for hirsutism differ significantly by ethnicity, with the Persian population having the highest cut offs. Ethnicity needs to be considered when assessing women for clinical hyperandrogenism. Presentation: Thursday, June 15, 2023

Validation of the Czech Version of the Voice Handicap Index

Objective(s)The present study aims to evaluate the reliability and construct validity of the Czech version of the Voice Handicap Index (VHI-CZ) and determine the cut-off value to distinguish dysphonic patients from nondysphonic individuals. Study designProspective study, Parallel group design. MethodsThe study investigated 100 adult patients with dysphonia, divided into three groups based on the etiology of the voice problem (neurogenic, functional, and structural). Out of these, 25 patients were used for test-retest analysis, and 45 patients to determine the responsiveness to change. The control group consisted of 51 healthy subjects. All 151 individuals completed the VHI-CZ and were examined with the videolaryngostroboscopy. The internal consistency (Cronbach’s alpha), the test-retest reliability (Intra-class Correlation Coefficient, ICC), and the construct validity were analyzed and the normative cut-off value was determined. ResultsThe internal consistency of the VHI-CZ was excellent (Cronbach α = 0.984), and test-retest reliability was also excellent (ICC = 0.95, P < 0.001). The correlation between the self-assessed severity of the voice disorder and the VHI-CZ score was strong (Spearman's ρ = 0.877, P < 0.001). The VHI scores differences between dysphonic and nondysphonic patients were statistically significant (Mann-Whitney U test, P < 0.001). The differences among the three etiological subgroups (neurogenic, functional, and structural) were also statistically significant (Kruskal-Wallis test, P < 0.001). Moreover, the differences in the VHI-CZ total scores between pretreatment and posttreatment were statistically significant (Wilcoxon test, P < 0.001). The cut-off score of 13 points was found, by the analysis of the Receiver Operating Characteristic (ROC, Youden Index), to be most suitable for preselecting dysphonic individuals. ConclusionThe existing VHI-CZ showed excellent reliability and construct validity. The Czech VHI is a useful and valid monitoring tool for clinicians.

Differential cholinergic systems' changes in progressive supranuclear palsy versus Parkinson's disease: an exploratory analysis.

Prior studies indicate more severe brainstem cholinergic deficits in Progressive Supranuclear Palsy (PSP) compared to Parkinson's disease (PD), but the extent and topography of subcortical deficits remains poorly understood. The objective of this study is to investigate differential cholinergic systems changes in progressive supranuclear palsy (PSP, n = 8) versus Parkinson's disease (PD, n = 107) and older controls (n = 19) using vesicular acetylcholine transporter [18F]-fluoroethoxybenzovesamicol (FEOBV) positron emission tomography (PET). A whole-brain voxel-based PET analysis using Statistical Parametric Mapping (SPM) software (SPM12) for inter-group comparisons using parametric [18F]-FEOBV DVR images. Voxel-based analyses showed lower FEOBV binding in the tectum, metathalamus, epithalamus, pulvinar, bilateral frontal opercula, anterior insulae, superior temporal pole, anterior cingulum, some striatal subregions, lower brainstem, and cerebellum in PSP versus PD (p < 0.05; false discovery rate-corrected). More severe and diffuse reductions were present in PSP vs controls. Higher frequency of midbrain cholinergic losses was seen in PSP compared to the PD participants using 5th percentile normative cut-off values (χ2 = 4.12, p < 0.05). When compared to PD, these findings suggested disease-specific cholinergic vulnerability in the tectum, striatal cholinergic interneurons, and projections from the pedunculopontine nucleus, medial vestibular nucleus, and the cholinergic forebrain in PSP.

The use of OCT to detect signs of intracranial hypertension in patients with sagittal suture synostosis: Reference values and correlations

PurposeTo obtain pediatric normative reference values and determine whether optical coherence tomography (OCT) corresponds better with clinical signs of intracranial hypertension (ICH) compared to the traditional screening method fundoscopy in a large cohort of one type of single suture craniosynostosis.MethodsControl subjects without optic nerve diseases and isolated sagittal synostosis patients aged 3–10 years who underwent fundoscopy and OCT were included in this prospective cohort study. Normative reference values were obtained through bootstrap analysis. Main outcome was the association between peripapillary total retinal thickness (TRT) and total retinal volume (TRV) and appearance on fundoscopy. Signs and symptoms suggestive of ICH, including skull growth arrest, fingerprinting, and headache, were scored.ResultsSixty-four healthy controls and 93 isolated sagittal synostosis patients were included. Normative cut-off values for mean TRT are < 256 μm and > 504 μm and for mean TRV < 0.21 mm3 and > 0.39 mm3. TRT was increased in 16 (17%) and TRV in 15 (16%) of 93 patients, compared to only 4 patients with papilledema on fundoscopy (4%). Both parameters were associated with papilledema on fundoscopy (OR = 16.7, p = 0.02, and OR = 18.2, p = 0.01). Skull growth arrest was significantly associated with abnormal OCT parameters (OR = 13.65, p < 0.01).ConclusionsThe established cut-off points can be applied to screen for ICH in pediatrics. The present study detected abnormalities with OCT more frequent than with fundoscopy, which were associated with skull growth arrest. Therefore, a combination of OCT, fundoscopy, and skull growth arrest can improve clinical decision-making in craniosynostosis.

Generalized chronic itch induced by small-fibre neuropathy: clinical profile and proposed diagnostic criteria.

Small-fibre neuropathy (SFN) is a known cause for pain, however, it may be also associated with chronic itch. The clinical profile of chronic itch due to SFN is poorly defined and accordingly under-diagnosed in clinical care. To establish the clinical profile of patients with SFN and to propose diagnostic criteria for this patient population. Clinical data from patients diagnosed with SFN [chronic generalized itch and reduced intraepidermal nerve fibre density (IENFD)] were analysed retrospectively. A total of 142 patients (60 females, median age: 62.5years) were included. Patients reported daily, moderate to severe itch intensity scores occurring mostly in attacks (62.5%). Only 11 patients experienced exclusively itch, while the remaining patients (92%) reported pruralgia (itch along with painful sensations). Burning (50%), a sensation like needle pricks (46%) and tingling (45%) were the sensory symptoms reported by most patients. Cold or ice application led to an alleviation of the symptoms. The IENFD did not correlate with itch intensity; however, patients with a severely reduced IENFD (<30% of the normative cut-off value) reported more frequently sharp, spiky and drilling sensations compared to the remaining patients. The quality of life was moderately impaired and correlated with itch intensity, whereas anxiety and depression scores were low. Onset of pruralgia on normal appearing skin, occurrence in attacks and symptomatic alleviation with cold/ice application should alert physicians for a possible neuropathic SFN-related origin of itch. A reduced IENFD can confirm the diagnosis of SFN.

Implementation and evaluation of a Danish test battery for auditory processing disorder in children

Objective: This study presents a Danish test battery for auditory processing disorder (APD). The tests were evaluated as to normative cut-off values (pass-fail criteria) and their test–retest reliability. Design: The battery consists of four behavioural tests: the filtered words (FW) test, the dichotic digits (DD) test, the gap detection (GD) test and the binaural masking level difference (BMLD) test. The tests were evaluated through listening experiments on children with no known history of auditory problems. Study sample: The normative cut-off values were obtained from 158 children (75 boys and 83 girls, aged 6–16 years), whereas the test–retest reliability was obtained from 20 children (10 boys and 10 girls, aged 6–11 years). Results: For each of the four tests one to four different cut-off values were determined depending on whether the scores from the two ears and the different age groups could be pooled. For each of the four tests the test–retest reliability was found to be satisfactory. The test–retest reliability was highest for the FW and the DD test. Conclusions: A Danish APD test battery is now available for clinical use with normative data.

Normative data for distal line bisection and baking tray task.

Line bisection is one of the tests used to diagnose unilateral spatial neglect (USN). Despite its wide application, no procedure or norms were available for the distal variant when the task was performed at distance with a laser pointer. Furthermore, the baking tray task was an ecological test aimed at diagnosing USN in a more natural context. The aim of this study was to collect normative values for these two tests in an Italian population. We recruited a sample of 191 healthy subjects with ages ranging from 20 to 89years. They performed line bisection with a laser pointer on three different line lengths (1, 1.5, and 2m) at a distance of 3m. After this task, the subjects performed the baking tray task and a second repetition of line bisection to test the reliability of measurement. Multiple regression analysis revealed no significant effects of demographic variables on the performance of both tests. Normative cut-off values for the two tests were developed using non-parametric tolerance intervals. The results formed the basis for clinical use of these two tools for assessing lateralized performance of patients with brain injury and for diagnosing USN.

Study on the facial and body terminal hair growth in women in Guangdong by using modified Ferriman-Gallwey scoring system

To study growth of facial and body terminal hair of women in Guangdong province and its relationship with age, menstrual irregularities and polycystic ovary, and determine normative cut-off score of modified Ferriman and Gallwey (mFG). A cross-sectional study was conducted on 2988 women at age of 20-45 years from 16 communities of two urban and two rural regions in Guangdong province from June 2008 to July 2009. Terminal body hair growth was assessed by using the modified Ferriman and Gallwey (mFG) scoring system. The normative cut-off value of mFG were calculated by using the K-means cluster analysis (K=2). Those women were classified into following groups, including 982 women at group of ages of 20- years, 765 women at group of 26- years, 597 women at group of 31- years, 384 women at group of 36- years, 260 women at group of 41-45 years. Due to absence or errors of medical records, some cases were excluded from this study. Based on menses irregularities (MI), polycystic ovaries (PCO), there were 488 cases in MI group, 2413 cases in normal menses group, 568 cases in PCO group, and 2207 cases in non-PCO group finally. The incidences of acne, MI, acanthosis nigricans, and polycystic ovaries were also analyzed in all the hirsute groups. (1) among 2988 women, it was observed 149 women (5%) with mFG≥7,314 women (10.5%) with ≥5,747 women with mFG≥2. (2) Cluster analysis identified an mFG score of 5 as the cut-off value that define abnormal hirsute in the total population and all the sub-groups with/without MI or PCO; (3) Based on age classification, it was found that increased age was associated with decreased trends of the percentile and cut-off value of hirsutism. The value of hirsutism of mFG were 6 in group of 20- years, 5 in group of 26- years, 4 in groups of 31- years, 36- years and 41-45 years. (4) The prevalence of acne, menstrual irregularities and POC were 45.5% (143/314), 73.6% (231/314), 25.8% (81/314) in total population, 25.1% (671/2674), 16.1% (431/2674), 19.8% (529/2674) in normal hair women, which reached statistical difference (P<0.05). The prevalence of acne, menstrual irregularities and acanthosis nigricans were 44.4% (130/293), 23.2% (68/293), 4.1% (12/293) in those age hirsute groups, 25.3% (681/2695), 16.2% (437/2695), 1.9% (51/2695) in normal hair women, which reached statistical difference (P<0.05). (1) among women in Guangdong province, mFG scoring showed decreased trends in women with increasing age. (2) An mFG score≥5 was cut-off value in diagnosis of hirsutism. (3) The hirsute women exhibited higher incidence of acne, menses irregularity, and acanthosis nigricans than those of women with normal hair growth.

The Broad Autism Phenotype Questionnaire: Prevalence and Diagnostic Classification

The Broad Autism Phenotype Questionnaire (BAPQ) was administered to a large community-based sample of biological parents of children with autism (PCAs) and comparison parents (CPs) (n = 1,692). Exploratory factor analysis and internal consistency parameters confirmed a robust three-factor structure of the BAPQ, corresponding to the proposed aloof, pragmatic language and rigidity subscales. Based upon the distribution of Broad Autism Phenotype (BAP) features in the general population, new normative cutoff values for BAPQ subscales were established that provide increased specificity relative to those previously reported, and thus enhance the utility of the BAPQ for diagnostically classifying the BAP. These cutoffs were also used to estimate prevalence of the BAP and its three components, with rates ranging between 14-23% for PCAs and between 5-9% for CPs. Analysis of patterns of BAP characteristics within family members revealed that BAP features were more likely to co-occur in PCAs relative to CPs. Collectively, these findings extend the utility of the BAPQ and provide additional evidence that it is an efficient and reliable tool for disaggregating the heterogeneity of autism through the identification of meaningful subgroups of parents. Autism Res 2013, 6: 134-143. © 2013 International Society for Autism Research, Wiley Periodicals, Inc.

Defining hyperandrogenaemia according to the free androgen index in Chinese women: a cross‐sectional study

To determine the normative cut-off value for the free androgen index (FAI) among reproductive-age women in China. Cross-sectional, population-based study. A multistage systematic cluster random sampling among 16 communities from two rural and two city regions. A total of 1526 women were randomly selected from a representative sample of 3009 women aged 20-45years from the general population of southern China. Among these women, 444 subjects without known factors affecting androgen levels were selected as the reference group. Subjects underwent physical examination, blood tests of hormone and metabolic profiles, and ultrasound evaluations. MEASUREMENT OF THE MAIN OUTCOMES: The FAI was calculated according to the following equation: FAI=100×total testosterone (nmol/l)/sex hormone-binding globulin (nmol/l). The normative cut-off value of the FAI was computed based on the 5th-95th percentiles and K-means cluster analysis (K=2). A reference range of 0·7-6·4 of the FAI was indicated by the 5th and 95th percentiles. K-means cluster analysis identified 6·1 as the cut-off value for the FAI in the total population, which was close to the upper limit determined by the 95th percentile. Hyperandrogenic women present with elevated risk factors for metabolic disorders. The mean FAI values decreased with age among the total population, as evaluated by either K-means clustering or a percentile analysis. The FAI value was negatively correlated with age (r=-0·185, P<0·0001) and positively correlated with body mass index after adjustment for age (r=0·250, P<0·0001). A reference range of 0·7-6·4 FAI was indicated by the 5th and 95th percentiles among the reference group, which excluded the subjects with factors known to affect androgen levels; 6·1 was identified by the K-means cluster analysis as the cut-off value of the FAI for the general population. Hyperandrogenic women present with higher risks for metabolic disorders.

Verbal and Visual Memory Performance and Hippocampal Volumes, Measured by 3-Tesla Magnetic Resonance Imaging, in Patients with Cushing's Syndrome

Cushing's syndrome (CS) affects cognition and memory. Our objective was to evaluate memory and hippocampal volumes (HV) on 3-tesla magnetic resonance imaging (3T MRI) in CS patients and controls. Thirty-three CS patients (11 active, 22 cured) and 34 controls matched for age, sex, and education underwent Rey Auditory Verbal Learning Test and Rey-Osterrieth Complex Figure memory tests. Gray matter and HV were calculated on 3T MRI, using FreeSurfer image analyses software. No differences in HV were observed between active and cured CS or controls. Memory performance was worse in CS patients than controls (P < 0.04 in active; P < 0.03 in cured CS) but did not differ among CS groups, which were therefore analyzed together; they performed worse for verbal (P = 0.02) and visual memory (P = 0.04) than controls. In 12 CS patients, memory was below normative cutoff values for verbal (n = 6, cured), visual memory (n = 10, six cured) or both (n = 4); these patients with severe memory impairments showed smaller HV compared with their matched controls (P = 0.02 with verbal impairment; P = 0.03 with visual impairment). They were older (P = 0.04), had shorter education (P = 0.02), and showed a trend toward longer duration of hypercortisolism (P = 0.07) than the remaining CS patients. Total (P = 0.004) and cortical (P = 0.03) brain gray matter volumes were decreased in CS compared with controls, indicating brain atrophy, whereas subcortical gray matter (which includes HV) was reduced only in the 12 patients with severe memory impairment. Verbal and visual memory is worse in CS patients than controls, even after biochemical cure. HV was decreased only in those whose memory scores were below normative cutoff values.

Bronchodilator reversibility testing in an adult general population; the importance of smoking and anthropometrical variables on the response to a β 2-agonist

Normative cut-off values for the bronchodilator reversibility test are published neglecting factors that may influence the test result other than disease. The objective of this cross-sectional study of a general population was to examine how a salbutamol reversibility test response is depending on anthropometrical variables and smoking. An age and gender stratified random sample of all adults aged 47–48 and 71–73 years living in Bergen, Norway, was invited. The 3506 attendants (69%) filled in a questionnaire and performed spirometry before and after inhalation of 400 μg salbutamol. The mean (SD) absolute FEV 1 bronchodilator response, the change in % predicted, and the change in % initial among middle-aged were 71 (122) ml, 2.0 (3.3)%, and 2.4 (4.1)%, and in the elderly 64 (113) ml, 2.4 (4.3)% and 3.3 (5.9)%, respectively. In a multiple linear regression analysis including adjustment for the initial FEV 1 in % predicted, smoking and pack-years were negatively correlated to all indices. Current smoking was considerably more important than past smoking. Female gender, old age, and BMI were positively correlated with the percentage change indices, but the correlation with BMI decreased with increasing heights. These trends were unchanged after excluding subjects with obstructive lung disease or coronary heart disease. This study demonstrates that smoking habits predict all indices expressing the salbutamol bronchodilator response among middle-aged and elderly from a general population. Also, the change in % predicted and the change in % initial indices are dependent on anthropometrical variables. However, although smoking and anthropometrical variables, as well as level of lung function predict the response to inhaled β 2-agonists, these factors explain only 7–16% of the total variation of the measurement indices, and seem therefore of minor importance to the interpretation of the test result.

Folate Deficiency Does Not Alter the Usefulness of the Serum Transferrin Receptor Concentration as an Index for the Detection of Iron Deficiency in Mexican Women during Early Lactation

The purpose of this study was to investigate the usefulness of soluble serum transferrin receptor (TfR) concentration, TfR index and log TfR:ferritin ratio (TfR outcomes) in detecting tissue Fe deficiency among breast-feeding Otomi women residing in Capulhuac, Mexico (2800 m above sea level) and to determine whether folate deficiency modifies the interpretation of these data. Lactating women (n = 68) provided blood samples at 22 +/- 13 d (mean +/- SD) postpartum. Using the 3-index Fe assessment model with and without Hb, 2 women (3%) had Fe-deficient erythropoiesis, 24 (36%) Fe deficiency anemia, and 19 (29%) indeterminate Fe status; 29 (43%) and 5 (7.5%) women had plasma and erythrocyte folate concentrations below normative cutoff values, respectively. Mean values for TfR outcomes were higher among women classified as Fe deficient than those who were Fe sufficient, but did not differ with low or normal blood folate concentrations. Similarly, TfR outcomes did not differ among women with normocytic or macrocytic erythrocytes. Receiver-operating characteristic (ROC) curves generated for TfR outcomes yielded areas under the curve from 0.62 to 0.68, indicating that each of these measures, on its own, is a poor predictor of tissue Fe deficiency in lactating women. In conclusion, low blood folate concentrations or the presence of macrocytosis in Otomi women from Capulhuac, Mexico (moderate altitude) did not influence the utility of TfR outcomes for the detection of Fe deficiency during early lactation. Further, on their own, TfR, TfR index, and TfR:ferritin ratio were poor predictors of tissue Fe deficiency for any given individual.

Assessment of preoperative anxiety: comparison of measures in patients awaiting surgery for breast cancer

We have compared three measurements of anxiety to determine their equivalence in assessing anxiety before surgery. Forty-four patients awaiting breast cancer surgery completed the state scale of the state-trait anxiety inventory (STAI), the hospital anxiety and depression scale (HAD) and a 100-mm visual analogue scale (VAS). Analysis restricted to correlations between the scales gave the misleading impression that VAS scores were inconsistent with those of the HAD and STAI. However, when scores were considered in relation to normative cut-off values to categorize anxiety levels, the three scales showed good agreement. We conclude that the scales were equivalent in their assessment of anxiety before surgery, but that reference to normative data was important in establishing such equivalence and in determining the patient's state.