Screen-positive Patients Research Articles

Gaps in secondary prevention among stroke survivors in rural Gadchiroli, India: a community-based cross-sectional study

Background: With epidemiological transition, stroke has emerged as a public health priority in rural India. However, population-level information on secondary prevention of stroke from rural areas of India and other low- and middle-income countries remains exceedingly rare. Methods: In a cross-sectional community-based survey, trained surveyors screened a well-defined population of 74,095 individuals living in 64 villages in Gadchiroli district of India for symptoms of stroke. A trained physician evaluated screen positive patients, diagnosed stroke, measured blood pressure and collected information on prior diagnosis of risk factors and current use of medications using a structured questionnaire. Results: A total of 265 stroke survivors were identified. Prior diagnosis of hypertension was made in 57.4%, diabetes in 9.8%, hyperlipidaemia in 0.4%, ischaemic heart disease in 1.5%. and atrial fibrillation in 1.1%. Blood pressure was uncontrolled (>140/90) in 46% of stroke survivors. Among men 71.2% used tobacco and 30% used alcohol, while among women 38.2% used tobacco and none used alcohol. Only 40.8% of stroke survivors were receiving antihypertensive medications, while 10.6% were on antiplatelet agents and 4.9% were on statins. In a multivariate analysis, age <50 years (OR 0.2, 95% CI 0.1-0.5), male sex (OR 0.2, 95% CI 0.2-0.8) and lower economic status (no assets vs four assets; OR 0.3, 95% CI 0.1-0.9) were associated with lower odds of receiving medications for secondary prevention of stroke. Conclusions: There were significant gaps in secondary prevention of stroke in rural Gadchiroli. Healthcare programmes for secondary prevention of stroke in rural areas will have to ensure that blood pressure is adequately controlled, alcohol and tobacco cessation is promoted and special attention is paid to those who are younger, men and economically weaker.

Gaps in secondary prevention among stroke survivors in rural Gadchiroli, India: a community-based cross-sectional study.

Background: With epidemiological transition, stroke has emerged as a public health priority in rural India. However, population-level information on secondary prevention of stroke from rural areas of India and other low- and middle-income countries remains exceedingly rare. Methods: In a cross-sectional community-based survey, trained surveyors screened a well-defined population of 74,095 individuals living in 64 villages in Gadchiroli district of India for symptoms of stroke. A trained physician evaluated screen positive patients, diagnosed stroke, measured blood pressure and collected information on prior diagnosis of risk factors and current use of medications using a structured questionnaire. Results: A total of 265 stroke survivors were identified. Prior diagnosis of hypertension was made in 57.4%, diabetes in 9.8%, hyperlipidaemia in 0.4%, ischaemic heart disease in 1.5%. and atrial fibrillation in 1.1%. Blood pressure was uncontrolled (>140/90) in 46% of stroke survivors. Among men 71.2% used tobacco and 30% used alcohol, while among women 38.2% used tobacco and none used alcohol. Only 40.8% of stroke survivors were receiving antihypertensive medications, while 10.6% were on antiplatelet agents and 4.9% were on statins. In a multivariate analysis, age <50 years (OR 0.2, 95% CI 0.1-0.5), male sex (OR 0.2, 95% CI 0.2-0.8) and lower economic status (no assets vs four assets; OR 0.3, 95% CI 0.1-0.9) were associated with lower odds of receiving medications for secondary prevention of stroke. Conclusions: There were significant gaps in secondary prevention of stroke in rural Gadchiroli. Healthcare programmes for secondary prevention of stroke in rural areas will have to ensure that blood pressure is adequately controlled, alcohol and tobacco cessation is promoted and special attention is paid to those who are younger, men and economically weaker.

California Cardiovascular Screening Tool: Findings from Initial Implementation.

Objective American College of Obstetricians and Gynecologists (ACOG) recently published the California (CA) cardiovascular disease (CVD) screening algorithm for pregnant and postpartum women. We aim to prospectively determine screen-positive and true-positive rates of CVD among women across two populations. Study Design This is a prospective cohort study of obstetrical patients from April 2018 to July 2019 at academic medical centers in CA and New York (NY). We attempted to screen all patients at least once during their pregnancy care (prenatal or postpartum). Women who screened positive (“Red Flags,” >3–4 moderate risk factors, abnormal physical examination, and persistent symptoms) underwent further testing. The primary outcome was the screen-positive rate. Secondary outcomes included the true-positive rate and the strength of each moderate factor in predicting a positive CVD screen. Results We screened 846 women. The overall screen-positive rate was 8% (5% in CA vs. 19% in NY). The sites differed in ethnicity, that is, African American women (2.7% in CA vs. 35% in NY, p < 0.01) and substance use (2.7 vs. 5.6%, p < 0.04). The true-positive rate was 1.5% at both sites. The percentage of screen-positive patients who did not complete follow-up studies was higher in NY (70%) than in CA (27%). CVD was confirmed in 30% with positive screens with complete follow-up. Combinations of moderate factors were the main driver of screen-positive rates in both populations. Conclusion This is the first data describing the performance of the CVD screening algorithm in a general obstetric population. Factors, such as proportion of African American women affect the likelihood of a positive screen. The screening algorithm highlights patients at higher lifetime risk of CVD and may identify a group that could be targeted for more direct care transitions postpartum. Data may be used to design a larger validation study.

Psychiatric Problems Amongst Adolescents Living With HIV at a Tertiary Care Centre in India

To assess the prevalence of psychiatric problems among adolescents living with HIV (ALHIV). Questionnaire-based cross-sectional study conducted at pediatric HIV clinic of a tertiary care hospital. Participants: 101 ALHIV between 10-18 years of age. Of the 101 ALHIV, 12 (11.88%) met criteria for psychiatric disorders, of which dysthymi (5,41.6%) and oppositional defiant disorder (6,50%) were the commonest. Father of 7 (58.34%) and mother of 8 (66.6%) screen positive patients were dead as compared to 22 (24.7%) and 13 (14.6%) of screen negative patients (P=0.016 and P=0.0003, respectively). Psychiatric problems are common in ALHIV in the age group more than 15 years.

Cost-effectiveness Analysis of Preoperative Screening Strategies for Obstructive Sleep Apnea among Patients Undergoing Elective Inpatient Surgery.

Obstructive sleep apnea is underdiagnosed in surgical patients. The cost-effectiveness of obstructive sleep apnea screening is unknown. This study's objective was to evaluate the cost-effectiveness of preoperative obstructive sleep apnea screening (1) perioperatively and (2) including patients' remaining lifespans. An individual-level Markov model was constructed to simulate the perioperative period and lifespan of patients undergoing inpatient elective surgery. Costs (2016 Canadian dollars) were calculated from the hospital perspective in a single-payer health system. Remaining model parameters were derived from a structured literature search. Candidate strategies included: (1) no screening; (2) STOP-Bang questionnaire alone; (3) STOP-Bang followed by polysomnography (STOP-Bang + polysomnography); and (4) STOP-Bang followed by portable monitor (STOP-Bang + portable monitor). Screen-positive patients (based on STOP-Bang cutoff of at least 3) received postoperative treatment modifications and expedited definitive testing. Effectiveness was expressed as quality-adjusted life month in the perioperative analyses and quality-adjusted life years in the lifetime analyses. The primary outcome was the incremental cost-effectiveness ratio. In perioperative and lifetime analyses, no screening was least costly and least effective. STOP-Bang + polysomnography was the most effective strategy and was more cost-effective than both STOP-Bang + portable monitor and STOP-Bang alone in both analyses. In perioperative analyses, STOP-Bang + polysomnography was not cost-effective compared to no screening at the $4,167/quality-adjusted life month threshold (incremental cost-effectiveness ratio $52,888/quality-adjusted life month). No screening was favored in more than 90% of iterations in probabilistic sensitivity analyses. In contrast, in lifetime analyses, STOP-Bang + polysomnography was favored compared to no screening at the $50,000/quality-adjusted life year threshold (incremental cost-effectiveness ratio $2,044/quality-adjusted life year). STOP-Bang + polysomnography was favored in most iterations at thresholds above $2,000/quality-adjusted life year in probabilistic sensitivity analyses. The cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.

The Effect of Illegal Drug Screening Results and Chronic Drug Use on Perioperative Complications in Trauma.

Context:Illegal drug use and need for surgery are common in trauma. This allows examination of the effects of perioperative drug use.Aim:The aim was to study the effects of illegal drug use on perioperative complications in trauma.Setting and Design:Propensity-matched analysis of perioperative complications between drug screen-positive (DSP) and drug screen-negative (DSN) patients from the National Trauma Data Bank (NTDB).Methods:The NTDB reports drug screening as a composite. We compared complications for DSP, DSN, and specific chronic drug disorders. Time to first procedure was analyzed to determine whether delay to surgery was associated with reduced complications.Statistics:Logistic regression with 11 predictor variables was used to calculate propensity scores. Categorical and continuous variables were compared using Chi-square and Student’s t-test, respectively.Results:752,343 patients (21.9%) were tested for illegal drugs. DSP was protective for mortality-relative risk (RR) 0.84 (P < 0.001) and arrhythmia RR 0.87 (P = 0.02). All complications (AC) were higher for DSP with a RR of 1.08 (P < 0.001). Cocaine, cannabis, and opioids were associated with reduced mortality. Cocaine was associated with increased myocardial infarction (MI). All four chronic drug disorders were associated with markedly higher arrhythmia. All except cannabis were associated with higher AC. Mortality was significantly lower for DSP for every time interval until first procedure. Continuous-time until procedure was associated with increased MI and arrhythmia.Conclusions:DSP was protective of mortality and cardiac complications. Drug disorders were protective for mortality but increased arrhythmia and AC. Delay until the surgery does not diminish cardiac or overall risk.

1023: A comparison of BMI and drug screens among pregnant patients at an Appalachian clinic

Appalachia has significantly higher rates of both obesity and opiate abuse compared to the national average. This study looks at the relationship of these two epidemics and how they may influence each other among pregnant women in one Appalachian clinic. This is a retrospective cohort study reviewing body mass index (BMI) at first prenatal visit to identify obesity (BMI >30kg/m2) and results of first urine drug screen (UDS) performed in pregnancy for all patients seen in one Appalachian clinic in the 2018 calendar year. Universal drug screening is performed on all pregnant patients in our population due to local high rates of substance abuse. A positive test for any one of the 12 drugs in the screening panel resulted in a “screen positive” result. Data was further analyzed using health insurance status as a socioeconomic marker. Data from 992 patients was collected and assessed. Data from 6 patients was not used because they lacked either BMI or UDS data. Screen positive samples were found in 318 UDS (32.3% of all samples); of these, 142 samples (14.4% of all samples) tested positive for buprenorphine. The median BMI for all patients was 27.5+/- 7.9 kg/m2. Obesity accounted for 35.6% of patients. Drug screen positive patients had an average BMI 2.5kg/m2 (p< 0.001) lower than drug screen negative patients. An even greater difference was seen when the subcategory of buprenorphine positive patients were compared to negative UDS patients. The buprenorphine positive patients had a BMI 3.6kg/m2 (p< 0.001) lower than drug screen negative patients. Among patients with insurance coverage through Medicaid, buprenorphine positive patients had a BMI 4.5kg/m2 (p< 0.001) lower than drug screen negative. Two separate epidemics appear to exist side by side in different populations of the same community. It is unclear whether the presence of one condition is protective against the occurrence of the other condition for an individual patient. Further research into socioeconomics, education, and experienced trauma could help better evaluate distinctions between these two epidemics.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Epidemiological correlates of Common Mental Disorders in a rural community of South India: A cross sectional study

Background: Common Mental Disorders (CMDs) encompass a range of anxiety/depressive disorders. They cause considerable morbidity at individual level and pose a significant burden to the community in terms of the suffering and cost. Objectives: This study was done to determine the prevalence, determinants, patterns and severity of CMDs in a rural community of Udupi district. Methods: A cross sectional two- stage study was done in rural field practice area of Department of Community Medicine with the help of the Rural Psychiatry team from Department of Psychiatry. Screening for psychological distress in the first stage was done using SRQ-20. In second stage screen positive patients were assessed in Nitte CHC by trained psychiatrists using M.I.N.I schedule. Assessment of severity was done using Hamilton A scale (HAM A), Hamilton D scale (HAM D), Yale Brown Obsessive Compulsive Scale (YBOCS) and the Scale for Assessment of Somatic Symptoms (SASS). Results: Prevalence of CMDs was 26.5 per thousand population. Dysthymia was the most common diagnosis. Gender, marital status and educational status were the significant determinants of CMDs. Those who were married but staying separate/ divorced, illiterates and those educated up to primary school were the only groups with higher adjusted odds on multivariate analysis. The common presenting symptoms were sad mood/ crying episodes and somatic complaints. Conclusion: Prevalence of CMDs was low at 26.5 per thousand. Sad mood/ crying episodes as well as somatic complaints are the common presentations which have to be borne in mind when treating patients at the primary care level.

Newborn Screening for Spinal Muscular Atrophy in China Using DNA Mass Spectrometry.

Background: Spinal muscular atrophy (SMA) is the most common neurodegenerative disorder and the leading genetic cause of infant mortality. Early detection of SMA through newborn screening (NBS) is essential to selecting pre-symptomatic treatment and ensuring optimal outcome, as well as, prompting the urgent need for effective screening methods. This study aimed to determine the feasibility of applying an Agena iPLEX SMA assay in NBS for SMA in China. Methods: We developed an Agena iPLEX SMA assay based on the matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and evaluated the performance of this assay through assessment of 167 previously-genotyped samples. Then we conducted a pilot study to apply this assay for SMA NBS. The SMN1 and SMN2 copy number of screen-positive patients were determined by multiplex ligation-dependent probe amplification analysis. Results: The sensitivity and specificity of the Agena iPLEX SMA assay were both 100%. Three patients with homozygous SMN1 deletion were successfully identified and conformed by multiplex ligation-dependent probe amplification analysis. Two patients had two SMN2 copies, which was correlated with severe SMA type I phenotype; both of them exhibited neurogenic lesion and with decreased muscle power. Another patient with four SMN2 copies, whose genotype correlated with milder SMA type III or IV phenotype, had normal growth and development without clinical symptoms. Conclusions: The Agena iPLEX SMA assay is an effective and reliable approach for population-based SMA NBS. The first large-scale pilot study using this assay in the Mainland of China showed that large-scale implementation of population-based NBS for SMA is feasible.

Screening for Anal Cancer in Women With a History of Vulvar High-Grade Squamous Intraepithelial Lesions.

The primary obkective was to determine the prevalence of (a) a positive anal cancer screen and (b) histological anal high-grade squamous intraepithelial lesion (HSIL) in women undergoing surveillance for previously diagnosed and treated human papillomavirus (HPV)-associated vulvar HSIL. The secondary objective was to determine the patients' acceptability of the screen. This is a single-institution, cross-sectional pilot study. Women, aged 30 to 80 years, with a history of biopsy-proven vulvar HSIL were invited to undergo screening for anal cancer. Positive screen characterized by abnormalities in any of the following: anal high-risk HPV (HR-HPV); anal cytology; and digital anorectal examination. All women with an abnormal screen were referred for high-resolution anoscopy. All women completed a postscreen questionnaire. Fifty-seven patients were recruited. The median (interquartile range) age was 61.5 (51.0-68.0) years. The prevalence of a positive screen was 56.1% (95% CI = 43.3%-68.2%). Of the 32 screen-positive patients, 12 had both abnormal cytology and HR-HPV, 3 had positive HR-HPV alone, and 17 had abnormal cytology alone. Of the 29 patients with a positive screen who went on to anoscopy, the prevalence of anal HSIL was 33.3% (95% CI = 19.2%-51.2%). The prevalence of anal HSIL among all of those who had screening (N = 57) was 18.2% (95% CI = 10.2%-30.3%). The examination was well tolerated with 100% of patients, indicating that they would have the screening again. Women with vulvar HSIL have an increased risk of developing anal HSIL. Larger studies are needed to define optimal screening protocols as well as algorithms for management in high-risk populations.

Emotion regulation in patients with heart failure: Its relationship with depressive symptoms and rehospitalization

ObjectiveTo examine the role of emotion regulation and its relationship to mental and physical health in patients with heart failure (HF). MethodsPatients hospitalized with HF were screened for depressive symptoms with the two-item Patient Health Questionnaire (PHQ-2) and classified as screen-positive if endorsing ≥1 item and otherwise as screen-negative. One month after hospital discharge, the Emotion Regulation Questionnaire (ERQ) was administered to assess suppression and reappraisal as emotion regulation strategies. In all participants who completed the ERQ (N = 394), all-cause rehospitalization and depressive symptoms using the PHQ-9 were assessed at 1-, 3-, and 6-months after hospital discharge. ResultsOverall, PHQ-9 scores decreased by 6-months (−0.13 points/month, p = .003), and although suppression showed a small association with depression, neither strategy modulated the slope of the decline in depressive symptoms. Multivariable-adjusted Cox models showed that reappraisal and suppression were not related to all-cause rehospitalization in the entire cohort. However, increasing reappraisal reduced rehospitalization risk by 24% for screen-positive patients (N = 311, HR = 0.76, p = .02), but increased it by 94% in screen-negative patients (N = 83, HR = 1.94, p = .009). ConclusionSuppression and reappraisal showed specific and divergent associations in patients with HF: Suppression may relate to depressive symptoms. Reappraisal was associated with rehospitalization, but differently for patients with a positive vs. negative depression screen. Further studies are needed to examine whether emotion-regulation skill training can improve mental and physical health in depressed patients with HF or ameliorate depression in those at-risk.

The profiles of health care utilization among a non-depressed population and patients with depressive symptoms with and without clinical depression

Objective: To examine health service (HS) utilization profiles among a non-depressive population and patients with depressive symptoms (DS) with and without clinical depression.Design, subjects and setting: The study population was based on primary care patients with DS scoring ≥10 in the 21-item Beck Depression Inventory (BDI) and who were at least 35 years old and had been referred to depression nurse case managers (n = 705). Their psychiatric diagnosis was confirmed with the Mini-International Neuropsychiatric Interview (M.I.N.I.). Of these patients, 447 had clinical depression. The number of patients with DS without clinical depression was 258. The control group consisted of a random sample of 414 residents with a BDI score < 10. Use of HS (visits and phone calls to a doctor and a nurse) was based on patient records.Main outcome measures: Number of visits and calls to physicians and nurses.Results: Patients with DS regardless of their depression diagnosis used primary health care (PHC) services three times more than the controls (p < 0.001). In the secondary care, the differences were smaller but significant. Of the controls, 70% had 0–4 HS contacts per year whereas a majority of the patients having DS had more than 5 contacts per year. The number of contacts correlated with the BDI from a score of 0 to 10 but not as clearly in the higher scores.Conclusion: Depressive symptoms, both with or without clinical depression, are associated with increased HS use, especially in PHC. This study suggests that even mild depressive symptoms are associated with an increased use of HS.KEY POINTSWe analyzed the health service (HS) use among primary health care patients screened for depression and non-depressive population.Screen positive patients without clinical depression used as much HS as those having clinical depression.Regardless of depression diagnosis, screen positive patients visited a GP and nurse three times more often than the control population.In the screen negative control population, milder depressive symptoms were correlated with the use of HS.Primary health care was responsible for most of the HS use among patients having depressive symptoms.

A Practical Two-Stage Frailty Assessment for Older Adults Undergoing Aortic Valve Replacement.

Despite evidence, frailty is not routinely assessed before cardiac surgery. We compared five brief frailty tests for predicting poor outcomes after aortic valve replacement and evaluated a strategy of performing comprehensive geriatric assessment (CGA) in screen-positive patients. Prospective cohort study. A single academic center. Patients undergoing surgical aortic valve replacement (SAVR) (n = 91; mean age = 77.8 y) or transcatheter aortic valve replacement (TAVR) (n = 137; mean age = 84.5 y) from February 2014 to June 2017. Brief frailty tests (Fatigue, Resistance, Ambulation, Illness, and Loss of weight [FRAIL] scale; Clinical Frailty Scale; grip strength; gait speed; and chair rise) and a deficit-accumulation frailty index based on CGA (CGA-FI) were measured at baseline. A composite of death or functional decline and severe symptoms at 6 months was assessed. The outcome occurred in 8.8% (n = 8) after SAVR and 24.8% (n = 34) after TAVR. The chair rise test showed the highest discrimination in the SAVR (C statistic = .76) and TAVR cohorts (C statistic = .63). When the chair rise test was chosen as a screening test (≥17 s for SAVR and ≥23 s for TAVR), the incidence of outcome for screen-negative patients, screen-positive patients with CGA-FI of .34 or lower, and screen-positive patients with CGA-FI higher than .34 were 1.9% (n = 1/54), 5.3% (n = 1/19), and 33.3% (n = 6/18) after SAVR, respectively, and 15.0% (n = 9/60), 14.3% (n = 3/21), and 38.3% (n = 22/56) after TAVR, respectively. Compared with routinely performing CGA, targeting CGA to screen-positive patients would result in 54 fewer CGAs, without compromising sensitivity (routine vs targeted: .75 vs .75; P = 1.00) and specificity (.84 vs .86; P = 1.00) in the SAVR cohort; and 60 fewer CGAs with lower sensitivity (.82 vs.65; P = .03) and higher specificity (.50 vs .67; P < .01) in the TAVR cohort. The chair rise test with targeted CGA may be a practical strategy to identify older patients at high risk for mortality and poor recovery after SAVR and TAVR in whom individualized care management should be considered. J Am Geriatr Soc 67:2031-2037, 2019.

SAT-060 Analysis of over 24,000 Aldosterone to Renin Ratio for Screening Hypertensive Patients for Primary Aldosteronism

Primary aldosteronism remains an underdiagnosed and undertreated endocrine disease2. More than 100 million adults in the USA are hypertensive, and 5% or more of the cases may be related to primary aldosteronism. The value of primary aldosteronism diagnosis is to guide surgical or medical treatment. Aldosterone to Renin Ratio (ARR) is the screening tool designated by the Endocrine Society’s 2016 guideline1 aimed at screening hypertensive patients for primary aldosteronism. Used properly, the test has a high negative predictive value and a moderate positive predictive value2. 24,508 ARR results were surveyed to determine the positivity rate for the ARR screen. Various cancellations eliminated 1592 results, and 20,656 results were valid. The frequency of ARR results greater than 30 was 8.75%. In addition, another 1.11% of results had undetectable renin values with aldosterone values greater than 20 ng/dL, thus these were designated as screen positives. The total frequency of screen positivity was 9.86%. A secondary study goal was to investigate available characteristics of the ARR positive screen patients. The median age of the positive ARR screen patients (57) was not significantly different from the age of all patients screened (56). The percent female was only slightly lower in the positive ARR group than in the negatives (57% vs 54%). High ARR patients had low potassium -with a frequency of 11.5%. The most common ICD10 codes in the screen positive patients were for primary hypertension (20.9% of all samples but 52.9% of positives), followed by hypokalemia (3.7% of all samples but 9.5% of positives), disorder of the adrenal gland (1.8% of all samples but 4.6% of positives). Chronic kidney disease due to hypertension was also found more frequently in positive ARR patients. In addition, many other codes at less than 1%, including vitamin D deficiency, hyperlipidemia, and hypothyroidism were found less frequently in ARR positive than in negative patients. Conclusions: The ratio of two routine blood tests, aldosterone to renin may have large implications for the hypertensive patient because high blood pressure due to primary aldosteronism may be better controlled medically or surgically with appropriate diagnosis. The positive screen rate in a large series of patient screens was about 10%. The Medicare cost of ARR screening is less than $80.00, and the reasonable cost underscores cost-effective ARR test utilization for screening hypertensive patients.

Evaluation of a collaborative care model for integrated primary care of common mental disorders comorbid with chronic conditions in South Africa

BackgroundThe rise in multimorbid chronic conditions in South Africa, large treatment gap for common mental disorders (CMDs) and shortage of mental health specialists demands a task sharing approach to chronic disease management that includes treatment for co-existing CMDs to improve health outcomes. The aim of this study was thus to evaluate a task shared integrated collaborative care package of care for chronic patients with co-existing depressive and alcohol use disorder (AUD) symptoms.MethodsThe complex intervention strengthened capacity of primary care nurse practitioners to identify, diagnose and review symptoms of CMDs among chronic care patients; and implemented a stepped up referral system, that included clinic-based psychosocial lay counsellors, doctors and mental health specialists. Under real world conditions, in four PHC facilities, a repeat cross-sectional Facility Detection Survey (FDS) assessed changes in capacity of nurses to correctly detect CMDs in 1310 patients before implementation and 1246 patients following implementation of the intervention at 12 months; and a non-randomly assigned comparison group cohort study comprising 373 screen positive patients with depressive symptoms using the Patient Health Questionnaire-9 (PHQ9) at baseline, evaluated responses of patients correctly identified and referred for treatment (intervention arm) or not identified and referred (control arm) at three and 12 months.ResultsThe FDS showed a significant increase in the identification of depression and AUD from pre-implementation to 12-month post-implementation. Depression: (5.8 to 16.4%) 95% CI [2.9, 19.1]); AUD: (0 to 13.8%) 95% CI [0.6–24.9]. In the comparison group cohort study, patients with depressive symptoms having more than a 50% reduction in PHQ-9 scores were greater in the treatment group (n = 69, 55.2%) compared to the comparison group (n = 49, 23.4%) at 3 months (RR = 2.10, p < 0.001); and 12 months follow-up (intervention: n = 57, 47.9%; comparison: n = 60, 30.8%; RR = 1.52, p = 0.006). Remission (PHQ-9 ≤ 5) was greater in the intervention group (n = 32, 26.9%) than comparison group (n = 33, 16.9%) at 12 months (RR = 1.72, p = 0.016).ConclusionA task shared collaborative stepped care model can improve detection of CMDs and reduce depressive symptoms among patients with chronic conditions under real world conditions.

Association between Inpatient Delirium and Hospital Readmission in Patients ≥ 65 Years of Age: A Retrospective Cohort Study.

Delirium affects more than seven million hospitalized adults in the United States annually. However, its impact on postdischarge healthcare utilization remains unclear. To determine the association between delirium and 30-day hospital readmission. A retrospective cohort study. A general community medical and surgical hospital. All adults who were at least 65 years old, without a history of delirium or alcohol-related delirium, and were hospitalized from September 2010 to March 2015. The patients deemed at risk for or displaying symptoms of delirium were screened by nurses using the Confusion Assessment Method with a followup by a staff psychiatrist for a subset of screen-positive patients. Patients with delirium confirmed by a staff psychiatrist were compared with those without delirium. The primary outcome was the 30-day readmission rate. The secondary outcomes included emergency department (ED) visits 30 days postdischarge, mortality during hospitalization and 30 days postdischarge, and discharge location. The cohort included 718 delirious patients and 7,927 nondelirious patients. Using an unweighted multivariable logistic regression, delirium was determined to be significantly associated with the increased odds of readmission within 30 days of discharge (odds ratio (OR): 2.60; 95% CI, 1.96-3.44; P < .0001). Delirium was also significantly (P < .0001) associated with ED visits within 30 days postdischarge (OR: 2.18; 95% CI: 1.77-2.69) and discharge to a facility (OR: 2.52; 95% CI: 2.09-3.01). Delirium is a significant predictor of hospital readmission, ED visits, and discharge to a location other than home. Delirious patients should be targeted to reduce postdischarge healthcare utilization.

Comparison of PROMIS Anxiety and Depression, PHQ-8, and GAD-7 to screen for anxiety and depression among patients presenting for spine surgery.

In this paper, the authors demonstrate to spine surgeons the prevalence and severity of anxiety and depression among patients presenting for surgery and explore the relationships between different legacy and Patient-Reported Outcomes Measurement Information System (PROMIS) screening measures. A total of 512 adult spine surgery patients at a single institution completed the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), 8-item Patient Health Questionnaire (PHQ-8) depression scale, and PROMIS Anxiety and Depression computer-adaptive tests (CATs) preoperatively. Correlation coefficients were calculated between PROMIS scores and GAD-7 and PHQ-8 scores. Published reference tables were used to determine the presence of anxiety or depression using GAD-7 and PHQ-8. Sensitivity and specificity of published guidance on the PROMIS Anxiety and Depression CATs were compared. Guidance from 3 sources was compared: published GAD-7 and PHQ-8 crosswalk tables, American Psychiatric Association scales, and expert clinical consensus. Receiver operator characteristic curves were used to determine data-driven cut-points for PROMIS Anxiety and Depression. Significance was accepted as p < 0.05. In 512 spine surgery patients, anxiety and depression were prevalent preoperatively (5% with any anxiety, 24% with generalized anxiety screen-positive; and 54% with any depression, 24% with probable major depression). Correlations were moderately strong between PROMIS Anxiety and GAD-7 scores (r = 0.72; p < 0.001) and between PROMIS Depression and PHQ-8 scores (r = 0.74; p < 0.001). The observed correlation of the PROMIS Depression score was greater with the PHQ-8 cognitive/affective score (r = 0.766) than with the somatic score (r = 0.601) (p < 0.001). PROMIS Anxiety and Depression CATs were able to detect the presence of generalized anxiety screen-positive (sensitivity, 86.0%; specificity, 81.6%) and of probable major depression (sensitivity, 82.3%; specificity, 81.4%). Receiver operating characteristic curve analysis demonstrated data-driven cut-points for these groups. PROMIS Anxiety and Depression CATs are reliable tools for identifying generalized anxiety screen-positive spine surgery patients and those with probable major depression.

1035: Five years’ experience with universal preterm birth screening using transvaginal ultrasound for cervical length measurement

To report on our 5 years of experience with a universal screening program for preterm birth (PTB), using transvaginal ultrasound for cervical length (CL) measurement at time of 2nd trimester anatomy scan. We performed a retrospective analysis of patients with nonanomalous singleton gestations diagnosed with short CL in our tertiary medical center between Oct 2012 and Dec 2017 identified through our universal screening program. Screen positive was defined as CL <25mm in women at high risk (HR) for PTB, based on their obstetrical history, and <20mm for those considered low risk (LR). Program acceptance, screen positive rates, and gestational outcome were evaluated. The HR group was compared to LR for maternal, gestational and neonatal outcome data. During the study period 25,939 of 27,952 (92.8%) women who had 2nd trimester anatomy scans elected CL screening. 430 (1.66%) patients were deemed screen positive: 135 (0.52%) in the HR group (CL <25mm) and 295 (1.14%) LR (CL <20mm). LR women were younger (29 vs 30.5 yrs., p=0.018) and had lower gravidity (3 vs 5.4, p<0.001) and parity (0.56 vs 1.75, P<0.001) than HR. There was no difference in gestational age at diagnosis, ethnicity, or BMI. 181 (42%) delivered <37 weeks. 19/135 HR women (14%) were receiving 17-Hydroxyprogesterone. HR women used vaginal progesterone and cerclage equally (28%) and LR women used vaginal progesterone (55%) more frequently than cerclage (18%).Groups were similar for gestational age at birth (34w1d HR vs 34w0d LR, p=0.78), neonatal death (6.67% HR vs 10.2% LR, p=0.22) and admission to NICU (29% HR vs 27% LR, p=0.76) but HR neonates had higher rates of necrotizing enterocolitis (6% vs 0.3%, p<0.001). The mean CL was shorter in the women who received cerclages (1.19 vs 1.66, P<0.001) and they were more likely to be high risk gravidas (P<0.001). There was no difference in neonatal outcomes between women using vaginal progesterone vs cerclage. Universal screening for PTB using transvaginal ultrasound for CL at time of 2nd trimester anatomy scan is highly acceptable to patients. Over two thirds of screen positive patients were considered low risk for PTB and would not have otherwise been identified and eligible for PTB preventative interventions.

Decision-making in dentistry related to temporomandibular disorders: a 5-yr follow-up study.

Temporomandibular disorders (TMDs) are common, but many patients with such disorders go undetected and under-treated. Our aim was to evaluate the outcome of using a screening tool (5yr after it was first implemented), on the clinical decision-making for patients with TMDs. Adults who attended for a dental check-up at the Public Dental Health Services in Västerbotten, Sweden, answered three screening questions (3Q/TMD) on frequent jaw pain, pain on jaw function, and catching/locking of the jaw. The dental records of a random sample of 200 individuals with at least one positive response to 3Q/TMD (3Q screen-positive patients) and 200 individuals with all negative responses (3Q screen-negative patients) were reviewed for TMD-related treatment decisions. A clinical decision related to TMD was absent in 45.5% of 3Q screen-positive patients. Treatment of TMDs was associated with a positive response to the screening question on jaw pain (OR = 6.7, 95% CI: 3.2-14.0) and was more frequent among 3Q screen-positive patients (24%) than among 3Q screen-negative patients (2%; OR = 15.5, 95% CI: 5.5-43.9), just as a female examiner was associated with more frequent treatment of TMDs (OR=3.1, 95% CI: 1.2-8.4). The results indicate under-treatment of TMD within general dental practice and that male clinicians are less likely to initiate TMD treatment.

Community-Based Cancer Screening Program: The DESH (Detect Early Save Her, Him) Initiative of Piramal Swasthya

Background and context: Two-thirds of global cancer deaths are from less developed countries. Late stage presentation and inability to access care are observed to be higher in lower and middle-income countries resulting in avoidable deaths and disability. Kamrup district in Assam has the fourth highest incidence of cancers in India. Detect Early Save Her, Him (DESH) initiative by Piramal Swasthya in Kamrup district focuses on reducing late-stage diagnosis and mortality. Aim: To reduce the proportion of late-stage diagnosis and mortality from breast, cervical and oral cancers through a community based screening and referral program. Strategy: 1. Community level interventions to increase awareness, improve knowledge, alter attitudes and motivate and mobilize people to undergo screening. 2. Evidence based highly sensitive screening and referral through mobile cancer screening unit. 3. Partnering with a regional cancer care institute (Dr. B. Borooah Cancer Institute - BBCI) to ensure end to end care to the patients. Program: DESH initiative in partnership with BBCI was launched in November 2017. The Mobile Cancer Screening Unit (MCSU) is fully equipped with state-of-the-art cancer screening facilities including a mammography unit. It is staffed by trained medical doctor, two nurses, a radiographer, two community mobilization officers, a counselor, a driver and a helper. Apart from the driver and the helper, the entire staff is women. In consultation with community networks, a schedule is prepared to conduct awareness programs at the community level. Subsequently, the MCSU visits the village and the staff screen the adult population over the age of 30 years for the presence of oral, breast and cervical cancer. A vehicle ferries those who are screened positive, to BBCI for diagnostic tests. The program is also supported by a helpline, which provides tele-counseling for suspected cases of cancer. Outcomes: A total of 1750 beneficiaries have been screened for oral, breast and cervical cancers through 43 screening clinics in 18 villages of Kamrup district from November 2017 through March 2018. Of them, 57% were females. 57 beneficiaries (3.25%) were screen-positive. Majority were positive for oral cancers (n=50) followed by breast and cervical cancers. Out of the 15 beneficiaries who visited BBCI, 3 were confirmed to have oral cancer. What was learned: Rural community of Kamrup district has been very receptive of the screening program with 1750 people screened in a short duration of time. Many screen-positive patients have not yet to visited the hospital for diagnostic tests, due to their financial difficulties. With financial support from the government through a special scheme, the number of screen-positive patients reaching the hospital for diagnostic tests is expected to increase substantially. DESH initiative aims to screen 15,000 individuals in the next 12 months and the results will provide better insights about the scalability and impact of the program.