Concordance with phase-one cardiac rehabilitation guidelines in the inpatient setting

The aim of the paper was to examine concordance with phase-one cardiac rehabilitation (CR) guidelines, undertake an intervention that might optimise adherence to the guidelines, and establish a benchmark for practice in the coronary care unit (CCU) setting.

Differences in parent-provider concordance regarding prognosis and goals of care among children with advanced cancer

Purpose Concordance between parents of children with advanced cancer and health care providers has not been described. We aimed to describe parent-provider concordance regarding prognosis and goals of care, including differences by cancer type.

Patient self-management in chronic heart failure – establishing concordance between guidelines and practice

 Chronic heart failure (CHF) is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. CHF patients are encouraged to self-manage their illness, such as adhering to medical regimens and monitoring symptoms, to optimise health outcomes and quality of life. In so doing, patients are asked to collaborate with their health service providers with regard to their care. However, patients generally do not self-manage well, even with specialist support. Moreover, self- management interventions are yet to demonstrate morbidity or mortality benefits. Social network approaches to self-management consider the availability and mobilisation of all resources, beyond those of only the patient and healthcare providers. Used in conjunction with e-health platforms, social network approaches may offer a means by which to optimise self-management programmes of the future.

Concordance in phylogeography and ecological niche modelling identify dispersal corridors for reptiles in arid Australia

Aim: Using the rock-specialist agamid Ctenophorus caudicinctus as a model, we test hypothesized biogeographical dispersal corridors for lizards in the Australian arid zone (across the western sand deserts), and assess how these dispersal routes have shaped phylogeographical structuring. Location: Arid and semi-arid Australia. Methods: We sequenced a c. 1400 bp fragment of mtDNA (ND2) for 134 individuals of C. caudicinctus as well as a subset of each of the mtDNA clades for five nuclear loci (BDNF, BACH1, GAPD, NTF3, and PRLR). We used phylogenetic methods to assess biogeographical patterns within C. caudicinctus, including relaxed molecular clock analyses to estimate divergence times. Ecological niche modelling (Maxent) was employed to estimate the current distribution of suitable climatic envelopes for each lineage. Results: Phylogenetic analyses identified two deeply divergent mtDNA clades within C. caudicinctus - an eastern and western clade - separated by the Western Australian sand deserts. However, divergences pre-date the Pleistocene sand deserts. Phylogenetic analyses of the nuclear DNA data sets generally support major mtDNA clades, suggesting past connections between the western C. c. caudicinctus populations in far eastern Pilbara (EP) and the lineages to the east of the sand deserts. Ecological niche modelling supports the continued suitability of climatic conditions between the Central Ranges and the far EP for C. c. graafi. Main conclusions: Estimates of lineage ages provide evidence of divergence between eastern and western clades during the Miocene with subsequent secondary contact during the Pliocene. Our results suggest that this secondary contact occurred via dispersal between the Central Ranges and the far EP, rather than the more southerly Giles Corridor. These events precede the origins of the western sand deserts and divergence patterns instead appear associated with Miocene and Pliocene climate change.

The nature of children's social interactions at school

Interpersonal interactions are important for emotional and psychological wellbeing. One attempt to systematically assess social interactions among gifted children was presented by Manor-Bullock et al. (1995) in their Social Interaction Questionnaire (SIQ). However, no psychometric properties of this scale or the nature of the factors that form students' social interactions have been reported. The aim of this study to ascertain the underlying factor structure of students' social interactions on scores on the SIQ and to compare the responses of children attending a regular school to those in Manor-Bullock et al.'s cohort of gifted children. Two independent factors emerged from the data: social/popular and confident/studious with internal reliability of {alpha} = 0.82 and {alpha} = 0.60 respectively. There were no gender differences on these factors in the current data. Chi square analyses revealed concordance between gifted and regular-school children on seven of 16 comparable items. Discussion of the items demonstrating an association is presented. Confirmation of the current factor structure is necessary and a matched comparison with gifted children is recommended.

Perceptions of relationship and sexual satisfaction among people with multiple sclerosis and their partners

The study evaluated relationships and sexuality among people with multiple sclerosis (MS) and their partners. The results were compared to findings among couples in the general population. Participants were 45 heterosexual people with MS and their partners and 32 heterosexual people from the general population and their partners. There was a high level of concordance between the views of couples from the general population, but not among couples where one partner had MS. Partners of people with MS were more likely than people with MS to feel that MS had a negative impact on the physical and emotional support in their relationship. People with MS also experienced more problems in their relationship and sexual functioning, but not their sexual satisfaction, than people from the general population. The implications of these results in terms of support programs for people with MS and their partners are discussed.

A comparison of self-reported puberty using the pubertal development scale and the sexual maturation scale in a school-based epidemiologic survey

Purpose: To examine concordance between two self-reported measures of puberty: Sexual Maturatiom Scale (SMS) and Pubertal Developl1!ent Scale (PDS) and their acceptability to adolescents. Methods: Participants of a school-based study in grades 5, 7 and 9 were classified into one of 5 pubertal stages using each method. Results: 2864 students (age 9-16 years) participated. Agreement was moderate for males (K 0.42, 95% CI 0.39,0.45) and females (K 0.57, 95% CI 0.53, 0.61). Concordance within one stage was excellent (females 97%, males 89%), with discrepancies due to females being classified one stage later on the PDS (26%) and males one stage earlier (32%). There were more missing data for the SMS (13%) than the PDS (4%).

Hope for sufferers of depression

The ultimate goal of the Language of Depression project conducted by linguists at Deakin University and psychiatrists at the Monash Medical Centre in Melbourne is to provide training programs for Acute Hospital staff to identify early their patients who suffer from depression and refer them to consultation- psychiatrists or psychologists for help. To date, only case studies from this project of 40 subjects have been reported. This paper presents the preliminary findings of the study of the language of depressed Acute Hospital patients. The generic structure of the data set will be described; the role and findings of the application of the WordSmith 3 concordance will be outlined; and in particular the semantic matches of features of depression will be presented. These are drawn especially from the application of APPRAISAL analysis. If Acute Hospital patients are listened to with the insights from these findings, with referral, they should receive help to curtail their suffering and be given hope of improvement and even the prospect of recovery from their depression.

Change of perspective: a measurable and desired outcome of chronic disease self-management intervention programs that violates the premise of preintervention/postintervention assessment

Objective: To determine if participants in chronic disease self-management courses have a change of perspective of their health status (a response shift), and if this is measurable with a paper-based questionnaire.

Methods: Nine items were developed to measure potential benefits of self-management courses. These were based on the constructs of a previous questionnaire, the Health Education Impact Questionnaire (HEI-Q). Cognitive interviews elicited spontaneous statements about the reasons for paper-based answers. Sensitivity, specificity, and overall accuracy of items were calculated using the interview as a relative gold standard. Response shift can be negative (i.e., after the course, participants realize that, before the course, they were worse than they thought they were), positive (i.e., participants now realize they were better than they thought they were), or absent (no change).

Results: Interviews (n = 39) reflected that true response shift occurred in approximately half the replies to questionnaire items. Of these, 31% were negative response shift, 20% were positive response shift. Response shift was absent in 32% of replies. Presence or absence of response shift could not be determined in 17% of replies across items. Significant concordance between questionnaires and cognitive interviews (average overall accuracy 0.79) indicated that the HEI-Q Perspective questionnaire detects response shift in participants of self-management courses. The questionnaire revealed that 87% of participants had response shift in at least 1 item.

Conclusion: This study suggests that preintervention/postintervention assessments of interventions such as self-management courses are confounded by a change in perspective of a large proportion of respondents. It also indicates response shift is a valuable outcome of self-management courses that can be measured with a paper-based questionnaire.

An examination of the 'gold standard' diagnosis of major depression in aged-care settings

Objectives: Individual clinical interviews are typically viewed as the “gold standard” when diagnosing major depressive disorder (MDD) and when examining the validity of self-rated questionnaires. However, this approach may be problematic with older people, who are known to underreport depressive symptomatology. This study examined the effect of including an informant interview on prevalence estimations of MDD in an aged-care sample.

Design: The results of an individual clinical interview for MDD were compared with those obtained when an informant interview was incorporated into the assessment. Results from each diagnostic approach were compared with scores on a self-rated depression instrument.

Setting: Low-level aged-care residential facilities in Melbourne (equivalent to “residential homes,” “homes for the elderly,” or “assisted living facilities” in other countries).

Participants: One hundred and sixty-eight aged-care residents (mean age: 84.68 years; SD: 6.16 years) with normal cognitive functioning.

Measurements: Individual clinical interviews were conducted using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders. This interview was modified for use with staff informants. Self-reported depression was measured using the Geriatric Depression Scale-15 (GDS-15).

Results: The estimated point prevalence of MDD rose from 16% to 22% by including an informant clinical interview in the diagnostic procedure. Overall, 27% of depressed residents failed to disclose symptoms in the clinical interview. The concordance of the GDS-15 with a diagnosis of MDD was substantially lower when an informant source was included in the diagnostic procedure.

Conclusion: Individual interviews and self-report questionnaires may be insufficient to detect depression among older adults. This study supports the use of an informant interview as an adjunct when diagnosing MDD among cognitively intact aged-care residents.

Testosterone, dominance signalling and immunosuppression in the house sparrow, Passer domesticus

The immunocompetence handicap hypothesis (ICHH) suggests that dominance signals are costly because their development is controlled by testosterone, which is immunosuppressive. Signal control therefore links an increased disease risk with a high quality signal. The chest bib of the house sparrow, Passer domesticus, is a signal known to be related to dominance and under control of testosterone levels. We experimentally manipulated testosterone in male sparrows during the breeding season and again independently during the post-breeding period to test whether variation in levels of testosterone could cause variation in levels of immunocompetence. There was no effect of testosterone manipulation on the cell-mediated response of birds to phytohaemagglutinin injection, nor did testosterone levels appear to affect either white blood cell ratios or red blood cell counts. In contrast, both breeding season and post-breeding season testosterone levels had significant effects upon the humoral response of the birds to sheep red blood cell injections. However, whilst testosterone during the breeding season appeared to act immunosuppressively, the role of post-breeding levels is less clear. In concordance with a previous study, there was an indication that corticosterone is involved in mediating the immunosuppressive effects of testosterone. The strength of the secondary humoral response and the cell-mediated response were negatively related suggesting the possibility of a trade-off between the different arms of the immune system. These results provide some support for the ICHH as a mechanism promoting the evolution of costly badges of status, although the results question whether the immunosuppressive cost can be mediated by testosterone at the time of badge development.

Range-wide phylogeography of the Little Penguin (Eudyptula minor): evidence of long-distance dispersal

The Little Penguin (Eudyptula minor), a colonial-nesting seabird that is widespread in New Zealand and southern Australia, has high dispersal potential but exhibits regional variation in morphology, coloration, and breeding phenology. We present a distribution-wide survey of mitochondrial DNA variation in the Little Penguin to document phylogeographic relationships and genetic structuring and to test for concordance with intraspecific taxonomy. Phylogeographic structuring was absent among Australian colonies (27 localities, 94 individuals), but the distribution of haplotypes among colonies was significantly nonrandom (ϕST = 0.110, P < 0.01). The Australian individuals exhibited close phylogenetic relationships with a subset of New Zealand birds (4 localities, 22 individuals), whereas the remaining New Zealand birds (20 localities, 106 individuals) were phylogenetically distinct, with ≥7% sequence divergence, and exhibited greater levels of genetic variation and geographic structuring (ϕST = 0.774, P < 0.05). These patterns are consistent with earlier suggestions of an origin in New Zealand followed by recent colonization of Australia and back-dispersal to New Zealand. Extinction and re-establishment processes may have been important factors in the development of genetic structuring across a range of spatiotemporal scales. The genetic data are consistent with suggestions that a single subspecies exists in Australia, but not with the subspecies distributions within New Zealand that have been suggested on the basis of morphology and coloration.

Spurious precision : variability in procedural validity of diagnostic procedures in psychotic disorders and implications for research and treatment

Very few studies have quantified the level of agreement among alternative diagnostic procedures that use a common set of fixed operational criteria. The authors examined the procedural validity of four independent methods of assigning DSM-III-R diagnoses of psychotic disorders. METHOD: The research was conducted as a satellite study to the DSM-IV Field Trial for Schizophrenia and Related Psychotic Disorders. The setting was the National Health and Medical Research Council Schizophrenia Research Unit's Early Psychosis Prevention and Intervention Centre, which focuses on first-episode psychosis. Consecutively admitted patients (N = 50) were assessed by independent raters who used four different procedures to determine a DSM-III-R diagnosis. These procedures were 1) the diagnostic instrument developed for the DSM-IV field trial, 2) the Royal Park Multidiagnostic Instrument for Psychosis, 3) the Munich Diagnostic Checklists, and 4) a consensus DSM-III-R diagnosis assigned by a team of clinician researchers who were expert in the use of diagnostic criteria. RESULTS: Concordance between pairs of diagnostic procedures was only moderate. Corresponding levels of percent agreement, however, ranged from 66% to 76%, with converse misclassification rates of 24%-34% (assuming one procedure to be "correct"). CONCLUSIONS: These findings have significant research and clinical implications. Despite the introduction of operationally defined diagnoses, there remained an appreciable level of differential classification or misclassification arising from variability in the method of assigning the diagnostic criteria rather than the criteria themselves. Such misclassification may impede neurobiological research and have harmful clinical effects on patients with first-episode psychosis.

The procedural validity of retrospective case note diagnosis

Objective: Deriving diagnoses from retrospective case note examination is a common practice in psychiatric research. The Operational Criteria (OPCRIT) diagnostic checklist is essentially a checklist built up of operational criteria defined by a comprehensive glossary and is designed to assign reliable diagnoses from case notes. However, the validity of such a procedure compared with procedures involving prospective assessment has never been tested. We examined the procedural validity of the OPCRIT diagnostic system in relation to four other diagnostic procedures mostly employing prospectively gathered information.

Method: Three experienced psychopathology raters rated the case notes and clinical abstracts, using the OPCRIT method of diagnostic assignment, of 50 subjects who had participated in an early procedural validity study as an adjunct to the DSM-IV Field Trial for psychotic disorders. The setting was the Early Psychosis Prevention and Intervention Centre (EPPIC), which focuses on first episode psychosis.

Results: The pairwise concordance with the other procedures for DSM-III-R diagnoses assigned by OPCRIT using ratings derived from either the clinical abstracts or the case notes was found to be only poor to moderate when compared with the pairwise concordance of the four other procedures. The per cent agreement between OPCRIT clinical abstracts diagnoses and the other procedures ranged from 49% to 60% with kappa values between 0.30 and 0.45, and for OPCRIT case note diagnoses and the other procedures the per cent agreement range was between 44% and 57% and the kappa values were between 0.35 and 0.49.

Conclusions: The procedural validity of diagnoses assigned via the application of checklists of operational criteria to case notes and clinical abstracts alone is unacceptably poor. Such sources need to be buttressed by other data, particularly direct patient interview and informant material.

Factors influencing consistency of triage using the Australasian triage scale : implications for guideline development

Objective: To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale.

Methods: A secondary analysis of survey data was conducted. The main study was undertaken to measure the reliability of 237 scenarios for inclusion in a national training programme. Nurses were recruited from a quota sample of Australian ED according to peer group. Analysis was performed to determine concordance: the percentage of responses in the modal triage category. Analysis of variance (anova) and Pearson correlations were used to investigate associations between the explanatory variables and concordance.

Results: A total of 42/50 (84%) participants returned questionnaires, providing 9946 scenario responses for analysis. Significant differences in concordance were observed by variables describing the type of patient presentation and level of urgency. Mean scores for the comparison group (adult pain; 70.7%) were higher than the groups involving a mental health or pregnancy presentations (61.4%; P≤ 0.001; 65.0%; P= 0.02). Modal responses at the extreme ends of the scale were higher than in the middle categories (P≤ 0.001). There was a significant main effect on concordance by type of service according to peer group (P= 0.03). Of the nine variables that described nurse characteristics, age was the only factor to influence the outcome (P= 0.05).

Conclusion: We identified significant problems with the consistency of triage for mental health and pregnancy presentations. Further research is needed to improve the guidelines on the implementation of the Australasian Triage Scale for these populations.