'A rose is a rose is a rose', but at-risk criteria differ

Background: Over the last 15 years, efforts to detect psychoses early in their prodromal states have greatly progressed; meanwhile, ultra-high risk (UHR) criteria have been the subject of such consensus that parts of them have been proposed for inclusion in DSM-5 in terms of an attenuated psychosis syndrome. However, it is frequently unacknowledged that the definitions and operationalizations of UHR-related at-risk criteria, including the relevant attenuated psychotic symptoms, vary considerably across centers and time and, thus, between prediction studies. Methods: These variations in UHR criteria are described and discussed with reference to the rates of transition to psychosis, their prevalence in the general population and the proposed new operationalization of the attenuated psychosis syndrome. Results: A comparison of samples recruited according to different UHR operationalizations reveals differences in the distribution of UHR criteria and transition rates as well as in the prevalence rates of at-risk criteria in the general population. Conclusion: The evidence base for the introduction of such a new syndrome is weaker than the number of studies using supposedly equal UHR criteria would at first suggest. Thus, studies comparing the effects of different (sub-)criteria not only on transition rates and outcomes but also on other important aspects, such as neurocognitive performance and brain imaging results, are necessary. Meanwhile, the preliminary attenuated psychosis syndrome in DSM-5 should not follow an altogether new definition but, rather, the currently most reliable UHR definition, which must still demonstrate its reliability and validity outside specialized psychiatric services.

Rationale and first results of developing at-risk (prodromal) criteria for bipolar disorder

Bipolar affective disorder (BD) is a severe, recurrent and disabling disorder with devastating consequences for individuals, families and society. Although these hazards and costs provide a compelling rationale for development of early detection and early intervention strategies in BD, the development of at-risk criteria for first episode mania is still in an early stage of development. In this paper we review the literature with respect to the clinical, neuroantomical and neuropsychological data, which support this goal. We also describe our recently developed bipolar at-risk criteria (BAR). This criteria comprises the peak age range of the first onset of bipolar disorder, genetic risk, presenting with sub-threshold mania, cyclothymic features or depressive symptoms. An initial pilot evaluation of the BAR criteria in 22 subjects indicated conversion rates to proxies of first-episode mania of 23% within 265 days on average, and high specificity and sensitivity of the criteria. If prospective studies confirm the validity of the BAR criteria, then the criteria would have the potential to open up new avenues of research for indicated prevention in BD and might therefore offer opportunities to ameliorate the severity of, or even prevent BD.

Is the metabolic syndrome a new childhood disease?

Overweight and obesity in children and adolescents have become a major public health problem in recent years throughout the world. The medical consequences of obesity may manifest as an increase in the prevalence of the metabolic syndrome in children and adolescents putting them at increased risk for future cardiovascular diseases. Obesity can cause insulin resistance and might disturb glucose homeostasis eventually leading to type 2 diabetes in susceptible patients. Insulin resistance is also involved in the pathogenesis of dyslipidemia in obese children characteristically presenting as hypertriglyceridemia and low HDL cholesterol. Even elevated blood pressure might be present in obese kids. Here we present a 12-year-old boy diagnosed with the metabolic syndrome. The diagnostic criteria of the metabolic syndrome in children and adolescents are discussed. Thoughts about pathophysiology and therapeutic options are offered.

Internet based multicenter study for thoracolumbar injuries: a new concept and preliminary results

This article reports about the internet based, second multicenter study (MCS II) of the spine study group (AG WS) of the German trauma association (DGU). It represents a continuation of the first study conducted between the years 1994 and 1996 (MCS I). For the purpose of one common, centralised data capture methodology, a newly developed internet-based data collection system ( http://www.memdoc.org ) of the Institute for Evaluative Research in Orthopaedic Surgery of the University of Bern was used. The aim of this first publication on the MCS II was to describe in detail the new method of data collection and the structure of the developed data base system, via internet. The goal of the study was the assessment of the current state of treatment for fresh traumatic injuries of the thoracolumbar spine in the German speaking part of Europe. For that reason, we intended to collect large number of cases and representative, valid information about the radiographic, clinical and subjective treatment outcomes. Thanks to the new study design of MCS II, not only the common surgical treatment concepts, but also the new and constantly broadening spectrum of spine surgery, i.e. vertebro-/kyphoplasty, computer assisted surgery and navigation, minimal-invasive, and endoscopic techniques, documented and evaluated. We present a first statistical overview and preliminary analysis of 18 centers from Germany and Austria that participated in MCS II. A real time data capture at source was made possible by the constant availability of the data collection system via internet access. Following the principle of an application service provider, software, questionnaires and validation routines are located on a central server, which is accessed from the periphery (hospitals) by means of standard Internet browsers. By that, costly and time consuming software installation and maintenance of local data repositories are avoided and, more importantly, cumbersome migration of data into one integrated database becomes obsolete. Finally, this set-up also replaces traditional systems wherein paper questionnaires were mailed to the central study office and entered by hand whereby incomplete or incorrect forms always represent a resource consuming problem and source of error. With the new study concept and the expanded inclusion criteria of MCS II 1, 251 case histories with admission and surgical data were collected. This remarkable number of interventions documented during 24 months represents an increase of 183% compared to the previously conducted MCS I. The concept and technical feasibility of the MEMdoc data collection system was proven, as the participants of the MCS II succeeded in collecting data ever published on the largest series of patients with spinal injuries treated within a 2 year period.

Incidence and outcome of chronic graft-versus-host disease using National Institutes of Health consensus criteria

Chronic graft-versus-host disease (cGVHD), a common complication after stem cell transplant (SCT), has an impact on morbidity and survival. Previous classification of cGVHD has not been reproducible or prognostic for nonrelapse mortality (NRM). Recently the National Institutes of Health (NIH) consensus criteria were proposed, but the ability of this classification to predict outcome of various subtypes of cGVHD is unknown. Patients (N = 110) undergoing an SCT for a hematologic malignancy and surviving until day 100 posttransplant from 2001 to 2003 were studied. The overall survival (OS) using a landmark analysis at day 100 was 44% versus 66% (no GVHD vs. GVHD, P = .026). The OS of patients with various types of GVHD as proposed by the NIH criteria were significantly different (P < .0001). In a univariate analyses, this was more apparent when patients with any acute features of GVHD were compared to classic cGVHD (3-year OS 46% vs. 68%, P = .033). The 3-year NRM for the entire cohort was 21%, and was not affected by presence or absence of GVHD or subtypes of GVHD. In a multivariable analysis, extensive cGVHD (hazard ratio [HR] 0.35, P = .015) and having any acute feature of GVHD after day 100 (HR 3.36, P = .0144) were significant independent predictors of survival. The OS with different NIH subtypes of GVHD after day 100 from SCT varies, and is superior for patients with classic cGVHD.

Neoplastic invasion of laryngeal cartilage: reassessment of criteria for diagnosis at MR imaging

PURPOSE: To evaluate whether proposed diagnostic criteria applied to magnetic resonance (MR) images of patients with laryngeal and hypopharyngeal carcinoma may be used to distinguish neoplastic from inflammatory involvement of the laryngeal cartilages. MATERIALS AND METHODS: The radiologic and histopathologic data in 121 consecutive patients with primary squamous cell carcinoma of the larynx (n = 63) or hypopharynx (n = 58) who underwent MR imaging before laryngectomy formed the basis of this retrospective study. Patient consent for retrospective chart review was waived by the institutional review board. All laryngectomy specimens were processed with a dedicated histopathologic whole-organ slice technique. MR images were evaluated by two readers according to established ("old") and proposed ("new") diagnostic criteria on the basis of the signal intensity behavior of cartilage on T2-weighted images and contrast material-enhanced T1-weighted images compared with that of the adjacent tumor. Specifically, with the new criteria, T2-weighted or postcontrast T1-weighted cartilage signal intensity greater than that of the adjacent tumor was considered to indicate inflammation, and signal intensity similar to that of the adjacent tumor was considered to indicate neoplastic invasion. The results of the MR image interpretation were compared with the histologic reference standard. RESULTS: The area under the receiver operating characteristic curve for the new criteria (0.94) was nominally but significantly larger than that for the old criteria (0.92) (P = .01). Overall specificity was significantly improved (82% for new vs 74% for old criteria, P < .001) and was greatest for the thyroid cartilage (75% for new vs 54% for old criteria, P < .001) with the new criteria. The sensitivities of the established and the proposed criteria were identical. CONCLUSION: The proposed MR imaging criteria enable improved differentiation of neoplastic cartilage invasion from peritumoral inflammation.

[New insights into diagnosis and management of gestational diabetes mellitus: recommendations of the Swiss Society for Endocrinology and Diabetes]

Physiology and current knowledge about gestational diabetes which led to the adoption of new diagnostic criterias and blood glucose target levels during pregnancy by the Swiss Society for Endocrinology and Diabetes are reviewed. The 6th International Workshop Conference on Gestational Diabetes mellitus in Pasedena (2008) defined new diagnostic criteria based on the results of the HAPO-Trial. These criteria were during the ADA congress in New Orleans in 2009 presented. According to the new criteria there is no need for screening, but all pregnant women have to be tested with a 75 g oral glucose tolerance test between the 24th and 28th week of pregnancy. The new diagnostic values are very similar to the ones previously adopted by the ADA with the exception that only one out of three values has to be elevated in order to make the diagnosis of gestational diabetes. Due to this important difference it is very likely that gestational diabetes will be diagnosed more frequently in the future. The diagnostic criteria are: Fasting plasma glucose > or = 5.1 mmol/l, 1-hour value > or = 10.0 mmol/l or 2-hour value > or = 8.5 mmol/l. Based on current knowledge and randomized trials it is much more difficult to define glucose target levels during pregnancy. This difficulty has led to many different recommendations issued by diabetes societies. The Swiss Society of Endocrinology and Diabetes follows the arguments of the International Diabetes Federation (IDF) that self-blood glucose monitoring itself lacks precision and that there are very few randomized trials. Therefore, the target levels have to be easy to remember and might be slightly different in mmol/l or mg/dl. The Swiss Society for Endocrinology and Diabetes adopts the tentative target values of the IDF with fasting plasma glucose values < 5.3 mM and 1- and 2-hour postprandial (after the end of the meal) values of < 8.0 and 7.0 mmol/l, respectively. The last part of these recommendations deals with the therapeutic options during pregnancy (nutrition, physical exercise and pharmaceutical treatment). If despite lifestyle changes the target values are not met, approximately 25 % of patients have to be treated pharmaceutically. Insulin therapy is still the preferred treatment option, but metformin (and as an exception glibenclamide) can be used, if there are major hurdles for the initiation of insulin therapy.

Reading on LCD vs e-Ink displays: effects on fatigue and visual strain

Purpose:  Most recently light and mobile reading devices with high display resolutions have become popular and they may open new possibilities for reading applications in education, business and the private sector. The ability to adapt font size may also open new reading opportunities for people with impaired or low vision. Based on their display technology two major groups of reading devices can be distinguished. One type, predominantly found in dedicated e-book readers, uses electronic paper also known as e-Ink. Other devices, mostly multifunction tablet-PCs, are equipped with backlit LCD displays. While it has long been accepted that reading on electronic displays is slow and associated with visual fatigue, this new generation is explicitly promoted for reading. Since research has shown that, compared to reading on electronic displays, reading on paper is faster and requires fewer fixations per line, one would expect differential effects when comparing reading behaviour on e-Ink and LCD. In the present study we therefore compared experimentally how these two display types are suited for reading over an extended period of time. Methods:  Participants read for several hours on either e-Ink or LCD, and different measures of reading behaviour and visual strain were regularly recorded. These dependent measures included subjective (visual) fatigue, a letter search task, reading speed, oculomotor behaviour and the pupillary light reflex. Results:  Results suggested that reading on the two display types is very similar in terms of both subjective and objective measures. Conclusions:  It is not the technology itself, but rather the image quality that seems crucial for reading. Compared to the visual display units used in the previous few decades, these more recent electronic displays allow for good and comfortable reading, even for extended periods of time.

Illegitimate Tasks: Accumulating Evidence for a New Stressor Concept

INTRODUCTION: Task stressors typically refer to characteristics such as not having enough time or resources, ambiguous demands, or the like. We suggest the perceived lack of legitimacy as an additional feature of tasks as a source of stress. Tasks are “illegitimate” to the extent that it is perceived as improper to expect employees to execute them – not because of difficulties in executing them, but because of their content for a given person, time, and situation; they are illegitimate because a) they are not conforming to a specific occupational role, as in “non-nursing activities” (called unreasonable) or b) there is no legitimate need for them to exist (called unnecessary; Semmer et al., 2007). These features make illegitimate tasks a unique task-related stressor. The concept of illegitimate tasks grew from the “Stress-as-Offense-to-Self” theory (SOS; Semmer et al, 2007); it is conceptually related to role stress (Kahn et al., 1964; Beehr & Glazer, 2005) and the organizational justice tradition (Cropanzano et al., 2001; Greenberg, 2010). SOS argues that a threat to one’s self-image is at the core of many stressful experiences. Violating role expectations, illegitimate tasks can be regarded as a special case of role conflict. As roles shape identities, this violation is postulated to constitute a threat to one’s professional identity. Being assigned a task considered illegitimate is likely to be considered unfair. Lack of fairness, in turn, contains a message about one’s social standing, and thus, the self. However, the aspects discussed have not received much attention in the role stress or the justice/fairness tradition. OBJECTIVE: Illegitimate tasks are a rather recent concept that has to be established as a construct in its own right by showing that it is associated with well-being/strain while controlling for other stressors, most notably role conflict and lack of justice. The aim of the presentation is to present the evidence accumulated so far. METHODS AND RESULTS: We present several studies employing different designs, using different control variables, and testing associations with different criteria. Study 1 demonstrates associations of illegitimate tasks with self-esteem, feelings of resentment against one’s organization, and burnout, controlling for distributive justice, role conflict, and social stressors (i.e. tensions). Study 2 yielded comparable results, using the same outcome variables but controlling for distributive as well as procedural / interactional justice. Study 3 demonstrated associations between illegitimate tasks and feelings of stress, sleeping problems, and emotional exhaustion, controlling for demands, control, and social support among medical doctors. Study 4 showed that feeling appreciated by one’s superior acted as a mediator between illegitimate tasks and job satisfaction and resentments towards the military in Swiss military officers. Study 5 demonstrated an association of illegitimate tasks with counterproductive work behavior (Semmer et al. 2010). Studies 1 to 5 were cross-sectional. In Study 6, illegitimate demands predicted irritability and resentments towards one’s organization longitudinally. Study 7 also was longitudinal, focusing on intra-individual variation in multilevel modeling; occasion-specific illegitimate tasks predicted cortisol among those who judged their health as comparatively poor. Studies 1-3 and 6 used SEM, and measurement models that used unreasonable and unnecessary tasks as indicators (isolated parceling) yielded a good fit. IMPLICATIONS & CONCLUSIONS: These studies demonstrate that illegitimate tasks are a stressor in its own right that is worth studying. It illuminates the social meaning of job design, emphasizing the implications of tasks for the (professional) self, and thus combining aspects that are traditionally treated as separate, that is, social aspects and task characteristics. Practical implications are that supervisors and managers should be alerted to the social messages that may be contained in task assignments (cf. Semmer & Beehr, in press).

The epidemiology of chronic fatigue in San Francisco

Chronic fatigue syndrome (CFS) is a recently defined condition characterized by severe disabling fatigue that persists for a minimum of six months, and a host of somatic and neurocognitive symptoms. Although conditions similar to CFS have been described in the medical literature for over 100 years, little is known about the epidemiology of CFS or of chronic fatigue generally. The San Francisco Fatigue Study was undertaken to describe the prevalence and characteristics of self-reported chronic fatigue and associated conditions in a diverse urban community. The study utilized a cross-sectional telephone survey of a random sample of households in San Francisco, followed by case/control interviews of fatigued and nonfatigued subjects. Respondents were classified as chronically fatigued (CF) if they reported severe fatigue lasting six months or longer, then further classified as having CFS-like illness if, based on self-reported information, their condition appeared to meet CFS case definition criteria. Subjects who reported idiopathic chronic fatigue that did not meet CFS criteria were classified as having ICF-like illness.^ 8004 households were screened, yielding fatigue and demographic information on 16970 residents. CF was reported by 635 persons, 3.7% of the study population. CFS-like illness was identified in 34 subjects (0.2%), and ICF-like illness in 259 subjects (1.6%). Logistic regression analysis indicated that prevalence odds ratios for CFS-like illness were significantly elevated for females compared to males (OR = 2.9), and in Blacks (OR = 2.9) and Native Americans (OR = 13.2) relative to Whites, but significantly lower in Asians (OR = 0.12). Above-average household income was protective for all categories of CF. CFS-like subjects reported more symptoms and were more severely disabled than ICF-like subjects, but the pattern of symptoms experienced by both groups was similar. In conclusion, unexplained chronic fatigue, including CFS-like illness, occurs in all sociodemographic groups, but may be most prevalent among persons with lower incomes and in some racial minorities. Future studies that include clinical evaluation of incident cases of CFS and ICF are required to further clarify the epidemiology of unexplained chronic fatigue in the population. ^

A new method to facilitate valid and consistent grading cardiac events in childhood cancer survivors using medical records

BACKGROUND Cardiac events (CEs) are among the most serious late effects following childhood cancer treatment. To establish accurate risk estimates for the occurrence of CEs it is essential that they are graded in a valid and consistent manner, especially for international studies. We therefore developed a data-extraction form and a set of flowcharts to grade CEs and tested the validity and consistency of this approach in a series of patients. METHODS The Common Terminology Criteria for Adverse Events version 3.0 and 4.0 were used to define the CEs. Forty patients were randomly selected from a cohort of 72 subjects with known CEs that had been graded by a physician for an earlier study. To establish whether the new method was valid for appropriate grading, a non-physician graded the CEs by using the new method. To evaluate consistency of the grading, the same charts were graded again by two other non-physicians, one with receiving brief introduction and one with receiving extensive training on the new method. We calculated weighted Kappa statistics to quantify inter-observer agreement. RESULTS The inter-observer agreement was 0.92 (95% CI 0.80-1.00) for validity, and 0.88 (0.79-0.98) and 0.99 (0.96-1.00) for consistency with the outcome assessors who had the brief introduction and the extensive training, respectively. CONCLUSIONS The newly developed standardized method to grade CEs using data from medical records has shown excellent validity and consistency. The study showed that the method can be correctly applied by researchers without a medical background, provided that they receive adequate training.

Persistence of ultrasound synovitis in patients with rheumatoid arthritis fulfilling the DAS28 and/or the new ACR/EULAR RA remission definitions: results of an observational cohort study.

OBJECTIVE The primary aim of the study was to evaluate whether rheumatoid arthritis (RA) patients considered to be in remission according to clinical criteria sets still had persisting ultrasound (US) synovitis. We further intended to evaluate the capacity of our US score to discriminate between the patients with a clinically active disease versus those in remission. METHODS This is an observational study nested within the Swiss Clinical Quality Management in Rheumatic Diseases (SCQM) rheumatoid arthritis cohort. A validated US score (SONAR score) based on a semi-quantitative B-mode and Doppler (PwD) score as part of the regular clinical workup by rheumatologists in different clinical settings was used. To define clinically relevant synovitis, the same score was applied to 38 healthy controls and the 90st percentile was used as cut-off for 'relevant' synovitis. RESULTS Three hundred and seven patients had at least one US examination and concomitant clinical information on disease activity. More than a third of patients in both DAS28 and ACR/EULAR remission showed significant gray scale synovitis (P=0.01 and 0.0002, respectively) and PwD activity (P=0.005 and 0.0005, respectively) when compared to controls. The capacity of US to discriminate between the two clinical remission groups and patients with active disease was only moderate. CONCLUSION This observational study confirms that many patients considered to be in clinical remission according the DAS and the ACR/EULAR definitions still have residual synovitis on US. The prognostic significance of US synovitis and the exact place of US in patients reaching clinical remission need to be further evaluated.