MyRisk_Stroke Calculator: A Personalized Stroke Risk Assessment Tool for the General Population

Background and Purpose

There is a variety of stroke risk factors, and engaging individuals in reducing their own personal risk is hugely relevant and could be an optimal dissemination strategy. The aim of the present study was to estimate the stroke risk for specific combinations of health- and lifestyle-related factors, and to develop a personalized stroke-risk assessment tool for health professionals and the general population (called the MyRisk_Stroke Calculator).

Methods

This population-based, longitudinal study followed a historical cohort formed from the 1992 or 1998 Santé Québec Health Surveys with information for linkage to health administrative databases. Stroke risk factors were ascertained at the time of survey, and stroke was determined from hospitalizations and death records. Cox proportional hazards models were used, modeling time to stroke in relationship to all variables.

Results

A total of 358 strokes occurred among a cohort of 17805 persons (men=8181) who were followed for approximately 11 years (i.e., -200000 person-years). The following regression parameters were used to produce 10-year stroke-risk estimates and assign risk points: for age (1 point/year after age 20 years), male sex (3 points), low education (4 points), renal disease (8 points), diabetes (7 points), congestive heart failure (5 points), peripheral arterial disease (2 points), high blood pressure (2 points), ischemic heart disease (1 point), smoking (8 points), >7 alcoholic drinks per week (3 points), low physical activity (2 points), and indicators of anger (4 points), depression (4 points), and anxiety (3 points). According to MyRisk_Stroke Calculator, a person with <50, 75, and 90 risk points has a 10-year stroke risk of <3%, 28%, and >75%, respectively.

Conclusions

The MyRisk_Stroke Calculator is a simple method of disseminating information to the general population about their stroke risk.     

Risk axis: Implementation of structured clinical guidelines for the assessment and management of risk in psychiatry

Introduction: Mental health clinicians routinely assess risk in three domains: suicide, violence and self neglect. While the published work on the assessment of these risks has increased, concerns are often expressed that assessment alone does not lead to management of the identified risk. Not all axes of multiaxial classificatory systems are used by clinicians to the same extent, despite their proven usefulness. It is possible that a dedicated axis for risk management as a part of a multiaxial classificatory system could align risk assessment with management and increase utility of multiaxial classificatory systems. Methods: Based on our earlier work we developed a comprehensive risk management axis (RMA), which was then further refined by conducting a pilot study and then used to collect data retrospectively from the case notes of 100 patients consecutively discharged from a general psychiatric ward. Results: Common association between risk factors and three risk domains were as follows. Violence: active symptoms of major mental illness, employment problems, and major mental illness; Suicide: history of abuse, clinically significant depressive symptoms, and alcohol and drug use; Self neglect: neglect of home, personal safety, noncompliance with treatment, male gender, and low income. We also investigated whether the presence of a particular risk factor acted as a barrier or prompt for clinicians to address management factors in the RMA. Discussion: It is possible to assess risk across the three domains and to derive management plans by using the proposed RMA. Minimal clinical background is necessary for collecting data retrospectively. It should be possible to apply this axis prospectively.     

Identification and characterization of prodromal risk syndromes in young adolescents in the community: a population-based clinical interview study

While a great deal of research has been conducted on prodromal risk syndromes in relation to help-seeking individuals who present to the clinic, there is a lack of research on prodromal risk syndromes in the general population. The current study aimed first to establish whether prodromal risk syndromes could be detected in non-help-seeking community-based adolescents and secondly to characterize this group in terms of Axis-1 psychopathology and general functioning. We conducted in-depth clinical interviews with a population sample of 212 school-going adolescents in order to assess for prodromal risk syndromes, Axis-1 psychopathology, and global (social/occupational) functioning. Between 0.9% and 8% of the community sample met criteria for a risk syndrome, depending on varying disability criteria. The risk syndrome group had a higher prevalence of co-occurring nonpsychotic Axis-1 psychiatric disorders (OR = 4.77, 95% CI = 1.81-12.52; P < .01) and poorer global functioning (F = 24.5, df = 1, P < .0001) compared with controls. Individuals in the community who fulfill criteria for prodromal risk syndromes demonstrate strong similarities with clinically presenting risk syndrome patients not just in terms of psychotic symptom criteria but also in terms of co-occurring psychopathology and global functioning.     

三种常用危险度测量方法之间的关系：相对危险度、危险差和比值比

概述：相对危险度(relative risk)、危险差(risk difference)和比值比(odds ratio)是最常用的三种比较不同群体之间疾病风险的方法。虽然它们在生物医学和社会心理学研究中广泛流行,但是尚无文献明确这三种方法之间的关系。许多研究人员误以为它们之间的关系是单调变化的,即某种测量方式中较高（或较低）的值与其它测量方式中的较高（或较低）的值相关。本文中,我们讨论了三个定理,并提供例子解释之前大部分研究人员所认为这三种方法之间的关系是不对的;这些测量方法相互之间并没有逻辑关系。研究人员在说明不同种测量方法之间的相关性时或结合使用不同种风险测量方法所得的研究结果时必须非常谨慎。     

Early detection of risk factors for seclusion and restraint: a prospective study

Aim: The study aims to examine the predictive power of static and dynamic risk factors assessed at admission to an acute psychiatric ward and to develop a prediction model evaluating the risk of seclusion and restraint. Methods: Over 20 months, data on demographic and clinical characteristics, psychosocial functioning, level of insight, uncooperativeness, and use of coercive measures were collected prospectively on 520 patients at admission. Logistic regression analysis was used to develop a prediction model. The magnitude of the predictive power of this model was estimated using receiver operating characteristic analysis. Results: The prediction model contained one static predictor (involuntary commitment) and two dynamic predictors (psychological impairment and uncooperativeness), with a high predictive power (receiver operating characteristic area under the curve = 0.83). The final risk model classified 72% of the patients correctly, with a higher sensitivity rate (80%) than specificity rate (71%). Conclusion: Early assessment of patients' psychological impairment and uncooperativeness can help clinicians to recognize patients at risk for coercive measures and approach them on time with preventive and less restrictive interventions. Although this simple, highly predictive model accurately predicts the risk of seclusion or restraint, further validation studies are needed before it can be adopted into routine clinical practice.     

L’impulsivité est-elle liée aux risques de récidive sexuelle,violente et générales des auteurs d’infractions à caractère sexuel d’enfants et d’adultes ?

Scales to assess an offender's risk of re-offending are based on risk factors. Impulsivity is often considered as treatment targets to prevent recidivism in sexual offenders. But the link between impulsivity and recidivism is barely detailed or contradictory. This study tries to examine these links in child's molesters and sexual offenders of adults.MethodIn all, 33 incarcerated adult male sexual offenders were having been divided in two groups: 25 sexual offenders of children and 8 sexual offenders of adults. Sexual offenders of children were assessed using the Static-2002, RSVP and UPPS and sexual offenders of adults were assessing using RSVP, HCR-20, LS/CMI and UPPS. Non-parametric correlation analyses (Spearman's Rho) were performed.Results–DiscussionFor child's molesters, Urgency showed positive relationships with sexual risk, referring to the emotional sensitivity of sexual offenders in social situations. Surprisingly, Sensation seeking was negatively related to sexual risk, which could be explained by the seriousness of the offences committed. For sexual offenders of adults, impulsivity sub-domains Lack of premeditation, Urgency and Sensation seeking show strong links with the risk of general recidivism and in particular the factors associated with Education and employment, Leisure and recreational activities and Alcohol and drug problems. A reflection on the evaluation of individual situational factors in interaction with psychological factors of high-risk sexual offenders is developed.     

Prognosis and Treatment of eizures in Children with Acute Lymphoblastic Leukemia

Summary: We reviewed the records of 127 consecutive pediatric patients with acute lymphoblastic leukemia (ALL) to determine the incidence, timing, etiologies, and recurrence rate of seizures in this population. Patients with ALL and seizures were identified retrospectively by review of the records of all pediatric ALL patients who were diagnosed and treated during the years 1983 through March 1993 in a large tertiary-care hospital. Seventeen patients (13%) developed one or more seizures. In 16 patients, seizures occurred during antileukemic treatment, and in almost all of them seizures were related to intrathecal methotrexate (IT MTX) or subcutaneous L-asparaginase treatment. One patient who developed a seizure while not receiving chemotherapy had a history of cerebral infarctions. In 8 patients, 47%), the initial seizure episode was associated with a cerebral lesion. One or more seizures recurred in 6 patients. Four of these patients had an isolated recurrence, in 3 patients %ge;3 months and in 1 patient >6 months after the initial event. Two patients (12%) with static encephalopathy and neurological deficits developed a chronic seizure disorder. There is a significant risk of acute symptomatic seizures in pediatric ALL patients. Most seizures in these patients occur during the acute treatment phase and are most frequently related to side effects of chemotherapy. The longterm recurrence risk is low; recurrence occurs most often in patients with evidence of cerebral structural lesions and neurological deficits. Long-term antiepileptic drug (AED) therapy should be restricted to such patients.     

Predictors of Historical Clinical Risk Management-20 Version 3 (HCR–20:V3) summary risk ratings

How individual risk factors on structured professional judgement (SPJ) assessment tools translate into SPJ final risk formulations is unclear due to a lack of structured criteria. Understanding pathways to risk formulations is vital, as they serve as intervention targets for risk management. This study examined how Historical Clinical Risk Management-20 Version 3 (HCR–20:V3) raters weighed varied information sources to complete summary risk ratings (SRRs). Four independent raters retrospectively coded an archived sample of 32 inpatients at a Canadian forensic psychiatric hospital. HCR–20:V3 SPJ SRRs were regressed on the 20 individual items and sample covariates to identify unique predictors of risk formulations across each rater. Raters consistently used HCR–20:V3 items and composite subscales for SRRs. Despite strong inter-rater agreement on the SRRs, there were variations across raters regarding which items informed each SRR. Rater-unique biases were also shown to influence SRRs. Implications for forensic practice and risk management are discussed.     

Maladaptive schemas as a mediator between social defeat and positive symptoms in young people at clinical high risk for psychosis

Aim: Social defeat may be the mechanism that links past social adversities with the development of psychosis. In depression research, it is accepted that adverse early social experiences can lead to enduring cognitive vulnerabilities, characterized by negative schemas about the self and others. The aim of this study was to examine whether negative beliefs about the self and others link social defeat to early signs of psychosis. Methods: Data from a sample of individuals at high risk for developing psychosis (n = 38) were assessed using measures of social defeat and schemas. Results: High levels of social defeat and negative evaluations of the self and others were displayed. Negative beliefs mediated the relationship between social defeat and early symptoms, offering some support for the notion that maladaptive self‐beliefs play a role in the onset of psychosis. Conclusions: These results have implications for prevention because these maladaptive schemas are malleable factors for which we have effective psychological interventions.     

Dangerous Children: Assessment and Management of Risk

Background:  Workers in the field of child health appear to be presented with increasing numbers of young people who exhibit behaviours that pose a potential or actual risk to the safety of others.
Method:  A review of the current literature on the assessment and management of these children and adolescents was conducted.
Results:  A history taking check-list has been devised on the basis of what is known about current associations with background and current factors and violent acts directed to others. There is emerging evidence of interventions that may be effective in reducing long-term risks in such youths. However, these are often resource intensive and may be less effective in older children and adolescents.
Conclusions:  Faced with the challenge of assessing and managing severely conduct disordered children, child and family mental health teams should develop formalised assessment procedures and protocols for managing risk factors in a multi-agency context.     

Criminal Engagement and Australian Culturally and Linguistically Diverse Populations: Challenges and Implications for Forensic Risk Assessment

There is a growing need for effective cross-cultural forensic health service delivery as Australia's population becomes increasingly diverse. The fastest growing migrant populations are of Culturally and Linguistically Diverse (CALD) origin and many refugees resettle in Australia through humanitarian intake programmes. As such it is important to ascertain whether there are cultural differences across factors that may directly or indirectly increase engagement in criminal behaviour. Similarly the applicability of violence risk instruments to Australian CALD populations is heavily under-researched and requires attention. This review addresses both key issues in an Australian context. Key risk items that may impact upon the criminal involvement of Australian CALD populations are identified and a review of violence risk studies with CALD populations is performed. Findings are discussed in view of a growing need for systemic cultural competence in the forensic health sector.     

Multiple modifiable risk factors for first ischemic stroke: a population-based epidemiological study

The aims of this epidemiological population-based cohort study were to examine the prevalence of the multiple modifiable vascular risk factors, their distribution patterns and outcomes among a Bulgarian urban population. A total of 500 volunteers, 200 men and 300 women, without clinical signs and symptoms of cerebrovascular disease, aged 50-79 years, were enrolled in the study. A structured questionnaire, physical examination, electrocardiogram records, a battery of laboratory tests and carotid duplex scanning were employed. Three or more modifiable vascular risk factors were detected in 52% (260/500) of the subjects. Dyslipidemias, hypertension, obesity, cigarette smoking and cardiac diseases were found to be the most prevalent single risk factors. Asymptomatic carotid stenosis (ACS) of 50% or greater was detected in 8.8% (23/260) of the volunteers examined. After a 2-year follow-up, 2.7% (7/260) of the persons with modifiable vascular risk factors reached the end point transient ischemic attacks (TIAs), ischemic stroke and myocardial infarction. The following combinations of risk factors among the subjects enrolled in the study were significantly associated with these outcomes: hypertension and cardiac diseases (OR = 6.82; 95% CI, 1.21-38.41), cardiac diseases and obesity (OR = 6.13; 95% CI, 1.27-29.72), ACS and high low-density lipoprotein (LDL) cholesterol levels (OR = 11.11; 95% CI, 1.58-78.29). The identification of subjects with multiple vascular risk factors may be important for primary medical or surgical stroke prevention.     

The role of vascular risk factors in late onset bipolar disorder

BACKGROUND: The association between late life depression and cerebro-vascular risk and cerebro-vascular disease is well established. Do similar links exist with late onset bipolar disorder? AIMS AND OBJECTIVES: Patients with early onset (less than 60 years of age) bipolar disorder were compared with those of late onset (aged 60 and above) in relation to cognitive function, physical health and vascular risk factors. METHOD: Cross-sectional survey of elderly bipolar disorder patients (above 65 years) involved with secondary care mental health services. Thirty patients with early onset were compared with 20 patients with a late onset bipolar disorder. Diagnosis of bipolar disorder was according to ICD-10 criteria and without an associated clinical diagnosis of dementia. Assessment of cognition included tests of frontal-executive function, and cerebro-vascular risk was quantified with the Framingham stroke risk score. RESULTS: The late onset group had a higher stroke risk score than the early onset group, this difference persisting despite taking age and gender differences into account. However, late onset patients' cognitive function (including frontal lobe tests) and physical health status was no different to the early onset group. CONCLUSION: There is higher 'cerebrovascular risk' in elderly patients with late onset bipolar disorder, compared to patients with an early onset. This suggests that cerebrovascular risk may be an important factor for the expression of bipolar disorders in later life, and has significant management implications for older bipolar patients.