Background-The Diabetes Prevention Program (DPP) found that an intensive lifestyle intervention can reduce the development of diabetes by more than half in adults with prediabetes, but there is little information about the feasibility of offering such an intervention in community settings. This study evaluated the delivery of a group-based DPP lifestyle intervention in partnership with the YMCA.

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Background and Purpose-The purpose of this study was to examine the performance of the Patient Health Questionnaire (PHQ)-9, a 9-item depression scale, as a screening and diagnostic instrument for assessing depression in stroke survivors. Methods-As part of a randomized treatment trial for poststroke depression (PSD), subjects with and without PSD completed the PHQ-9, a 9-item summed scale, with scores ranging from 0 (no depressive symptoms) to 27 (all symptoms occurring daily). Subjects endorsing 2 or more symptoms of depression were administered the criterion standard Structured Clinical Interview for Depression (SCID). Receiver operating characteristic analysis was used to examine the sensitivity and specificity of the PHQ-9 Results-Of 316 subjects enrolled, 145 met SCID criteria for major depression or other depressive disorder, and 171 were not depressed. PHQ-9 scores discriminated well between subjects with any versus no depressive disorder, with an area under the curve (AUC) of 0.96, as well as between subjects with and without major depression (AUCϭ0.96). The AUC was similar regardless of patient age, gender, or ethnicity. A PHQ-9 score Ն10 had 91% sensitivity and 89% specificity for major depression, and 78% sensitivity and 96% specificity for any depression diagnosis. Conclusions-The PHQ-9 performs well as a brief screener for PSD with operating characteristics similar or superior to other depression measures and similar to its characteristics in a primary care population. Moreover, PHQ-9 scores discriminate equally well between those with and without PSD regardless of age, gender, or ethnicity. Key Words: depression Ⅲ stroke P oststroke depression (PSD) affects approximately onethird of ischemic stroke survivors, is often undiagnosed and inadequately treated, and is associated with increased morbidity and mortality after stroke. 1-4 Depression screening after stroke is thus important but can be complicated by cognitive and physical symptoms of stroke that may introduce additional variability in assessment of depressive symptoms and depression diagnosis. Although several established depression screening instruments have been validated in stroke cohorts, 5-10 these scales can be burdensome for patients to complete, require a trained interviewer to administer, and often are designed only for screening and not as a diagnostic depression tool. The Patient Health Questionnaire 9-item depression scale (PHQ-9) is a 9-item self-administered depression screening and diagnostic tool increasingly used in primary care and other medical populations. 11,12 Although it has excellent measurement properties in other settings, it has not been previously validated in patients with PSD. The purpose of this study was to examine the performance of the PHQ-9 as a screening and diagnostic instrument for assessing depression in ischemic stroke survivors. Subjects and MethodsSubjects were patients enrolled in the National Institute for Neurologic Disorders and Stroke-funded AIM (Activate, Initiate treatment, Monitor) PSD study....

Background and Purpose-Proxy respondents are often needed to report outcomes in stroke survivors, but they typically systematically rate impairments worse than patients themselves. The magnitude of this difference, the degree of agreement between patients and proxies, and the factors influencing agreement are not well known. Methods-We compared patient and family proxy health-related quality of life (HRQL) responses in 225 patient-proxy pairs enrolled in a clinical trial for poststroke depression. We used paired t-tests and the intraclass correlation (ICC) statistic to evaluate the agreement between patient and proxy domain scores and the overall Stroke-specific Quality of Life (SS-QOL) score. We used multivariate linear regression to model patient-and proxy-reported SS-QOL scores. Results-Patients were older (63 versus 55 years) and less often female (48% versus 74%) than proxies. Proxies rated all domains of SS-SQOL slightly worse than patients. The Mood, Energy, and Thinking domains had the greatest disparity with mean patient-proxy differences of 0.45, 0.37, and 0.37 points, respectively. The ICC for each domain ranged from 0.30 (role function) to 0.59 (physical function). Proxy overall SS-QOL score was also lower (worse) than patient score (3.7 versus 3.4, PϽ0.001) with ICC of 0.41. Agreement was higher among patient-proxy pairs with higher patient depression scores and with lower proxy report of caregiving burden. Conclusions-Proxies systematically report more dysfunction in multiple aspects of HRQL than stroke patients themselves. Agreement between patient and proxy HRQL domain scores is modest at best and is affected by patient depression and proxy perception of burden. These differences may be large enough to impact the outcome assessment in stroke clinical trials.

These findings support careful monitoring for relapse in patients receiving voriconazole treatment for histoplasmosis, particularly in those who were previously treated with fluconazole.

Subsequent STI frequently follow an initial STI, but there is substantial variation in the causal organism. These data suggest the importance of comprehensive STI prevention programs for adolescents rather than organism-specific interventions.

Background and Purpose-Poststroke depression is a prevalent and disabling disorder, yet evidence regarding the effectiveness of treating poststroke depression is inconclusive. Our objective was to determine the effectiveness of the Activate-Initiate-Monitor care management program for the treatment of poststroke depression. Methods-We conducted a prospective, randomized, outcome-blinded trial in 188 ischemic stroke survivors identified at the time of admission to one of 4 Indianapolis hospitals. Depression screening and enrollment occurred between 1 and 2 months poststroke. The Activate-Initiate-Monitor intervention was a care management program that included Activation of the patient to recognize depression symptoms and accept treatment, Initiation of an antidepressant medication, and Monitoring and adjusting treatment. Usual care subjects received nondepression-related education and were prescribed antidepressants at the discretion of their provider. The primary outcome measure was depression response, defined as a Hamilton Depression Inventory score Ͻ8 (remission) or a decrease from baseline of at least 50% at 12 weeks. Results-Intervention and usual care groups did not differ on any key baseline measures. Both depression response (51% versus 30%, Pϭ0.005) and remission (39% versus 23%, Pϭ0.01) were more likely in the Activate-Initiate-Monitor intervention than in the usual care group. This difference in depression scores was present by 6 weeks and persisted through the 12-week assessment. Serious adverse events did not differ between the 2 groups. Conclusion-The Activate-Initiate-Monitor care management model is significantly more effective than usual care in improving depression outcomes in patients with poststroke depression.

This study was conducted to test the hypothesis that physiological changes which occur during aging increase the biological impact of fluoride and reduce the threshold of safe fluoride exposure. Four groups of rats were fed a low-fluoride diet (< 1.2 ppm) ad libitum and received 0, 5, 15, or 50 ppm fluoride in their drinking water. Animals were killed after three, six, 12, or 18 months of treatment. Blood and urine were monitored for biochemical markers of tissue function, and plasma, urine, feces, and representative tissues were analyzed for fluoride. In addition, bone marrow cells from animals killed after 18 months of treatment were examined for frequency of sister chromatid exchange (SCE), a marker of genetic damage. Study results indicated that, within treatment groups, fluoride intake, excretion, and retention did not change significantly between three and 18 months. Fluoride concentration in soft tissues did not change with treatment duration in the fluoride-treated animals. Mineralized tissue fluoride concentration and the total fluoride in the carcasses increased continually as the animals aged. In spite of significant, dose-related differences in tissue fluoride levels which occurred in all age groups in this study, there were no indications that increased fluoride in the tissues caused any adverse physiological or genotoxic effects. None of the monitored clinical "wellness" markers of tissue integrity and function was altered by fluoride in a clinically significant manner. Therefore, there was no evidence from this study that aging reduces the threshold of safe chronic fluoride exposure.