The influence of severity of personality disorder on outcome of depression is unclear. Four hundred and ten patients with depression in 9 urban and rural communities in Finland, Ireland, Norway, Spain and the United Kingdom, were randomised to individual problem-solving treatment (n = 121), group sessions on depression prevention (n = 106) or treatment as usual (n = 183). Depressive symptoms were recorded at baseline, 6 and 12 months. Personality assessment was performed using the Personality Assessment Schedule and analysed by severity (no personality disorder, personality difficulty, simple personality disorder, complex personality disorder). Complete personality assessments were performed on 301 individuals of whom 49.8% had no personality disorder; 19.3% had personality difficulties; 13.0% had simple personality disorder; and 17.9% had complex personality disorder. Severity of personality disorder was correlated with Beck Depression Inventory (BDI) scores at baseline (Spearman's r = 0.21; p < 0.001), 6 months (r = 0.14; p = 0.02) and 12 months (r = 0.21; p = 0.001). On multi-variable analysis, BDI at baseline (p < 0.001) and type of treatment offered (individual therapy, group therapy, treatment as usual) (p = 0.01) were significant independent predictors of BDI at 6 months. BDI at baseline was the sole significant independent predictor of BDI at 12 months (p < 0.001). There was no interaction between personality disorder and treatment type for depression.

While multi-variable analyses indicate that depressive symptoms at baseline are the strongest predictor of depressive symptoms at 6 and 12 months, the strong correlations between severity of personality disorder and depressive symptoms make it difficult to establish the independent effect of personality disorder on outcome of depression.

Based on background information in this special issue of the journal, possible triage recommendations for the first 4 days following a nuclear detonation, when response resources will be limited, are provided. The series includes: modeling for physical infrastructure damage; severity and number of injuries; expected outcome of triage to immediate, delayed, or expectant management; resources required for treating injuries of varying severity; and how resource scarcity (particularly medical personnel) worsens outcome. Four key underlying considerations are: 1.) resource adequacy will vary greatly across the response areas by time and location; 2.) to achieve fairness in resource allocation, a common triage approach is important; 3.) at some times and locations, it will be necessary to change from “conventional” to “contingency” or “crisis” standards of medical care (with a resulting change in triage approach from treating the “sickest first” to treating those “most likely to survive” first); and 4.) clinical reassessment and repeat triage are critical, as resource scarcity worsens or improves. Changing triage order and conserving and allocating resources for both lifesaving and palliative care can maintain fairness, support symptomatic care, and save more lives. Included in this article are printable triage cards that reflect our recommendations. These are not formal guidelines. With new research, data, and discussion, these recommendations will undoubtedly evolve.

(Disaster Med Public Health Preparedness. 2011;5:S111-S121)

Objective: A pediatric triage tool is needed during times of resource scarcity to optimize critical care utilization. This study compares the modified sequential organ failure assessment score (M-SOFA), the Pediatric Early Warning System (PEWS) score, the Pediatric Risk of Admission Score II (PRISA-II), and physician judgment to predict the need for pediatric intensive care unit (PICU) interventions.

Methods: This retrospective cohort study evaluates three illness severity scores for all non-neonatal pediatric patients transported and admitted to a single center in 2006. The outcome of interest was receipt of a PICU intervention (mechanical ventilation, acute dialysis, depressed consciousness, or persistent hypotension). Predictive ability was assessed using receiver operating curves (ROCs).

Results: Of 752 patients admitted to the hospital, 287 received a PICU intervention. Median scores for all tools were significantly higher for children receiving an intervention than for those who did not. ROCs showed PEWS had the least discriminatory ability, followed by PRISA-II and pediatric M-SOFA. No value of the pediatric M-SOFA produced both positive and negative predictive values better than clinician judgment.

Conclusions: No score had a clinically acceptable discriminate ability to predict patients who required a PICU intervention from those who did not. Physician judgment outperformed all three triage scores.

(Disaster Med Public Health Preparedness. 2012;6:126–130)

Conventional triage algorithms assume unlimited medical resource availability. After a nuclear detonation, medical resources are likely to be particularly limited, suggesting that conventional triage algorithms need to be rethought. To test various hypotheses related to the prioritization of victims in this setting, we developed the model of resource- and time-based triage (MORTT). This model uses information on time to death, probability of survival if treated and if untreated, and time to treat various types of traumatic injuries in an agent-based model in which the time of medical practitioners or materials can be limited. In this embodiment, MORTT focuses solely on triage for surgical procedures in the first 48 hours after a nuclear detonation. MORTT determines the impact on survival based on user-selected prioritization of victims by severity or type of injury. Using MORTT, we found that in poorly resourced settings, prioritizing victims with moderate life-threatening injuries over victims with severe life-threatening injuries saves more lives and reduces demand for intensive care, which is likely to outstrip local and national capacity. Furthermore, more lives would be saved if victims with combined injury (ie, trauma plus radiation >2 Gy) are prioritized after nonirradiated victims with similar trauma.

(Disaster Med Public Health Preparedness. 2011;5:S98-S110)

Background: Patients do not respond to treatment in a predictable manner. Individual preconceptions determine help seeking, compliance and treatment outcome, yet clinicians rarely explore these issues. The illness perception approach sees the patient as an active participant in the healthcare process.

Aims: The aim of this study was to investigate the illness perceptions of people with dysphonia. The subsidiary aims were to correlate the Illness Perception Questionnaire with any psychological distress identified and a self-report measure of dysphonia, and to consider any potential implications for patient management.

Design: Prospective, cross-sectional observation.

Setting: Primary and secondary care, two general and four community hospitals.

Participants: Fifty adult patients with dysphonia due to benign disease completed three self-administered questionnaires, which investigated their illness perceptions, psychological distress and perceptions of the impact of the presenting ‘illness’.

Measures: The dysphonia was categorised as being due to functional (n=40) or organic (n=10) causes. All the voices were rated by an expert listener according to the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale. Participants completed the Illness Perception Questionnaire, the Vocal Performance Questionnaire and the Hospital Anxiety and Depression scale.

Results: Patients showed a wide variation in perception of causation. They had no strong perceptions about the causes, consequences or duration of the presenting dysphonia. Functional dysphonics reported greater consequences, lower perceived control and increased anxiety when compared to patients with organic dysphonia. In terms of cure/control, all patients expected treatment to be helpful but this expectancy reduced as time increased. Anxiety was more associated with functional dysphonia, however, only 17 per cent of the subjects in this group showed clinically significant levels of signs of psychological distress.

Conclusions: Lay illness representations often diverge from the clinician's understanding of the presenting problem and strongly influence treatment behaviour. Early exploration of illness perceptions may enhance health behaviour and maximise the impact of intervention.