Depressive symptom clusters are differentially associated with atherosclerotic disease

2010 ◽  
Vol 41 (7) ◽  
pp. 1419-1428 ◽  
Author(s):  
B. A. A. Bus ◽  
R. M. Marijnissen ◽  
S. Holewijn ◽  
B. Franke ◽  
N. Purandare ◽  
...  
Keyword(s):  
Depressive Symptoms ◽  
Depressive Symptom ◽  
Symptom Clusters ◽  
Symptom Cluster ◽  
Cardiac Patients ◽  
Depression Symptom ◽  
Vascular Events ◽  
Affective Symptom ◽  
Affective Symptoms ◽  
Sum Score

BackgroundDepression increases the risk of subsequent vascular events in both cardiac and non-cardiac patients. Atherosclerosis, the underlying process leading to vascular events, has been associated with depression. This association, however, may be confounded by the somatic-affective symptoms being a consequence of cardiovascular disease. While taking into account the differentiation between somatic-affective and cognitive-affective symptoms of depression, we examined the association between depression and atherosclerosis in a community-based sample.MethodIn 1261 participants of the Nijmegen Biomedical Study (NBS), aged 50–70 years and free of stroke and dementia, we measured the intima–media thickness (IMT) of the carotid artery as a measure of atherosclerosis and we assessed depressive symptoms using the Beck Depression Inventory (BDI). Principal components analysis (PCA) of the BDI items yielded two factors, representing a cognitive-affective and a somatic-affective symptom cluster. While correcting for confounders, we used separate multiple regression analyses to test the BDI sum score and both depression symptom clusters.ResultsWe found a significant correlation between the BDI sum score and the IMT. Cognitive-affective, but not somatic-affective, symptoms were also associated with the IMT. When we stratified for coronary artery disease (CAD), the somatic-affective symptom cluster correlated significantly with depression in both patients with and patients without CAD.ConclusionsThe association between depressive symptoms and atherosclerosis is explained by the somatic-affective symptom cluster of depression. Subclinical vascular disease thus may inflate depressive symptom scores and may explain why treatment of depression in cardiac patients hardly affects vascular outcome.

scholarly journals Identifying classes of the pain, fatigue, and depression symptom cluster in long-term prostate cancer survivors—results from the multi-regional Prostate Cancer Survivorship Study in Switzerland (PROCAS)

2021 ◽  
Author(s):  
Salome Adam ◽  
Melissa S. Y. Thong ◽  
Eva Martin-Diener ◽  
Bertrand Camey ◽  
Céline Egger Hayoz ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Depressive Symptoms ◽  
Cancer Survivorship ◽  
Latent Class ◽  
Multinomial Logistic Regression ◽  
Symptom Cluster ◽  
Depression Symptom ◽  
Class 1 ◽  
Eortc Qlq

Abstract Purpose Aside from urological and sexual problems, long-term (≥5 years after initial diagnosis) prostate cancer (PC) survivors might suffer from pain, fatigue, and depression. These concurrent symptoms can form a cluster. In this study, we aimed to investigate classes of this symptom cluster in long-term PC survivors, to classify PC survivors accordingly, and to explore associations between classes of this cluster and health-related quality of life (HRQoL). Methods Six hundred fifty-three stage T1-T3N0M0 survivors were identified from the Prostate Cancer Survivorship in Switzerland (PROCAS) study. Fatigue was assessed with the EORTC QLQ-FA12, depressive symptoms with the MHI-5, and pain with the EORTC QLQ-C30 questionnaire. Latent class analysis was used to derive cluster classes. Factors associated with the derived classes were determined using multinomial logistic regression analysis. Results Three classes were identified: class 1 (61.4%) – “low pain, low physical and emotional fatigue, moderate depressive symptoms”; class 2 (15.1%) – “low physical fatigue and pain, moderate emotional fatigue, high depressive symptoms”; class 3 (23.5%) – high scores for all symptoms. Survivors in classes 2 and 3 were more likely to be physically inactive, report a history of depression or some other specific comorbidity, be treated with radiation therapy, and have worse HRQoL outcomes compared to class 1. Conclusion Three distinct classes of the pain, fatigue, and depression cluster were identified, which are associated with treatment, comorbidities, lifestyle factors, and HRQoL outcomes. Improving classification of PC survivors according to severity of multiple symptoms could assist in developing interventions tailored to survivors’ needs.

scholarly journals Extracellular vesicle associated and soluble immune marker profiles of psychoneurological symptom clusters in men with prostate cancer: an exploratory study

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Dilorom Sass ◽  
Leorey Saligan ◽  
Wendy Fitzgerald ◽  
Ann M. Berger ◽  
Isaias Torres ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Depressive Symptoms ◽  
Sleep Disturbances ◽  
Metastatic Prostate Cancer ◽  
Extracellular Vesicle ◽  
Symptom Clusters ◽  
Symptom Cluster ◽  
External Beam Radiation ◽  
Immune Markers ◽  
Bivariate Correlation

AbstractPsychoneurological symptom clusters are co-occurring and interrelated physiological symptoms that may include cancer-related fatigue, pain, depressive symptoms, cognitive disturbances, and sleep disturbances. These symptoms are hypothesized to share a common systemic proinflammatory etiology. Thus, an investigation of systemic immune biomarkers is an important approach to test this hypothesis. Here, we investigated the associations between extracellular vesicle (EV)-associated and soluble cytokines with immune markers and symptom clusters in men with non-metastatic prostate cancer. This observational study included 40 men with non-metastatic prostate cancer at the start (T1) of external beam radiation therapy (EBRT) and 3 months post treatment (T2), as well as 20 men with non-metastatic prostate cancer on active surveillance (AS) seen at one time point. Collected questionnaires assessed patient-reported fatigue, sleep disturbances, depressive symptoms, and cognitive fatigue. In total, 45 soluble and EV-associated biomarkers in plasma were determined by multiplex assays. Principal component analysis (PCA) was used to identify psychoneurological symptom clusters for each study group and their time points. Bivariate correlation analysis was run for each identified PCA cluster with the concentrations of EV-associated and soluble cytokines and immune markers. Both EV-associated and soluble forms of RANTES significantly correlated with the symptom cluster for EBRT at T1, whereas, at T2, soluble IFNα2, IL-9, and IL-17 correlated with the corresponding symptom cluster. For the AS group, soluble survivin correlated with psychoneurological symptoms. Linking specific inflammatory cytokines with psychoneurological symptom clusters in men receiving prostate cancer treatment can enhance understanding of the underlying mechanisms of this phenomenon and aid in developing targeted interventions.

Abstract TMP48: Longitudinal Course of Depressive Symptoms Following Stroke: Preliminary Results From the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Emily Goldmann ◽  
Bernadette Boden-Albala
Keyword(s):  
Depressive Symptoms ◽  
Depressive Symptom ◽  
Multinomial Logistic Regression ◽  
Group Model ◽  
Stroke Patients ◽  
Vascular Events ◽  
Targeted Interventions ◽  
Longitudinal Course ◽  
Symptom Level ◽  
Clinically Significant

It is well-established that depression is common after stroke. Much less is known about the longitudinal course of depressive symptoms in stroke survivors. Data for this study came from the DESERVE trial of a skills-based intervention to reduce vascular risk in mild/moderate stroke/TIA patients. Depressive symptoms were assessed at baseline (pre-discharge), 6 months and 1 year post-discharge using the Center for Epidemiologic Studies - Depression (CES-D) scale. Discrete mixture models identified distinct trajectories of depressive symptom severity over time and assigned patients to trajectory groups. We ran Poisson models using linear and quadratic parameters and chose the best-fitting model based on Bayesian information criterion and interpretability. Associations between baseline characteristics and trajectory group membership were examined using ANOVA and bivariable multinomial logistic regression. So far, 285 patients completed all three study waves and ≥ 1 depression assessment. A four-group model was selected: 1) resistance - low depressive symptom level at all waves (50% of patients); 2) delayed - low baseline symptom level, increasing to clinically significant levels (CES-D > 16) by 6 months, remaining high at 1 year (18%); 3) recovery - clinically significant baseline symptom levels, dropping to low levels by 6 months, remaining low at 1 year (22%); 4) chronic - severe symptoms at all waves (10%). Hispanic patients had greater odds of delayed symptoms vs. resistance compared to non-Hispanics. Moderate stroke patients had greater odds of delayed and chronic symptoms vs. resistance compared to mild stroke patients. Patients with stroke history had greater odds of delayed symptoms and recovery vs. resistance compared to those without; those with psychiatric history had greater odds of recovery and chronic symptoms vs. resistance compared to those without. Those with chronic symptoms had significantly greater baseline disability compared to other groups. The course of post-stroke depressive symptoms is heterogeneous and associated with race/ethnicity and several clinical factors. Targeted interventions may be required to prevent the development of depression and address chronic symptoms that may interfere with stroke recovery.

scholarly journals Trajectories of depression in sepsis survivors: an observational cohort study

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Monique Boede ◽  
Jochen S. Gensichen ◽  
James C. Jackson ◽  
Fiene Eißler ◽  
Thomas Lehmann ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Depressive Symptoms ◽  
Depressive Symptom ◽  
Critical Illness ◽  
Posttraumatic Stress ◽  
Symptom Trajectories ◽  
Sum Score ◽  
Icu Discharge ◽  
Sepsis Survivors

Abstract Background Advances in critical care medicine have led to a growing number of critical illness survivors. A considerable part of them suffers from long-term sequelae, also known as post-intensive care syndrome. Among these, depressive symptoms are frequently observed. Depressive symptom trajectories and associated factors of critical illness survivors have rarely been investigated. Study objective was to explore and compare different trajectories of depressive symptoms in sepsis survivors over 1 year after discharge from ICU. Methods Data of a randomized controlled trial on long-term post-sepsis care were analyzed post hoc. Depressive symptoms were collected at 1, 6 and 12 months post-ICU discharge using the Major Depression Inventory (MDI), among others. Statistical analyses comprised descriptive analysis, univariate and multivariate, linear and logistic regression models and Growth Mixture Modeling. Results A total of 224 patients were included into this analysis. We identified three latent classes of depressive symptom trajectories: Over the course of 1 year, 152 patients recovered from mild symptoms, 27 patients showed severe persistent symptoms, and 45 patients recovered from severe symptoms. MDI sum scores significantly differed between the three classes of depressive symptom trajectories at 1 and 6 months after ICU discharge (p < 0.024 and p < 0.001, respectively). Compared with other classes, patients with the mild recovered trajectory showed lower levels of chronic pain (median sum score of 43.3 vs. 60.0/53.3 on the Graded Chronic Pain Scale, p < 0.010) and posttraumatic stress (4.6% with a sum score of ≥ 35 on the Posttraumatic Stress Scale 10 vs. 48.1%/33.3%, p < 0.003); and higher levels of health-related quality of life (HRQOL) using the Short Form-36 scale within 1 month after ICU discharge (p < 0.035). Conclusions In the first year after discharge from ICU, sepsis survivors showed three different trajectories of depressive symptoms. Course and severity of depressive symptoms were associated with chronic pain, posttraumatic stress and reduced HRQOL at discharge from ICU. Regular screening of sepsis survivors on symptoms of depression, chronic pain and posttraumatic stress within 1 year after ICU may be considered. Trial registration ISRCTN, ISRCTN 61744782. Registered April 19, 2011—Retrospectively registered, http://www.isrctn.com/ISRCTN61744782.

scholarly journals Effects of the JC JoyAge Stepped-Care Model Are Differentially Associated With Older Adults’ Baseline Profiles

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 305-305
Author(s):  
Tianyin Liu ◽  
Gloria Hoi Yan Wong ◽  
Shiyu Lu ◽  
Terry Lum
Keyword(s):  
Older Adults ◽  
Depressive Symptom ◽  
Preventive Care ◽  
Intervention Group ◽  
Symptom Clusters ◽  
Stepped Care ◽  
Care Model ◽  
Affective Symptoms ◽  
Patient Health ◽  
The Impact

Abstract Depression is a multidimensional construct consists of different symptom clusters. This paper aims to investigate if the impact of a stepped-care model, JC JoyAge, differs for older adults with different baseline depressive symptom clusters. Data came from 702 older people aged 65 and over who completed the JoyAge program. Their depression (measured by Patient Health Questionnaire-9 [PHQ-9]), anxiety, loneliness, and cognition were assessed by social workers at baseline and 12-months follow-up. Among them 609 were at risk or with mild symptoms and received group-based preventive care (prevention group), and 93 had moderate or above symptoms and received intensive intervention (intervention group). Their responses to PHQ-9 were coded to indicate affective, cognitive, behavioral, and somatic symptom clusters. It was found that somatic complaints had the highest prevalence (91%), followed by affective (83%), behavioral (60%), and cognitive symptoms (41%). Logistic regressions were used to estimate the effects of the program. For the prevention group, the JoyAge preventive care is more effective among those who reported behavioral symptoms (b=0.44, p&lt;0.05, OR=1.55, 95% CI: 1.01, 2.40), but less so in those who had cognitive appraisal issues (b=-0.42, p&lt;0.05, OR=0.66, 95% CI: 0.46, 0.96). For the intervention group, the JoyAge intervention was more effective in treatment among those who reported more affective symptoms (b=0.46, p&lt;0.05, OR=1.59, 95% CI: 1.05, 2.42). The benefits of JC JoyAge stepped-care are differentially associated with participants’ baseline profile. Participants’ overall depressive symptom severity and the presentation of symptom clusters need to be taken into consideration when delivering the services.

Abstract 13604: Physical and Affective Symptom Clusters Are Strongly Associated in Heart Failure

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Quin E Denfeld ◽  
Jill M Gelow ◽  
Shirin O Hiatt ◽  
James O Mudd ◽  
Christopher V Chien ◽  
...  
Keyword(s):  
Heart Failure ◽  
Nyha Class ◽  
Strong Association ◽  
Physical Symptom ◽  
Physical Symptoms ◽  
Brief Symptom Inventory ◽  
Symptom Clusters ◽  
Class Iii ◽  
Affective Symptom ◽  
Affective Symptoms

Introduction: The syndrome of heart failure (HF) is a constellation of both physical and affective symptoms. How physical and affective symptom clusters are associated, however, is not well understood. Hypothesis: There is a strong association between physical symptom clusters and affective symptom clusters among adults with moderate to advanced HF. Methods: This was a secondary analysis of combined data collected during two prospective cohort studies of symptoms among adults with moderate to advanced HF. Physical symptoms of dyspnea and wake disturbances were measured with the Heart Failure Somatic Perception Scale Dyspnea subscale (HFSPS-D) and the Epworth Sleepiness Scale (ESS), respectively. Affective symptoms of depression and anxiety were measured with the Patient Health Questionnaire-9 (PHQ-9) and the Brief Symptom Inventory Anxiety subscale (BSIANX), respectively. Physical and affective symptoms were clustered separately using latent mixture modeling and then compared using cross classification modeling and traditional comparative statistics (i.e. student’s t, Kendall’s tau-b and chi-square tests). Results: The average age of the sample (n=291) was 56.7±13.3 years, and most were male (61.9%). A majority of subjects were classified as NYHA Class III HF (56.4%), and most had non-ischemic etiology (65.2%). Two physical symptom clusters (severe physical (26.3%) and mild physical (73.7%); dyspnea t=7.35, p<0.001; wake disturbances t=16.80, p<0.001) and two affective symptom clusters (severe affective (21.2%) and mild affective (78.8%); depression t=22.1, p<0.001; anxiety t=7.87, p<0.001) were identified in a model with good fit (entropy=0.80). Subjects with severe physical symptoms were more likely to have severe than mild affective symptoms, and those with mild physical symptoms were more likely to have mild than severe affective symptoms (χ2=106.8, p<0.001; tau b=0.62). Conclusions: There is a strong association between physical and affective symptom clusters among adults with moderate to advanced HF that may be helpful in identifying adults with HF at risk for multiple, co-occurring symptoms.

A symptom profile of depression among Asian Americans: is there evidence for differential item functioning of depressive symptoms?

2014 ◽  
Vol 44 (12) ◽  
pp. 2567-2578 ◽  
Author(s):  
Z. Kalibatseva ◽  
F. T. L. Leong ◽  
E. H. Ham
Keyword(s):  
Depressive Symptoms ◽  
Differential Item Functioning ◽  
Asian Americans ◽  
Composite International Diagnostic Interview ◽  
Depression Symptom ◽  
Symptom Profile ◽  
European Americans ◽  
Affective Symptoms ◽  
Item Functioning ◽  
Measurement Variance

BackgroundTheoretical and clinical publications suggest the existence of cultural differences in the expression and experience of depression. Measurement non-equivalence remains a potential methodological explanation for the lower prevalence of depression among Asian Americans compared to European Americans.MethodThis study compared DSM-IV depressive symptoms among Asian Americans and European Americans using secondary data analysis of the Collaborative Psychiatric Epidemiology Surveys (CPES). The Composite International Diagnostic Interview (CIDI) was used for the assessment of depressive symptoms. Of the entire sample, 310 Asian Americans and 1974 European Americans reported depressive symptoms and were included in the analyses. Measurement variance was examined with an item response theory differential item functioning (IRT DIF) analysis.Resultsχ2analyses indicated that, compared to Asian Americans, European American participants more frequently endorsed affective symptoms such as ‘feeling depressed’, ‘feeling discouraged’ and ‘cried more often’. The IRT analysis detected DIF for four out of the 15 depression symptom items. At equal levels of depression, Asian Americans endorsed feeling worthless and appetite changes more easily than European Americans, and European Americans endorsed feeling nervous and crying more often than Asian Americans.ConclusionsAsian Americans did not seem to over-report somatic symptoms; however, European Americans seemed to report more affective symptoms than Asian Americans. The results suggest that there was measurement variance in a few of the depression items.

scholarly journals A-11 Comparison of the PHQ-9 and ImPACT Affective Symptom Cluster Scores in Measuring Depression at Baseline Among College Athletes

2020 ◽  
Vol 35 (5) ◽  
pp. 607-607
Author(s):  
A DaCosta ◽  
K Grueninger ◽  
S Hurt ◽  
A Crane ◽  
F M Webbe ◽  
...  
Keyword(s):  
Clinical Utility ◽  
College Athletes ◽  
Physical Symptom ◽  
Symptom Clusters ◽  
Symptom Cluster ◽  
Depression Symptoms ◽  
Mild Depression ◽  
Affective Symptom ◽  
Patient Health ◽  
The Individual

Abstract Objective Previous research has suggested that the affective symptom cluster in ImPACT can be used to screen for mood-related depressive symptoms in college athletes in place of a standalone mood measure (Riegler, Guty & Arnett, 2019). However, examining the clinical utility of a mood measure that additionally assesses for non-affective depression symptoms should be explored. Method Division II college athletes (n = 1,209) completed ImPACT and the Patient Health Questionnaire (PHQ-9) at their first annual pre-participation baseline assessment (mean age = 19.28, 37% female). ImPACT symptoms were divided into four symptom clusters: physical, sleep, cognitive, and affective. Results Mean affective symptom cluster score was 0.51 while mean PHQ-9 total score was 1.32. Ninety (7.44%) of the 1,209 athletes fell above the cutoff for mild depression on the PHQ-9. The sleep symptom cluster was the best individual predictor of PHQ-9 total score (R2 = .202, p &lt; .001) compared to the affective symptom cluster (R2 = .147, p &lt; .001), physical symptom cluster (R2 = .124, p &lt; .001) and cognitive symptom cluster (R2 = .145, p &lt; .001). The individual ImPACT symptom of “fatigue” accounted for the most individual variance in PHQ-9 total score (R2 = .158, p &lt; .001). Conclusions These results suggest there is clinical utility in utilizing a stand-alone mood measure to assess dysphoria that presents in a sleep-related manner as opposed to a purely affective manner.

Longitudinal trajectory of depression symptom severity and the influence of concussion history and physical function over a 19-year period among former National Football League (NFL) players: an NFL-LONG Study

2021 ◽  
pp. jnnp-2021-326602
Author(s):  
Benjamin L Brett ◽  
Zachary Y Kerr ◽  
Samuel R Walton ◽  
Avinash Chandran ◽  
J D Defreese ◽  
...  
Keyword(s):  
Depressive Symptoms ◽  
Depressive Symptom ◽  
Physical Function ◽  
Symptom Severity ◽  
Rate Of Change ◽  
American Football ◽  
Football Players ◽  
Depression Symptom ◽  
Depressive Symptom Severity ◽  
Concussion History

ObjectiveThis study investigated the longitudinal course of depressive symptom severity over 19 years in former American football players and the influence of concussion history, contact sport participation and physical function on observed trajectories.MethodsFormer American football players completed a general health questionnaire involving demographic information, medical/psychiatric history, concussion/football history and validated measures of depression and physical function at three time points (2001, 2010 and 2019). Parallel process latent growth curve modelling tested associations between concussion history, years of football participation, and overall and change in physical function on the overall level and trajectory of depressive symptoms.ResultsAmong the 333 participants (mean(SD) age, 48.95 (9.37) at enrolment), there was a statistically significant, but small increase in depressive symptom severity from 2001 (48.34 (7.75)) to 2019 (49.77 (9.52)), slope=0.079 (SE=0.11), p=0.007. Those with greater concussion history endorsed greater overall depressive symptom severity, B=1.38 (SE=0.33), p<0.001. Concussion history, B<0.001 (SE=0.02), p=0.997 and years of participation, B<0.001 (SE=0.01), p=0.980, were not associated with rate of change (slope factor) over 19 years. Greater decline in physical function, B=−0.71 (SE=0.16), p<0.001, was predictive of a faster growth rate (ie, steeper increase) of depression symptom endorsement over time.ConclusionsConcussion history, not years of participation, was associated with greater depressive symptom severity. Neither factor was predictive of changes over a 19-year period. Decline in physical function was a significant predictor of a steeper trajectory of increased depressive symptoms, independent of concussion effects. This represents one viable target for preventative intervention to mitigate long-term neuropsychiatric difficulties associated with concussion across subsequent decades of life.

scholarly journals Relationship Between Self-Reported Concomitant Depressive and Anxiety Symptoms and the Post-Concussion Symptoms Scale (PCSS)

2021 ◽  
pp. 1-11
Author(s):  
Garrett A. Thomas ◽  
Kaitlin E. Riegler ◽  
Erin T. Guty ◽  
Peter A. Arnett
Keyword(s):  
Depressive Symptoms ◽  
Anxiety Symptoms ◽  
Symptom Clusters ◽  
Symptom Cluster ◽  
Anxiety And Depression ◽  
Cognitive Symptoms ◽  
Test Results ◽  
Affective Disturbance ◽  
Healthy Control ◽  
Affective Disturbances

ABSTRACT Objectives: The current study explored how affective disturbances, particularly concomitant anxiety and depressive symptoms, impact baseline symptom self-reporting on the Post-Concussion Symptoms Scale (PCSS) in college athletes. Methods: Athletes were separated into four groups (Healthy Control (HC) (n = 581), Depression Only (n = 136), Anxiety Only (n = 54), Concomitant Depression/Anxiety (n = 62)) based on their anxiety and depression scores. Groups were compared on Total PCSS Score as well as 5 PCSS Symptom Cluster scores (Cognitive, Physical, Affective, Sleep, and Headache). Results: The three affective groups reported significantly greater symptomatology than HCs, with the Concomitant group showing the highest symptomatology scores across all clusters. The depressive symptoms only group also reported significantly elevated symptomatology, compared to HCs, on every symptom cluster except headache. The anxiety symptoms only group differed from HCs on only the cognitive symptoms cluster. Additionally, the Concomitant group reported significantly increased PCSS symptomatology, in terms of total scores and all 5 symptom clusters, compared to the depressive symptoms only and anxiety symptoms only groups. Conclusions: Our findings suggest that athletes experiencing concomitant depressive/anxiety symptoms report significantly greater levels of symptomatology across all 5 PCSS symptom clusters compared to HCs. Further, results suggest that athletes experiencing concomitant affective disturbance tend to report greater symptomatology than those with only one affective disturbance. These findings are important because, despite the absence of concussion, the concomitant group demonstrated significantly elevated symptomatology at baseline. Thus, future comparisons with post-concussion data should account for this increased symptomatology, as test results may be skewed by affective disturbances at baseline.

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