HPV screening performance indicators in women who previously tested HPV-negative: The second round of Vallecamonica screening programme, Northern Italy

2020 ◽  
Vol 27 (4) ◽  
pp. 207-214
Author(s):  
Luigi Pasquale ◽  
Paolo G Rossi ◽  
Francesca Carozzi ◽  
Serena Domenighini ◽  
Cristina Ruggeri ◽  
...  
Keyword(s):  
Positive Predictive Value ◽  
Cervical Intraepithelial Neoplasia ◽  
Performance Indicators ◽  
Predictive Value ◽  
Screening Programme ◽  
Intraepithelial Neoplasia ◽  
Female Population ◽  
Hpv Test ◽  
Hpv Screening ◽  
One Year

Objective To present performance indicators from the second round of the Vallecamonica-Sebino HPV screening programme in women who had tested negative about four years earlier (mean 45 months). Methods From 2010 to 2012, the target female population (aged 25–64) was invited to the first HPV screening round. In 2013–2017, women were rescreened for the second round. HPV-negative women at the first round were initially rescreened after three years. The interval was gradually increased to five years. HPV-positive women underwent cytology triage: positives were referred to colposcopy and negatives to repeat testing after one year. If HPV was persistently positive, women were referred to colposcopy, if negative, to normal interval rescreening. Results In the second round, of 13,824 previously HPV-negative women, 598 were HPV-positive (4.3%), of whom 297 were positive at cytology triage. Of those referred to one-year HPV test, 291 complied (98.0%), 133 (50.2%) of whom were persistently positive. Total referral was 3.1% compared with 6.6% in the first round (age-adjusted relative referral 0.59, 95% CI: 0.53–0.65). There were 24 cervical intraepithelial neoplasia 2+ (three cervical intraepithelial neoplasia 3+). Detection was 0.17%, compared with 0.9% in the first round. Age-adjusted relative detections were 0.25 (95% CI: 0.16–0.39) and 0.18 (95% CI: 0.05–0.61) for cervical intraepithelial neoplasia 2+ and cervical intraepithelial neoplasia 3+, respectively. Positive predictive value was 5.7%, compared with 14.6% in the first round. Conclusions At second round, referral was half that at first round, while cervical intraepithelial neoplasia 2+ detection decreased nine-fold. Consequently, positive predictive value decreased dramatically. Rescreening four years after an HPV-negative test makes the process inefficient due to the low prevalence of lesions.

Hybrid capture 2 and cobas® 4800: Comparison of performance of two clinically validated tests for human papillomavirus primary screening of cervical cancer

2021 ◽  
pp. 096914132199282
Author(s):  
A Mongia ◽  
G Pompeo ◽  
C Sani ◽  
E Burroni ◽  
G Fantacci ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
High Risk ◽  
Positive Predictive Value ◽  
Cervical Intraepithelial Neoplasia ◽  
Predictive Value ◽  
Screening Program ◽  
Intraepithelial Neoplasia ◽  
Cervical Intraepithelial Neoplasia Grade ◽  
Hybrid Capture ◽  
Hybrid Capture 2

Objective To compare, in a primary human papillomavirus screening setting, two different validated human papillomavirus tests, considering their analytical and clinical screening performances. Methods In Tuscany, a human papillomavirus screening program was implemented in 2013. Hybrid capture 2 (Qiagen) was used for testing until May 2016, when it was replaced by the cobas® 4800 human papillomavirus test (Cobas; Roche). We evaluated the performance of Hybrid capture 2 and Cobas on: the same screening population in two different periods (before and after changing to Cobas); the same Hybrid capture 2-positive consecutive samples. Discordant samples (Hybrid capture 2-positive/Cobas negative) were typed on the L1 gene (reverse line blot, AB Analitica) and E6/E7 genes (BD Onclarity assay). Results In the considered time period ( n = 37,775), human papillomavirus positivity was 9.8% and 7.4%, respectively, for Hybrid capture 2 and Cobas ( p < 0.0001). At immediate colposcopy, the cervical intraepithelial neoplasia, grade 2 positive predictive value was, respectively, 23.8% and 34% ( p < 0.001). At one-year recall, human papillomavirus persistence was, respectively, 40.6% and 62.2% ( p < 0.0001). Of Hybrid capture 2-positive re-tested samples ( n = 620), 32.4% were Cobas negative. Of discordant samples typed on L1, 7% were positive for the 12 high-risk human papillomavirus. Of the samples found to be negative for the 12 high-risk human papillomavirus types on L1, 14.5% were positive on E6/E7 typing. Among the discordant samples, the only two cervical intraepithelial neoplasia (CIN) grade 3 lesions were non-high-risk human papillomavirus positive on both L1 and E6/E7 typing. Conclusion At baseline, Hybrid capture 2 showed greater human papillomavirus positivity and a lower CIN2+ positive predictive value than Cobas, which was more specific than Hybrid capture 2 in detection of high-risk human papillomavirus: 80% of discordant samples were confirmed as high-risk human papillomavirus negative. This higher analytical specificity determined the non-identification of two CIN3 lesions.

scholarly journals Analysis of the Role of the Human Papillomavirus 16/18 E7protein Assay in Screening for Cervical Intraepithelial Neoplasia: A Case Control Study

2020 ◽  
Author(s):  
Linghua Kong ◽  
Xiaoping Xiao ◽  
Huiping Lou ◽  
Pengfei Liu ◽  
Shuhui Song ◽  
...  
Keyword(s):  
Cervical Cancer ◽  
Human Papillomavirus ◽  
Cervical Intraepithelial Neoplasia ◽  
Protein Level ◽  
Predictive Value ◽  
Gynecological Cancer ◽  
Intraepithelial Neoplasia ◽  
Detection Accuracy ◽  
Protein Assay ◽  
Hpv Test

Abstract Background: Cervical cancer is the second-most common gynecological cancer, early screening plays a key role in the diagnosis and treatment of cervical intraepithelial neoplasia (CIN). Sustained E7 protein expression is the pathological basis for CIN and cervical cancer. Methods: We collected the cervical cell samples of 205 women who visited the gynecological clinic of Peking Union Medical College Hospital between September 2018 and September 2019 and submitted them to the high-risk human papillomavirus (Hr-HPV) test. We performed a magnetic particle–based chemiluminescence enzyme immunoassay to analyze the Hr-HPV16/18 E7 protein level in CIN of different severities and compared the results with those of cervical pathology (gold standard) and the Hr-HPV test. Results: The positive rate of Hr-HPV16/18 E7 protein increased with the severity of CIN: 26.55% in normal tissue, 58.33% in CIN1, and 70.59% in CIN2/CIN3. For CIN2 and above, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the E7 protein were 70.59%, 67.88%, 52.17%, and 82.30%, respectively. These values of the Hr-HPV test were 86.76%, 44.53%, 43.70%, and 87.14%, respectively. With the combination of the E7 protein assay and Hr-HPV test, the specificity for diagnosing CIN2 and above was 78.10%, which was significantly higher than that of the Hr-HPV test alone. Conclusions: Hr-HPV16/18 E7 protein level is correlated with the severity of CIN and has a high concordance rate with the pathological result. For cervical cancer screening, the combination of HPV16/18 E7 protein assay and Hr-HPV test improves the CIN diagnostic specificity, detection rate, and detection accuracy.

The Positive Predictive Value of High-Grade Squamous Intraepithelial Lesion on Cytology for the Histological Diagnosis of Cervical Intraepithelial Neoplasia 2 or Higher: A Systematic Review

2019 ◽  
Vol 63 (3) ◽  
pp. 206-214 ◽  
Author(s):  
Nina Karia ◽  
Alison Van Loon ◽  
Cindy Simoens ◽  
Ina Benoy ◽  
Johannes Bogers
Keyword(s):  
Systematic Review ◽  
Cervical Cancer ◽  
Positive Predictive Value ◽  
Cervical Intraepithelial Neoplasia ◽  
Predictive Value ◽  
Intraepithelial Neoplasia ◽  
Histological Diagnosis ◽  
High Grade ◽  
Cervical Lesions ◽  
Intraepithelial Lesion

Cervical cancer is a major worldwide health problem. Therefore, regular cervical screening in order to make an early diagnosis can help to prevent cervical cancer, through identifying and treating preinvasive cervical lesions. The aim of this review is to evaluate the correlation between the cytological screening result and the final gold standard histological outcome in the diagnosis of cervical lesions. More specifically, the correlation between high-grade intraepithelial lesion (HSIL) on cytology and histological cervical intraepithelial neoplasia grade 2 or higher (CIN2+) was intended, by calculating the positive predictive value (PPV). PPV is an important value from a clinical point of view. An electronic search was carried out in the electronic databases MEDLINE (through PubMed) and the Cochrane Library (last searched beginning of December 2017), supplemented with the related article feature in PubMed and snowballing. Article selection (predefined inclusion and exclusion criteria) and data extraction were evaluated by two independent reviewers (N.K. and A.V.L.). After identifying 1,146 articles, 27 articles were finally included in this systematic review, representing 28,783 cytological HSIL diagnoses in total. The PPV of HSIL was 77.5% (range: 45.4–95.2%) for the histological diagnosis of CIN2+ and 55.4% (range: 36.4–67.6%) for the diagnosis of CIN3+. In this systematic review, 77.5% of the HSIL-positive women eventually had a CIN2+ diagnosis. The diagnostic value of a cytological HSIL result (conventional or liquid-based cytology) in the diagnosis of CIN2+ lesions is good, but a combination of tests could raise this value.

scholarly journals The Role of Self-Collection by Vaginal Lavage for the Detection of HPV and High-Grade Intraepithelial Neoplasia

2017 ◽  
Vol 61 (6) ◽  
pp. 425-433 ◽  
Author(s):  
Larissa de Melo Kuil ◽  
Adriana Tarla Lorenzi ◽  
Maíra Degiovani Stein ◽  
Júlio César Possati Resende ◽  
Márcio Antoniazzi ◽  
...  
Keyword(s):  
High Risk ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
Pap Test ◽  
Intraepithelial Neoplasia ◽  
Cervical Cytology ◽  
High Grade ◽  
Vaginal Lavage ◽  
Hpv Test ◽  
High Risk Hpv

Objective: To compare the results of cervical cytology and high-risk HPV tests using samples obtained using two different collection modalities in a population of Brazilian women: self-collection (vaginal lavage) and cervical Pap testing. Methods: We enrolled 204 women who were aged 18-64 years and had previously obtained abnormal cervical cytology test results; 83.8% of them agreed to participate. The sample was divided into two aliquots: one for the cytological study and one for the molecular analysis of high-risk HPV. Results: Fifty-eight percent of the participants preferred to utilize self-collection as an alternative screening method. However, we noticed that the HPV positivity rate was significantly lower in self-collected samples when compared to those obtained using the conventional collection method (p = 0.035). The cytology tests of the samples obtained via self-collection were sensitive and had a positive predictive value and an area under the curve (AUC) that were significantly lower than those of the Pap test. However, the specificity and negative predictive value of these tests were similar. When compared with the HPV test, the self-collected samples demonstrated lower accuracy in predicting high-grade cervical intraepithelial neoplasia or worse, with a significantly lower sensitivity, positive predictive value, and AUC than the cervical Pap test samples. Conclusion: Self-collection by vaginal lavage is simple and well accepted by women. Due to its limitations, however, self-collection by lavage should be utilized with caution.

scholarly journals Analysis of the role of the human papillomavirus 16/18 E7 protein assay in screening for cervical intraepithelial neoplasia: a case control study

2020 ◽  
Author(s):  
Linghua Kong ◽  
Xiaoping Xiao ◽  
Huiping Lou ◽  
Pengfei Liu ◽  
Shuhui Song ◽  
...  
Keyword(s):  
Cervical Cancer ◽  
Human Papillomavirus ◽  
Cervical Intraepithelial Neoplasia ◽  
Protein Level ◽  
Predictive Value ◽  
Gynecological Cancer ◽  
Intraepithelial Neoplasia ◽  
Detection Accuracy ◽  
Protein Assay ◽  
Hpv Test

Abstract Background: Cervical cancer is the second-most common gynecological cancer, early screening plays a key role in the diagnosis and treatment of cervical intraepithelial neoplasia (CIN). Sustained E7 protein expression is the pathological basis for CIN and cervical cancer. Methods: We collected the cervical cell samples of women who visited the gynecological clinic of Peking Union Medical College Hospital between September 2018 and September 2019 and submitted them to the high-risk human papillomavirus (Hr-HPV) test. We performed a magnetic particle–based chemiluminescence enzyme immunoassay to analyze the HPV16/18 E7 protein level in CIN of different severities and compared the results with those of cervical pathology (gold standard) and the HPV test. Results: The positive rate of HPV16/18 E7 protein increased with the severity of CIN: 26.6% in normal tissue, 58.3% in CIN1, and 70.6% in CIN2 or higher (CIN2+). For CIN2+, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the E7 protein were 70.6%, 67.9%, 52.2%, and 82.3%, respectively. These values of the HPV test were 86.8%, 44.5%, 43.7%, and 87.1%, respectively. With the combination of the E7 protein assay and HPV test, the specificity for diagnosing CIN2+ was 78.1%, which was significantly higher than that of the HPV test alone. Conclusions: HPV16/18 E7 protein level is correlated with the severity of CIN and has a high concordance rate with the pathological result. For cervical cancer screening, the combination of HPV16/18 E7 protein assay and HPV test improves the CIN diagnostic specificity, detection rate, and detection accuracy.

scholarly journals Analysis of the role of the human papillomavirus 16/18 E7 protein assay in screening for cervical intraepithelial neoplasia: a case control study

BMC Cancer ◽  
2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Linghua Kong ◽  
Xiaoping Xiao ◽  
Huiping Lou ◽  
Pengfei Liu ◽  
Shuhui Song ◽  
...  
Keyword(s):  
Cervical Cancer ◽  
Human Papillomavirus ◽  
Cervical Intraepithelial Neoplasia ◽  
Protein Level ◽  
Predictive Value ◽  
Gynecological Cancer ◽  
Intraepithelial Neoplasia ◽  
Detection Accuracy ◽  
Protein Assay ◽  
Hpv Test

Abstract Background Cervical cancer is the second-most common gynecological cancer, early screening plays a key role in the diagnosis and treatment of cervical intraepithelial neoplasia (CIN). Sustained E7 protein expression is the pathological basis for CIN and cervical cancer. Methods We collected the cervical cell samples of women who visited the gynecological clinic of Peking Union Medical College Hospital between September 2018 and September 2019 and submitted them to the high-risk human papillomavirus (Hr-HPV) test. We performed a magnetic particle–based chemiluminescence enzyme immunoassay to analyze the HPV16/18 E7 protein level in CIN of different severities and compared the results with those of cervical pathology (gold standard) and the HPV test. Results The positive rate of HPV16/18 E7 protein increased with the severity of CIN: 26.6% in normal tissue, 58.3% in CIN1, and 70.6% in CIN2 or higher (CIN2+). For CIN2+, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the E7 protein were 70.6, 67.9, 52.2, and 82.3%, respectively. These values of the HPV test were 86.8, 44.5, 43.7, and 87.1%, respectively. With the combination of the E7 protein assay and HPV test, the specificity for diagnosing CIN2+ was 78.1%, which was significantly higher than that of the HPV test alone. Conclusions HPV16/18 E7 protein level is correlated with the severity of CIN and has a high concordance rate with the pathological result. For cervical cancer screening, the combination of HPV16/18 E7 protein assay and HPV test improves the CIN diagnostic specificity, detection rate, and detection accuracy.

scholarly journals Accuracy of Smartphone Images of the Cervix After Acetic Acid Application for Diagnosing Cervical Intraepithelial Neoplasia Grade 2 or Greater in Women With Positive Cervical Screening: A Systematic Review and Meta-Analysis

2021 ◽  
pp. 1711-1721
Author(s):  
Emma R. Allanson ◽  
Natacha Phoolcharoen ◽  
Mila P. Salcedo ◽  
Bryan Fellman ◽  
Kathleen M. Schmeler
Keyword(s):  
Systematic Review ◽  
Acetic Acid ◽  
Positive Predictive Value ◽  
Cervical Intraepithelial Neoplasia ◽  
Predictive Value ◽  
Precancerous Lesions ◽  
Meta Analysis ◽  
Cervical Screening ◽  
Intraepithelial Neoplasia ◽  
Cervical Intraepithelial Neoplasia Grade

PURPOSE Smartphones are used in cervical screening for visual inspection after acetic acid or Lugol's iodine (VIA/VILI) application to capture and share images to improve the sensitivity and interobserver variability of VIA/VILI. We undertook a systematic review and meta-analysis assessing the diagnostic accuracy of smartphone images of the cervix at the time of VIA/VILI (termed S-VIA) in the detection of precancerous lesions in women undergoing cervical screening. METHODS This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 1, 2010, to June 30, 2020, were assessed. MEDLINE/PubMed, Embase, CINAHL, Cochrane, and LILACS were searched. Cohort and cross-sectional studies were considered. S-VIA was compared with the reference standard of histopathology. We excluded studies where additional technology was added to the smartphone including artificial intelligence, enhanced visual assessment, and other algorithms to automatically diagnose precancerous lesions. The primary outcome was the accuracy of S-VIA for the diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN 2+). Data were extracted, and we plotted the sensitivity, specificity, negative predictive value, and positive predictive value of S-VIA using forest plots. This study was prospectively registered with The International Prospective Register of Systematic Reviews:CRD42020204024. RESULTS Six thousand three studies were screened, 71 full texts assessed, and eight studies met criteria for inclusion, with six included in the final meta-analysis. The sensitivity of S-VIA for the diagnosis of CIN 2+ was 74.56% (95% CI, 70.16 to 78.95; I2 61.30%), specificity was 61.75% (95% CI, 56.35 to 67.15; I2 95.00%), negative predictive value was 93.71% (95% CI, 92.81 to 94.61; I2 0%), and positive predictive value was 26.97% (95% CI, 24.13 to 29.81; I2 61.3%). CONCLUSION Our results suggest that S-VIA has accuracy in the detection of CIN 2+ and may provide additional support to health care providers delivering care in low-resource settings.

scholarly journals Feasibility, Acceptability, and Efficacy of a Community Health Worker–Driven Approach to Screen Hard-to-Reach Periurban Women Using Self-Sampled HPV Detection Test in India

2020 ◽  
pp. 658-666
Author(s):  
Usha Rani Poli ◽  
Richard Muwonge ◽  
Triveni Bhoopal ◽  
Eric Lucas ◽  
Partha Basu
Keyword(s):  
Positive Predictive Value ◽  
Community Health ◽  
Predictive Value ◽  
Local Community ◽  
Health Workers ◽  
Day Treatment ◽  
Real Life ◽  
Intraepithelial Neoplasia ◽  
Real Life Setting ◽  
Hpv Test

PURPOSE Detection of high-risk human papillomavirus (HPV) in self-collected vaginal samples can significantly improve participation of hard-to-reach women; however, the implementation of such an approach in a real-life setting, especially in countries with limited resources, has certain challenges. Our study aimed to evaluate the feasibility, acceptability, and efficacy of implementing an HPV self-sampling–based approach to screen a socioeconomically disadvantaged, unscreened population with support from community health workers (CHWs) for community mobilization, counseling, and navigation. Different triaging options for HPV-positive women were also assessed. METHODS Women age 30 to 65 years from low socioeconomic periurban areas who had never been screened before were motivated by CHWs to attend local community centers and provide self-collected vaginal samples for careHPV testing. Screen-positive women were informed and navigated by CHWs to attend colposcopy clinics where cervical biopsy and same-day ablative treatment were offered. RESULTS Women readily accepted to provide self-collected samples after counseling by CHWs. Screen positivity was 6.4%, and CHWs successfully navigated 65% of HPV-positive women to colposcopy. Cervical intraepithelial neoplasia (CIN) 2+ detection rate was 9.7 per 1,000 women screened. The HPV test had a positive predictive value of 15.3% to detect CIN 2+ lesions. Triage using visual inspection with acetic acid significantly improved the positive predictive value (49.5% to detect CIN 2+), but missed a significant number of CIN 2+ lesions. Colposcopy sensitivity was also suboptimal. Of 51 women with lesions, 80% underwent ablative treatment and the majority accepted same-day treatment. CONCLUSION CHW-driven self-sampling for HPV testing is feasible, well-accepted, and effective for screening unscreened hard-to-reach women. The screen-and-treat approach can ensure strong linkage between screening and treatment.

scholarly journals The role of human papillomavirus typization and cytology in early detection of relapse of cervical intraepithelial neoplasia

2011 ◽  
Vol 68 (4) ◽  
pp. 314-320
Author(s):  
Radomir Zivadinovic ◽  
Vekoslav Lilic ◽  
Biljana Djordjevic ◽  
Zorica Stanojevic ◽  
Aleksandra Petric ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
Cervical Intraepithelial Neoplasia ◽  
Predictive Value ◽  
Pap Smear ◽  
Clinical Investigation ◽  
Intraepithelial Neoplasia ◽  
Female Population ◽  
Adequate Treatment ◽  
Predictive Values ◽  
Severe Degree

Background/Aim. Female patients who underwent ceratin treatment forms of cervical intraepithelial neoplasia (CIN) are at five times greater risk for disease relapse in comparison to the rest of female population. The aim of the study was to investigate validity of human papillomavirus (HPV) typization and cytology in detection of relapse. Methods. The prospective clinical investigation included 35 patients with relapse and 30 ones without it after adequate treatment of cervical intraepithelial neoplasia. HPV typization using PCR methods and cytological test (conventional Pap smear) were performed in all the patients. Validation of tests applied was performed by determining their sensitivity, specificity, and positive and negative predictive value. Results. More severe degrees of CIN relapse occur significantly more often in patients which remain HPV positive despite of the treatment. The patients which remain positive on HPV type 18 or, on both HPV types 18 and 16, have more often CIN relapses of more severe degree in relation to those just positive on HPV type 16. HPV typization has higher predictive value for diagnosis of the rezidual disease in older patients. Sensitivity of HPV typization for diagnosis all CIN relapse degrees is 68.57%, for more severe degrees (HSIL and MIC) 90.47%, specificity is 93.33%, while positive and negative predictive values are 90.47% and 93.53%, respectively. Sensitivity of cytology for diagnosis of more severe CIN relapses is 80.95%. HPV typization used along with cytology ofters the highest sensitivity (95.23%). Conclusion. Both tests, HPV typization and Pap smear, offer satisfactory sensitivity and high specificity in detection of relapse, parcticularly those with more severe degree. The highest sensitivity in detection of CIN relapse is obtained by using both tests.

scholarly journals A machine learning approach for predicting suicidal thoughts and behaviours among college students

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Melissa Macalli ◽  
Marie Navarro ◽  
Massimiliano Orri ◽  
Marie Tournier ◽  
Rodolphe Thiébaut ◽  
...  
Keyword(s):  
Mental Health ◽  
College Students ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
Screening Tools ◽  
Receiver Operating Curve ◽  
Depression Symptoms ◽  
Suicidal Thoughts ◽  
One Year

AbstractSuicidal thoughts and behaviours are prevalent among college students. Yet little is known about screening tools to identify students at higher risk. We aimed to develop a risk algorithm to identify the main predictors of suicidal thoughts and behaviours among college students within one-year of baseline assessment. We used data collected in 2013–2019 from the French i-Share cohort, a longitudinal population-based study including 5066 volunteer students. To predict suicidal thoughts and behaviours at follow-up, we used random forests models with 70 potential predictors measured at baseline, including sociodemographic and familial characteristics, mental health and substance use. Model performance was measured using the area under the receiver operating curve (AUC), sensitivity, and positive predictive value. At follow-up, 17.4% of girls and 16.8% of boys reported suicidal thoughts and behaviours. The models achieved good predictive performance: AUC, 0.8; sensitivity, 79% for girls, 81% for boys; and positive predictive value, 40% for girls and 36% for boys. Among the 70 potential predictors, four showed the highest predictive power: 12-month suicidal thoughts, trait anxiety, depression symptoms, and self-esteem. We identified a parsimonious set of mental health indicators that accurately predicted one-year suicidal thoughts and behaviours in a community sample of college students.

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