Striatal dopamine release tracks the relationship between actions and their consequences

The acquisition and performance of goal-directed actions has long been argued to depend on the integration of glutamatergic inputs to the posterior dorsomedial striatum (pDMS) under the modulatory influence of dopamine. Nevertheless, relatively little is known about the dynamics of striatal dopamine during goal-directed actions. To investigate this, we chronically recorded dopamine release in the pDMS as rats acquired two actions for distinct outcomes as these action-outcome associations were incremented and then subsequently degraded or reversed. We found that bilateral dopamine release scaled with action value, whereas the lateralized dopamine signal, i.e., the difference in dopamine release ipsilaterally and contralaterally to the direction of the goal-directed action, reflected the strength of the action-outcome association independently of changes in movement. Our results establish, therefore, that striatal dopamine activity during goal-directed action reflects both bilateral moment-to-moment changes in action value and the long-term action-outcome association.

1365 PROACTIVE IT-ASSISTED CGA IN CARE HOMES IMPROVES ADHERENCE TO PREFERRED PLACE OF CARE AND DEATH, HOSPITALISATION AND MORTALITY RATES

Introduction

Primary care-based frailty identification and proactive comprehensive geriatric assessment (CGA) remains challenging. Our Devon-based Primary Care Network has developed and introduced an innovative, community-based IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We wished to see if this process could improve effectiveness of ACP in residential care home (CH) residents.

Methods/Intervention

Interim analysis focused on adherence to ACP-documentation in severely frail residents, comparing groups:

Results

i-CGA group: 196 residents (16 mild/69 moderate/111 severe frailty); control group: 100(13 mild/31 moderate/56 severe). No significant baseline differences. 100% residents in the i-CGA group had documented resuscitation decisions, vs 72% (72/100) controls: in 97% of both groups (191/196,70/72) to ‘allow a natural death'. 85% (94/111) severely frail i-CGA residents preferred not to be hospitalised. 55% (52/94) died, 90% (47/52) in their CH. Compared to the preceding year, unplanned hospitalisation rates fell:0.86 to 0.68/person years alive. In severely frail control residents, unplanned hospitalisations increased: 0.87 to 2.05/person years alive. 29% (16/56) had no hospitalisation preferences documented. 16/16 died, 25% (4/16) in hospital. 40/56 had documented decisions, not all recent:38% (15/40) wished for admission. Significant group mortality difference was seen: 55% (62/111) severely frail i-CGA residents died compared to 77% (43/56) controls, p=0.0013.

Conclusions

Proactive primary care-led i-CGA in severely frail CH residents promotes up-to-date discussions regarding preferred place of care and death. Most prefer not to be hospitalised, despite traditionally high rates of unplanned admissions. Our i-CGA/ACP process improves adherence to preferences, reduces unplanned hospitalisations and mortality rates. Progressive i-CGA completion and annual/opportunistic reviews should confer progressive benefits.

South African guidelines for receptor radioligand therapy (RLT) with Lu-177-PSMA in prostate cancer

BACKGROUND

Prostate cancer is an important cause of morbidity and mortality in South Africa, as it is in the rest of the world. In African men, however, prostate cancer tends to follow a more aggressive course when compared to their European counterparts. This is attributed to a plethora of diverse factors of which an underlying genetic component has been shown to be an important aspect. Such differences highlight the need for individualised therapy and for local guidelines. The aim of this guideline is to aid nuclear physicians and other clinicians who manage patients with prostate cancer in the correct identification and treatment of patients who are likely to benefit from receptor radioligand therapy.

RECOMMENDATIONS

There are a multitude of treatment modalities available for the treatment of prostate cancer and these therapies may be required at various time points during the course of the disease in any individual patient. A multidisciplinary approach is crucial in deciding which therapy, or combination of therapies, would be most advantageous at particular time points. The multidisciplinary team should include a urologist, oncologist and nuclear medicine physician as a minimum, and should ideally also involve a palliative/pain specialist, a dietician and a psychologist.

CONCLUSION

Treatment with 177Lu-PSMA has emerged as a promising systemic modality, which involves the delivery of targeted radiation therapy in the form of β-particles to sites of tumour tissue. Therapy is provided on an outpatient basis, is well tolerated with relatively few side effects and has a positive effect on overall survival and quality of life. At present, it is used mostly in the setting of advanced, castrate-resistant cancer. Patients are selected (amongst other criteria) based on the prior PSMA-based SPECT/PET/CT imaging (99mTc-,68Ga- or 18F-PSMA), which should demonstrate sufficient receptor expression in order to consider PSMA-based targeted radionuclide therapy. Such imaging of an intended target prior to its therapeutic targeting is known as a theranostic approach.

Photostimulated Luminescence Detection of Irradiated Herbs, Spices, and Seasonings: International Interlaboratory Trial

An interlaboratory trial was conducted to validate photostimulated luminescence (PSL) methods for herbs, spices, and seasonings. Forty products (11 herbs, 17 spices, and 12 seasonings) were purchased from a local commercial source, and randomly selected samples were irradiated with 10 kGy. Four blended products were prepared at Scottish Universities Research and Reactor Centre, mixing varying proportions of irradiated material with the untreated product. Precharacterization against a predefined threshold identified low sensitivity products (black and white peppers) and products with high natural signals (thyme, sage, parsley, and mixed herbs), both of which might be susceptible to misclassification. Precharacterization also revealed whether calibration was likely to resolve overlap between classification categories. Eight sets of screening data and 5 sets of calibrated data were returned by participants. Of the 840 samples sent, 1593 screening measurements and 788 calibrated measurements were received from 662 samples. In screening mode, participants reached definitive conclusions in 87% of cases, 99% of which were correct. Of the remaining 13%, calibration to identify low-sensitivity resolved 60% of cases. Overall, 94% of samples were correctly identified by either screening alone, or screening plus calibration; 6% remained unclassified and therefore required further investigation by thermoluminescence. The results confirm the validity of the PSL method for herbs, spices, seasonings, and blends, and emphasize the need for calibration to identify low-sensitivity samples. This method has now been adopted by the European Committee for Standardization (CEN) and the Codex Alimentarius Commission.

Assessment of agreement and interchangeability between the TEG5000 and TEG6S thromboelastography haemostasis analysers: a prospective validation study

Background

TEG6S® and TEG5000® (Haemonetics Corp, USA) are haemostasis analysers that measure viscoelasticity properties of whole blood. Both use different mechanisms to assess similar components of the coagulation process. The aim of this study was to assess agreement and interchangeability between the TEG6S and TEG5000 analysers.

Methods

3.5 mL whole blood was collected from 25 adult patients in a tertiary intensive care unit (ICU). Analysis was performed using TEG6S and TEG5000 haemostatic platforms. Agreement between platforms was measured using Lin’s concordance coefficient (Lin’s CC), further validated using intraclass correlation coefficients and reduced major axis regression (RMAR).

Results

Sixteen (64%) patients were male; mean (range) age: 59yo (23–86). TEG6S and TEG5000 systems were broadly interchangeable. The majority of TEG variables demonstrated almost perfect or substantial agreement and minimal proportional bias (maximum amplitude demonstrated a fixed bias). LY30%, however, demonstrated poor agreement and a proportional bias. Lin’s CC coefficients (95% CI, RMAR slope, intercept) between TEG6S and TEG5000 variables were: R time: 0.78 (0.64–0.92, 0.76, 0.92); K time: 0.82 (0.69–0.94, 1.30, − 0.93); alpha angle: 0.79 (0.64–0.95, 1.04, − 1.43); maximum amplitude (MA): 0.90 (0.83–0.96, 0.99, − 5.0); LY30%: 0.34 (0.1–0.58, 0.43, 0.04).

Conclusions

Adult patients with critical illness demonstrate almost perfect agreement in the R time and MA, substantial agreement in K time and alpha angle, but poor agreement in LY30%, as measured by the TEG6S and TEG5000 analysers. With the exception of LY30%, the TEG6S and TEG5000 platforms appear interchangeable. This has important implications for use in clinical practice and multi-site research programs.

Trial registration

ANZCRT number: 12617000062325, registered 12/Jan17. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0717-7) contains supplementary material, which is available to authorized users.

Sexual behaviours and sexually transmitted infection outcomes in a cohort of HIV-negative men who have sex with men attending sexual health clinics in England

Men who have sex with men (MSM) attending sexual health (SH) clinics are at high risk for HIV acquisition and are disproportionately affected by sexually transmitted infections (STIs). We collected standardised behavioural data from MSM attending clinics to characterise sexual behaviours and identify predictors for HIV and STIs. In 2012–2013, HIV-negative MSM attending five SH clinics in England reported sexual behaviours in the previous three months via a self-administered questionnaire. Behaviours were linked to the individual’s clinical records using national surveillance. The prevalence and incidence of bacterial STIs (gonorrhoea, Chlamydia, lymphogranuloma venereum and syphilis) and incidence of HIV were calculated. Adjusted odds ratios and hazard ratios with 95% confidence interval (CI) were reported for significant predictors. Of 1278 HIV-negative MSM, 54% were of white ethnicity and UK-born and 43% were 25–34 years old. Almost all men reported at least one partner in the last three months. Half reported condomless anal sex and 36% condomless receptive anal intercourse (CRAI). Incidence of bacterial STIs was 46/100 (95%CI 39–54) person years (py) and of HIV was 3.1/100 (95%CI 1.7–5.6) py. A STI at baseline and CRAI with increasing numbers of partners were associated with both incident infections. In this cohort of MSM high-risk behaviours and STIs were prevalent. Engagement in CRAI increased the likelihood of subsequent infection, while men diagnosed with a bacterial STI were at increased risk of a future STI. Clinical and behavioural risk assessments to determine an individual’s risk of infection could allow a more nuanced prevention approach that has greater success in reducing transmission.

TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi

SETTING

Urban Blantyre, Malawi.

OBJECTIVE

To understand why men with tuberculosis (TB) in the community remain undiagnosed.

DESIGN

A multi-method qualitative study applying a modified grounded theory approach. Data were gathered from March 2011 to March 2012 from 134 men and women taking part in 1) focus group discussions with community members (n = 6) and health care workers (n = 2), and 2) in-depth interviews with TB patients (n = 20, females n = 14) and chronic coughers (n = 20, women n = 8). Data were analysed inductively to identify, refine and consolidate, and verify emerging concepts and themes.

RESULTS

Two emerging themes highlighting compound stigma in this high human immunodeficiency virus (HIV) prevalence, low-income setting are presented. First, cough or any illness that portended a 'serious' condition were accompanied by portrayals of cough, TB and HIV as being interchangeable. Chronic coughers and TB patients described their illness in ways that foregrounded bodily decimation and rupture of social life and masculine identity. Second, 'resistance strategies' entailed resisting classification as (seriously) ill by evading or ambivalently approaching health care, or acknowledging the 'ill' status then actively pursuing health-appropriate behaviours, including changing lifestyle or adopting non-normative gender roles.

CONCLUSIONS

Managing patients requires 1) going beyond syndromic management based on vital signs and clinical indicators to recognising and intervening on health care-seeking related tensions to retain individuals in care, and 2) understanding and addressing TB stigma as it manifests and affects men and women differently in specific settings.

Availability, diversification and versatility explain human selection of introduced plants in Ecuadorian traditional medicine

Globally, a majority of people use plants as a primary source of healthcare and introduced plants are increasingly discussed as medicine. Protecting this resource for human health depends upon understanding which plants are used and how use patterns will change over time. The increasing use of introduced plants in local pharmacopoeia has been explained by their greater abundance or accessibility (availability hypothesis), their ability to cure medical conditions that are not treated by native plants (diversification hypothesis), or as a result of the introduced plants’ having many different simultaneous roles (versatility hypothesis). In order to describe the role of introduced plants in Ecuador, and to test these three hypotheses, we asked if introduced plants are over-represented in the Ecuadorian pharmacopoeia, and if their use as medicine is best explained by the introduced plants’ greater availability, different therapeutic applications, or greater number of use categories. Drawing on 44,585 plant-use entries, and the checklist of >17,000 species found in Ecuador, we used multi-model inference to test if more introduced plants are used as medicines in Ecuador than expected by chance, and examine the support for each of the three hypotheses above. We find nuanced support for all hypotheses. More introduced plants are utilized than would be expected by chance, which can be explained by geographic distribution, their strong association with cultivation, diversification (except with regard to introduced diseases), and therapeutic versatility, but not versatility of use categories. Introduced plants make a disproportionately high contribution to plant medicine in Ecuador. The strong association of cultivation with introduced medicinal plant use highlights the importance of the maintenance of human-mediated environments such as homegardens and agroforests for the provisioning of healthcare services.

Age, time living with diagnosed HIV infection, and self-rated health

OBJECTIVES

An increasing proportion of people living with HIV are older adults, who may require specialized care. Adverse physical and psychological effects of HIV infection may be greatest among older people or those who have lived longer with HIV.

METHODS

The ASTRA study is a cross-sectional questionnaire study of 3258 HIV-diagnosed adults (2248 men who have sex with men, 373 heterosexual men and 637 women) recruited from UK clinics in 2011-2012. Associations of age group with physical symptom distress (significant distress for at least one of 26 symptoms), depression and anxiety symptoms (scores ≥ 10 on PHQ-9 and GAD-7, respectively), and health-related functional problems (problems on at least one of three domains of the Euroqol 5D-3L)) were assessed, adjusting for time with diagnosed HIV infection, gender/sexual orientation and ethnicity.

RESULTS

The age distribution of participants was: < 30 years, 5%; 30-39 years, 23%; 40-49 years, 43%; 50-59 years, 22%; and ≥ 60 years, 7%. Overall prevalences were: physical symptom distress, 56%; depression symptoms, 27%; anxiety symptoms, 22%; functional problems, 38%. No trend was found in the prevalence of physical symptom distress with age [adjusted odds ratio (OR) for trend across age groups, 0.96; 95% confidence interval (CI) 0.89, 1.04; P = 0.36]. The prevalence of depression and anxiety symptoms decreased with age [adjusted OR 0.86 (95% CI 0.79, 0.94; P = 0.001) and adjusted OR 0.85 (95% CI 0.77, 0.94; P = 0.001), respectively], while that of functional problems increased (adjusted OR 1.28; 95% CI 1.17, 1.39; P < 0.001). In contrast, a longer time with diagnosed HIV infection was strongly and independently associated with a higher prevalence of symptom distress, depression symptoms, anxiety symptoms, and functional problems (P < 0.001 for trends, adjusted analysis).

CONCLUSIONS

Among people living with HIV, although health-related functional problems were more common with older age, physical symptom distress was not, and mental health was more favourable. These results suggest that a longer time with diagnosed HIV infection, rather than age, is the dominating factor contributing to psychological morbidity and lower quality of life.

HIV incidence in an open national cohort of men who have sex with men attending sexually transmitted infection clinics in England

OBJECTIVES

The aim of the study was to determine HIV incidence among men who have sex with men (MSM) who repeat test for HIV at sexually transmitted infection (STI) clinics in England, and identify associated factors.

METHODS

Annual HIV incidence and 95% confidence interval (CI) were calculated for a national cohort of MSM who tested HIV negative at any STI clinic in England in 2012 and had a follow-up test within 1 year using routinely collected data. Cox regression analyses were performed to identify predictors of HIV acquisition and population attributable risk for HIV infection was calculated for predictors.

RESULTS

In 2012, 85 500 MSM not known to be HIV positive attended any STI clinic in England, and 31% tested for HIV at least twice within 1 year at the same clinic. HIV incidence was 2.0 per 100 person-years (PY; 95% CI 1.8-2.2) among repeat testers. Incidence was higher among MSM of black ethnicity (3.2 per 100 PY) and those with a bacterial STI diagnosis at the initial attendance (3.2 per 100 PY). MSM with a previous syphilis or gonorrhoea infection were at significantly greater risk of acquiring HIV in the subsequent year [adjusted hazard ratio 4.1 (95% CI 2.0-8.3) and 2.1 (95% CI 1.4-3.2), respectively]. The predictors accounted for 37% of HIV infections.

CONCLUSIONS

Annual HIV incidence among MSM attending STI clinics in England is high. Previous STIs were predictors of HIV acquisition but only accounted for one in five infections. More discriminatory behavioural predictors of HIV acquisition could provide better triaging of HIV prevention services for MSM attending STI clinics.

Macitentan treatment retards the progression of established pulmonary arterial hypertension in an animal model

BACKGROUND

Macitentan is a new endothelin receptor antagonist that is used to treat pulmonary arterial hypertension in humans. Treatment of established pulmonary hypertension with macitentan was studied using the monocrotaline model of pulmonary hypertension.

METHODS

Three groups of rats were created (n=12): control (CON: macitentan only), monocrotaline (MCT: monocrotaline only) and macitentan (MACI: macitentan and monocrotaline). Monocrotaline (60 mg/kg) was injected in the MCT and MACI groups on day 0; volume matched saline was injected in the CON groups. Macitentan therapy (30 mg/kg/day) was commenced on day 11 in the CON and MACI groups. Serial echocardiography and ECGs were performed. The rats were sacrificed if they showed clinical deterioration.

RESULTS

The MCT and MACI rats showed signs of pulmonary hypertension by day 7 (maximum pulmonary velocity, CON 1.15 ± 0.15m/s vs MCT 1.04 ± 0.10 m/s vs MACI 0.99 ± 0.18 m/s; p<0.05). Both the MCT and MACI groups developed pulmonary hypertension, but this was less severe in the MACI group (day 21 pulmonary artery acceleration time, MCT 17.55 ± 1.56 ms vs MACI 22.55 ± 1.00 ms; pulmonary artery deceleration, MCT 34.72 ± 3.72 m/s(2) vs MACI 17.30 ± 1.89 m/s(2); p<0.05). Right ventricular hypertrophy and QT interval increases were more pronounced in MCT than MACI (right ventricle wall thickness, MCT 0.13 ± 0.1cm vs MACI 0.10 ± 0.1cm; QT interval, MCT 85 ± 13 ms vs MACI 71 ± 14 ms; p<0.05). Survival benefit was not seen in the MACI group (p=0.50).

CONCLUSIONS

Macitentan treatment improves haemodynamic parameters in established pulmonary hypertension. Further research is required to see if earlier introduction of macitentan has greater effects.

Radiation protection in dental X-ray surgeries--still rooms for improvement

AIM

To illustrate the authors' experience in the provision of radiation protection adviser (RPA)/medical physics expert (MPE) services and critical examination/radiation quality assurance (QA) testing, to demonstrate any continuing variability of the compliance of X-ray sets with existing guidance and of compliance of dental practices with existing legislation.

METHOD

Data was collected from a series of critical examination and routine three-yearly radiation QA tests on 915 intra-oral X-ray sets and 124 panoramic sets. Data are the result of direct measurements on the sets, made using a traceably calibrated Unfors Xi meter. The testing covered the measurement of peak kilovoltage (kVp); filtration; timer accuracy and consistency; X-ray beam size; and radiation output, measured as the entrance surface dose in milliGray (mGy) for intra-oral sets and dose-area product (DAP), measured in mGy.cm(2) for panoramic sets. Physical checks, including mechanical stability, were also included as part of the testing process.

RESULTS

The Health and Safety Executive has expressed concern about the poor standards of compliance with the regulations during inspections at dental practices. Thirty-five percent of intra-oral sets exceeded the UK adult diagnostic reference level on at least one setting, as did 61% of those with child dose settings. There is a clear advantage of digital radiography and rectangular collimation in dose terms, with the mean dose from digital sets 59% that of film-based sets and a rectangular collimator 76% that of circular collimators. The data shows the unrealised potential for dose saving in many digital sets and also marked differences in dose between sets.

CONCLUSION

Provision of radiation protection advice to over 150 general dental practitioners raised a number of issues on the design of surgeries with X-ray equipment and critical examination testing. There is also considerable variation in advice given on the need (or lack of need) for room shielding. Where no radiation protection adviser (RPA) or medical physics expert (MPE) appointment has been made, there is often a very low level of compliance with legislative requirements. The active involvement of an RPA/MPE and continuing education on radiation protection issues has the potential to reduce radiation doses significantly further in many dental practices.