The impact of fluphenazine withdrawal: a mirror-image study

BACKGROUND

Fluphenazine decanoate licenced as a long-acting injectable (LAI) first-generation antipsychotic (FGA) was withdrawn from sale in 2018. This study evaluates if its withdrawal resulted in increased relapse rates of psychosis in an Irish patient cohort and examines which prescribed alternative antipsychotic medications were associated with more optimal outcomes.

METHODS

Fifteen participants diagnosed with a psychotic disorder were included. A mirror-image study over 24-months' pre-and post-withdrawal of fluphenazine was conducted. Kaplan-Meier survival and proportional hazards analyses were conducted. The impact of alternate antipsychotic agents (LAI flupenthixol compared to other antipsychotic medications) was evaluated. Semi-structured interviews with participants examined subjective opinions regarding the change in their treatment.

RESULTS

Seven participants (46.7%) relapsed in the 24-month period subsequent to fluphenazine discontinuation compared to one individual (6.7%) in the previous identical time-period (p = 0.035). Flupenthixol treatment was associated with reduced relapse rates compared to other antipsychotics (χ2 = 5.402, p = 0.02). Thematic analysis revealed that participants believed that the discontinuation of fluphenazine deleteriously impacted the stability of their mental disorder.

CONCLUSION

The withdrawal of fluphenazine was associated with increased relapse rate in individuals previously demonstrating stability of their psychotic disorder. While acknowledging the limitation of small sample size, preliminary evidence from this study suggests that treatment with the first-generation antipsychotic (FGA) flupenthixol was associated with a lower risk of relapse compared to SGAs. Reasons for this lower risk of relapse are not fully clear but could be related to dopamine hypersensitivity with this treatment change.

Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants

INTRODUCTION

Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited.

METHODS

Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed.

RESULTS

Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71).

CONCLUSION

Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.

Opinions of key stakeholders regarding the inpatient Individual Care Plan

OBJECTIVES

In Ireland, regularly reviewed Individual Care Plans (ICPs) for inpatients at all acute psychiatric inpatient units are a requirement of the Mental Health Act . In this study, we comprehensively evaluated and compared opinions of key stakeholders in relation to the ICP as a care delivery tool.

METHODS

We employed a descriptive survey design. Questionnaires were distributed to 123 stakeholders (patients and mental health professionals (MHPs)) to evaluate and compare opinions regarding the impact of the ICP in relation to healthcare delivery and health outcomes, and regarding the structure and frequency of use of the ICP.

RESULTS

Ninety-eight stakeholders (80%) completed study questionnaires. Stakeholders (patients (58%) and MHPs (85%)) reported that the ICP assisted in healthcare delivery. However, different attitudes between groups were noted in relation to whether the ICP contributed towards healthcare outcomes, with 64% of patients, but only 41% of MHPs reporting that the ICP positively contributed to mental healthcare outcomes. Some free-text comments described patient dissatisfaction with the role of the ICP for healthcare delivery, and MHP dissatisfaction that the ICP was time-consuming and did not significantly enhance standard patient care.

CONCLUSION

Whilst the implementation of the ICP is generally viewed positively by both patients and MHPs, considerable dissatisfaction by MHPs was also noted with certain aspects of how the ICP was delivered in practice. Practical adjustments to the implementation of ICP in order to build more positive stakeholder experiences appear warranted and worthy of further research.

A comparison of rate and methods of probable suicide for 2 years pre and post the onset of the COVID-19 pandemic

OBJECTIVES

To examine and compare rates and methods of probable suicide in a Western region of Ireland during a 24 month period since the onset of the COVID-19 pandemic compared with a similar period immediately prior to the pandemic onset.

METHODS

Post-mortem reports between March 1st 2018 and February 29th 2020 were reviewed and compared with data from March 1st 2020 to February 28th 2022. Relevant demographic data, rates and methods of probable suicide and lifetime engagement with mental health services were compared across the two time points.

RESULTS

Identical rates of probable suicide (85 individuals at both time points) were demonstrated with no difference evident in the utilisation of violent compared to non-violent methods.

CONCLUSIONS

This study demonstrates that despite previous reports of increased rates of self-harm and some evidence of increased mental distress since the onset of the COVID-19 pandemic, no change in rates of or methods employed by individuals who died by probable suicide were evident in this geographical region.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Feasibility of Cognitive-Sparing Stereotactic Radiosurgery for Brain Metastases: Initial Report of Phase II COG-SRS Trial

PURPOSE/OBJECTIVE(S)

Radiotherapy at high doses leads to white matter (WM) and hippocampal injury which can cause cognitive decline. We designed the first, to our knowledge, evidence-based cognitive sparing brain SRS trial for patients with limited brain metastases. In this report we analyze feasibility of cognitive-sparing SRS, utilizing dose constraints for eloquent WM tracts and bilateral hippocampi.

MATERIALS/METHODS

This is a single-institution phase II NCI-funded clinical trial (NCT04343157) of cognitive-sparing brain SRS; eloquent regions of interest (ROI) and associated cognitive domains are outlined in Table 1. Patients underwent high-resolution quantitative diffusion and volumetric MRI at baseline and post-SRS follow-up. Comprehensive neurocognitive assessment was performed at baseline and 3 months post-SRS by a neuropsychologist evaluating different neurocognitive domains (Table 1). Clinical processing/workflow was largely automated with robust, validated segmentation tools of eloquent WM tracts and the hippocampi. Single fraction dose constraints to WM tracts were 12 Gy Dmax and 8.4 Gy to hippocampi with 3 and 5 fraction equivalent doses, based on our prior NTCP studies. Patient accrual, follow up imaging and neurocognitive testing is still active.

RESULTS

To date, n = 59 patients and 114 lesions have been treated with cognitive-sparing Linac-based SRS on trial. Median age is 63 years. Lung cancer was the most common primary (35.6%), along with breast cancer (23.7%) and melanoma (15.3%). Patients had 1-4 brain metastases; median prescription dose was 24 Gy/1, 27 Gy/3, or 30 Gy/5 depending on target volume. Most patients were treated < 7 business days from MRI. Cognitive endpoints have been collected on 89.5% of patients. Cognitive sparing constraints were met in 79.3% of plans while maintaining standard clinical SRS plan indices and coverage benchmarks. 38.9% of the plans that failed to meet the Dmax constraint kept D0.03cc under constraints. Plans going over constraints had tumors overlying or within 1 mm of eloquent ROIs. Local control for treated lesions at 6 months was 97.9% and 95.7% at 12 months. Distant intracranial control was 68.1% at 6 and 12 months. Median OS was 18 months.

CONCLUSION

Cognitive-sparing SRS treatment planning was successfully implemented for the majority of treated lesions with excellent local control. Mitigation of damage to eloquent structures has potential to further reduce cognitive decline after SRS. Full neurocognitive outcomes will be reported after accrual and testing are complete.

Quantitative Analysis of BrainAge using Neuroimaging Data to Estimate Radiation-Induced Brain Aging and Associations with Cognitive Changes in Brain Metastases Patients

PURPOSE/OBJECTIVE(S)

Radiotherapy is critical in brain tumor management yet causes accelerated aging via irreparable damage to white matter, cortex, and subcortical areas. BrainAGE is an open-source machine learning tool that analyses morphology from raw quantitative structural MRI to generate a predictive 'BrainAge' value, enabling analyses of patients with neurodegenerative diseases. We assessed the utility of this algorithm in measuring brain age morphology in brain metastases patients on a clinical trial, analyzed differences in BrainAge and chronological age, and explored associations with cognitive performance.

MATERIALS/METHODS

We analyzed pre-SRS high-resolution T1-weighted noncontrast volumetric MRI in patients with brain metastases (n = 57, median age 63 years, range 20-87) treated on a prospective clinical trial of cognitive-sparing SRS. The BrainAGE machine learning tool processed images to derive a BrainAge; it reliably generates this value using a Gaussian Processes regression, with a robust neurotypical training cohort. We examined correlations between BrainAge and chronological age with regression. Brain-predicted age gap (Brain-Gap) was calculated, defined as the difference between a patient's BrainAge and chronological age. We assessed cognitive function at baseline pre-SRS with a comprehensive battery of validated tests across multiple domains performed by a neuropsychologist, including memory (HVLT total), executive function (COWAT category fluency), and language (COWAT letter fluency). Raw test scores were scaled to T-scores adjusting for age, sex, and education level per testing norms. We examined if Brain-Gap was associated with cognitive performance pre-SRS.

RESULTS

BrainAGE software was robust, estimating a BrainAge for all input MRI sequences. We found a strong correlation between BrainAge and chronological age (r-squared = 0.82). The Brain-Gap median value was 0.84 and the mean was -0.90, in years (range -18.30-11.36 years). Brain-Gap was not significantly associated with cognitive performance across the three tests at the pre-SRS timepoint. Among patients with impaired cognition (T<35), there was no significant difference in BrainAge relative to chronological age.

CONCLUSION

To our knowledge, this is the first study utilizing the BrainAGE model as a biomarker of neuroanatomical age for brain tumors patients. Existing publications had lesion-free cohorts. Our results show that BrainAge was reliably associated with chronologic age in brain metastases patients pre-SRS. The Brain-Gap difference was minimal at baseline, and we found no significant association with pre-SRS cognitive performance. Future studies will examine this biomarker after SRS to look for individual aging radiation effects and prediction for cognitive changes after therapy.

Evidence-Based Multivariate Normal Tissue Complication Probability (NTCP) Study of Domain-Specific Cognitive Decline after Partial Brain RT

PURPOSE/OBJECTIVE(S)

Beyond the hippocampus, there are no evidence-based dose constraints for eloquent brain structures which subserve memory and attention/processing speed. We performed a multivariate normal tissue complication probability analysis of post-RT neurocognitive decline, examining dosimetric predictors of eloquent brain regions.

MATERIALS/METHODS

Data were analyzed from a prospective longitudinal clinical trial. Patients (n = 78) with primary brain tumors receiving fractionated RT complete a comprehensive neurocognitive evaluation and high-resolution volumetric and diffusion MRI at baseline and 6 months post-RT. Image processing using robust, validated automated segmentation parcellated individual WM tracts, cortical regions, and hippocampi. Well-validated neurocognitive tests including Delis-Kaplan Executive Function System and Wechsler Adult Intelligence Scale-IV coding (attention/processing), Boston Naming Test (language) and Hopkins Verbal Learning Test and Brief Visuospatial Memory Test (verbal/visuospatial memory) were assessed. Reliable change indices adjusted for practice effects (RCI-PE) were calculated for each patient between baseline and 6 months; a negative RCI-PE was scored as decline. Univariate logistic regression was performed with mean and max dose to structures of interest as well as clinical variables. Multivariate model building was performed using automated bootstrapped logistic regression, LASSO and random forest modeling.

RESULTS

On univariate analysis mean and max dose to multiple regions of the corpus callosum (CC) were correlated with attention/processing speed decline; most significantly in WAIS coding, including Dmax to the anterior CC (p = 0.011) and central CC (p = 0.010), and Dmax and Dmean to the mid anterior CC (p = 0.006 and 0.010). Mean dose to the left fornix was associated with decline in memory (p = 0.023, cutoff 12.9 Gy), as were increasing age and both concurrent and adjuvant chemotherapy. On multivariate analysis for attention, automated bootstrapped logistic regression showed the most frequently selected variable was mean dose to the mid anterior CC. Performance at nested cross-validation by AUC was 0.80 (0.75-0.84); LASSO model performance by AUC was 0.76 (0.72-0.81) with Dmean to the mid anterior CC being the most frequent variable. The top five most important variables in the Random Forest as ranked by mean decrease in Gini coefficient were mean dose to mid anterior CC, all white matter, combined CC and max dose to CC and posterior CC. Model performance by AUC was 0.66 (0.60-0.71).

CONCLUSION

Here, we present the first, to our knowledge, NTCP model for decline in attention/processing speed, along with dosimetric predictors of memory decline beyond the hippocampus. We found that after partial brain RT, dose to several ROIs significantly correlated with post-RT impairment. These data can guide future cognitive-sparing strategies for brain RT.

A 2-year longitudinal evaluation of the impact of the COVID-19 pandemic on individuals with pre-existing anxiety disorders

OBJECTIVES

To examine if the COVID-19 pandemic is associated with a differential effect over a 2-year time period in relation to its psychological and social impact on patients with established anxiety disorders.

METHODS

Semi-structured interviews were conducted with 21 individuals attending the Galway-Roscommon Mental Health Services in Ireland with an ICD-10 diagnosis of an anxiety disorder. Interviews occurred at three time-points over a 2-year period to determine the impact of the COVID-19 pandemic and associated restrictions on anxiety and depressive symptoms, social and occupational functioning, and quality of life.

RESULTS

No statistical difference in symptomatology was noted between the three time-points in relation to anxiety symptoms as measured utilising psychometric rating scales (Beck Anxiety Inventory (BAI), Hamilton Anxiety Rating Scale (HARS) or Likert Scale measures). The greatest impact of COVID-19 at all time-points related to social functioning and quality of life. Significant variability was noted for individual participants. Qualitative analysis noted a tentative optimism for the future in the setting of vaccination and societal re-opening. Fear of re-emerging anxiety symptoms with the removal of societal restrictions was noted.

CONCLUSIONS

No significant overall change in symptomatology or functioning over time was noted for individuals with pre-existing anxiety disorders, however variability was demonstrated, with some individuals describing ongoing anxiety, social isolation and concern for their future. A strong theme of hope for the future and less concern regarding the COVID-19 pandemic was evident; however tailored supports including the utilisation of tele-psychiatry is suggested, particularly for those experiencing increased anxiety with the removal of societal restrictions.

Proximal humerus fractures: A review of current practice

The management of proximal humeral fractures (PHF) remains controversial. Its incidence is increasing. Patients should be meticulously assessed clinically for co-morbidities and neuro-vascular injuries. Radiological investigation helps provide information on the fracture configuration and dislocations. Enhanced by 3-dimensional CT scanning, these further help in decision making and operative planning. PHF classifications have been demonstrated to have poor intra-observer and inter-observer reliability. Research has identified some radiographic predictive factors for humeral head ischaemia and likely failure of surgical fixation. The range of management options include non-operative treatment, operative fixation, intramedullary nailing and arthroplasty (hemiarthroplasty, reverse shoulder replacement). The majority of PHFs are stable injuries and non-operative management is usually successful. Some degree of malunion is readily tolerated especially by elderly patients. Surgical management of significantly displaced, unstable proximal humerus fractures should aim to stabilise the fracture adequately and provide satisfactory function for the long term. Management of the greater tuberosity is pivotal for the eventual outcome. When fixation may appear to be compromised by poor bone quality, likely poor function, age related rotator cuff degeneration or likely humeral head ischaemia clinicians may opt for arthroplasty. Successful hemiarthroplasty outcomes are dependent on sufficient healing of the tuberosity and recovery of the rotator cuff integrity. Reverse shoulder replacement can predictably deliver good functional outcomes for the shoulder in elderly patients, where rotator cuff dysfunction is suspected or as a revision procedure following failure of other surgical interventions. As opposed to hemiarthroplasty, which has shown a downward trend, there has been an increasing trend towards the use of reverse shoulder replacement in proximal humeral fractures. The management of PHFs should be patient specific, fracture specific and meet the functional demands and needs of the individual patient. The surgeon's skill set and clinical experience also plays an important role in the options of management available.

Kynanthropic and vampirism delusions: a case report and review of the literature

Zooanthropy (delusional beliefs of turning into an animal) is a rare but well recognised psychiatric phenomenon. This case describes the presence of kynanthropic delusions (delusional beliefs of turning into a dog). Multiple other psychotic symptoms were also evident including unusually the additional presence of delusions of vampirism. Delusional beliefs in this case were associated with behavioural changes including growling and barking, and less commonly an expressed craving for biting people's necks to suck human blood. Symptom intensity was associated with increased psychosocial stressors for this patient, with some benefit noted from very high doses of anti-psychotic medications. Brief admissions to the acute psychiatric inpatient unit and thus removal from environmental stressors has been associated with an amelioration in symptomatology.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 10⁹/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Quality of life after involuntary psychiatric admission

Studies seeking predictors of outcomes after involuntary admission, including quality of life (QoL), are limited and results inconsistent. We aimed to describe QoL 3 months after involuntary psychiatric admission and to investigate associated factors. One hundred and fifty-three involuntarily admitted inpatients were assessed for a range of sociodemographic and clinical variables. Structured scales included the Brief Psychiatric Rating Scale (BPRS), the MacArthur Admission Experience Survey, the Heinrichs Quality of Life Scale and the World Health Organisation Quality of Life Brief Assessment (WHOQOL-BREF, n = 124). The mean total score on the Heinrichs QoL scale at 3 months was 69.3 (SD = 24.1). Predictors of higher 3 month QoL after involuntary admission in a multiple regression model (adjusted R² = 0.37, F = 7.1 (14, 138), p ≤0.001) were less severe negative symptoms on the BPRS at baseline (B = -4.56, p < 0.001), improvement in negative symptom scores between baseline and follow up (B = 4.58, p < 0.001) and higher current social class (B = -14.31, p = 0.001). Events during involuntary admission, such as being subject to coercive experiences, were not significantly associated with QoL after admission. The results suggest that a core determinant of service users' QoL after involuntary admission is negative symptom severity and change over time.

Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R): protocol for a pilot randomised controlled study

BACKGROUND

Psychosis, even in its early stages, is associated with significant disability, causing it to be ranked ahead of paraplegia and blindness in those aged 18-35 in terms of years lived with disability. Current pharmacological and psychological interventions intervention have focused primarily on the reduction of positive symptoms (hallucinations and delusions), with little benefit to domains of psychosis such as cognitive difficulties and social and occupational functioning.

METHODS/DESIGN

The CReSt-R intervention trial is a single center, pilot randomised controlled study based at the National University of Ireland (NUI), Galway. The trial will recruit participants from four clinical sites with assessment and intervention completed by the primary NUI Galway team. The trial will explore the feasibility, acceptability, and effectiveness of a novel psychosocial intervention for early psychosis based on a combined cognitive remediation training and cognitive behavioural therapy approach focused on social recovery. Participants, aged 16-35 within the first 5 years of a diagnosed psychotic disorder, will be recruited from the Children and Adolescent Mental Health Service and the Adult Mental Health Services in the region.

DISCUSSION

Cognitive remediation training (for improving cognition) and social recovery focused cognitive behavioural therapy, have both separately demonstrated effectiveness. This trial will evaluate the feasibility, acceptability, and explore the efficacy of a treatment approach that combines both approaches as part of an integrated, multicomponent intervention.

TRIAL REGISTRATION

Cognitive Remediation & Social Recovery in Early Psychosis (CReSt-R): ClincialTrials.gov Identifier NCT04273685. Trial registered Feb 18th, 2020. Last updated April 14th, 2021.

A191 PERSISTENT BENEFIT OF DIETITIAN-LED GLUTEN-FREE DIET EDUCATION AT CD DIAGNOSIS ON DIETARY ADHERENCE IN CHILDREN AND ADULTS WITH TYPE 1 DIABETES AND CELIAC DISEASE

Background

Celiac disease (CD) is a common autoimmune comorbidity of type 1 diabetes (T1D) with a gluten-free diet (GFD) being the current gold standard treatment for this condition. Adherence to a GFD can be impacted by several factors including dietetic counselling, yet little is known about the impact of clinic-based interventions on long-term GFD adherence in this population.

Aims

To prospectively evaluate the impact of a dietitian-led GFD education intervention on adherence to a GFD in children and adults with T1D and CD over a 3-year period.

Methods

A cohort of N=62 pediatric and adult subjects who screened seropositive for CD as part of the CD-DIET clinical trial were followed over a 3-year period post-CD diagnosis and assessed on the basis of the GFD education regimen they received at initial CD diagnosis. This included 3 groups: 1) intensive dietitian training (IDT = 5 dietitian visits over 1 year while following GFD), 2) single dietitian training (SDT = 1 GFD training session after 1 year of following GCD) and 3) no dietitian training (NDT) at CD diagnosis. Annual visits included serologic testing of TTG-IgA titres, anthropometric assessments and the completion of questionnaires evaluating diet and adherence to a GFD. Data was analysed longitudinally using linear mixed effects and generalized estimating equations (GEE) regression modeling adjusting for the fixed effects of age, sex, duration of diabetes and time.

Results

At baseline, participants who received IDT (n=15), SDT (n=16) and NDT (n=31) represented 24.2%, 25.8%, and 50.0% of the cohort, respectively. Over the 3-year study period, participants in the IDT group had the greatest odds of self-reporting being a GFD, with odds 4.3 (95%CI: 1.1 to 16.4; P=0.033) and 9.5 (95%CI: 2.7 to 33.7; P&lt;0.001) greater than the SDT and NDT groups, respectively. The assessment of daily gluten intakes less than 10mg, as recommended for a GFD, revealed a lack of differences between the IDT and SDT groups. In contrast, the NDT group had significantly lower odds of meeting this threshold relative to those who received IDT (OR=0.2; 95%CI: 0.04 to 0.56; P=0.004). No longitudinal differences in TTG-IgA levels were seen between groups over the 3-year period.

Conclusions

In diabetes patients greater contact with a dietitian at CD diagnosis was associated with higher levels of GFD adherence over time, which was not reflected in follow-up Serologic evaluation. These findings highlight the importance of nutritional support in patients with both diabetes and celiac disease at the time of CD diagnosis. In addition, following TTG-IgA alone does not fully inform dietary compliance to a GFD.

Diet teaching stratification

Funding Agencies

Juvenile Diabetes Research Foundation / PSI

Psychiatric and psycho-social characteristics of suicide completers: a 13-year comprehensive evaluation of psychiatric case records and post-mortem findings

Currently, there are limited data comparing demographic and clinical characteristics of individuals who died by probable suicide and who did and did not previously attend mental health services (MHSs). This study compared demographic and clinical factors for both groups, in a Western region of Ireland over a 13-year period. Postmortem reports between January 1, 2006 and March 31, 2019 were reviewed for 400 individuals who died by probable suicide. Relevant sociodemographic and clinical data were extracted from individuals’ lifetime case notes. One hundred and fifty nine individuals (40%) had attended MHSs at some stage (“attendee”). Hanging was the most common method of suicide (61%), followed by drowning (18%) for both attendees and nonattendees of MHSs, with more violent methods utilized overall by nonattendees (p = 0.028). Sixty-eight percent of individuals who previously attempted hanging subsequently died utilizing this method. A higher proportion of attendees were female compared to nonattendees of MHSs (28.9 vs. 14.5%, p = 0.001). Recurrent depressive disorder (55%) was the most common diagnosed mental health disorder. For individuals with a diagnosis of schizophrenia, 39% had antipsychotic medications detectable in their toxicology reports. In conclusion, the majority of people who died by probable suicide had never had contact with MHSs, and nonattendees overall were more likely to utilize violent methods of suicide. Nonconcordance with psychotropic medications in psychotic patients and previous hanging attempt were highlighted as potential risk factors for death by probable suicide.

Review of the current empirical literature on using videoconferencing to deliver individual psychotherapies to adults with mental health problems

PURPOSE

The COVID-19 pandemic has resulted in a widespread adoption of videoconferencing as a communication medium in mental health service delivery. This review considers the empirical literature to date on using videoconferencing to deliver psychological therapy to adults presenting with mental health problems.

METHOD

Papers were identified via search of relevant databases. Quantitative and qualitative data were extracted and synthesized on uptake, feasibility, outcomes, and participant and therapist experiences.

RESULTS

Videoconferencing has an established evidence base in the delivery of cognitive behavioural therapies for post-traumatic stress disorder and depression, with prolonged exposure, cognitive processing therapy, and behavioural activation non-inferior to in-person delivery. There are large trials reporting efficacy for health anxiety and bulimia nervosa compared with treatment-as-usual. Initial studies show applicability of cognitive behavioural therapies for other anxiety and eating disorders and obsessive-compulsive spectrum disorders, but there has yet to be study of use in severe and complex mental health problems. Therapists may find it more difficult to judge non-verbal behaviour, and there may be initial discomfort while adapting to videoconferencing, but client ratings of the therapeutic alliance are similar to in-person therapy, and videoconferencing may have advantages such as being less confronting. There may be useful opportunities for videoconferencing in embedding therapy delivery within the client's own environment.

CONCLUSIONS

Videoconferencing is an accessible and effective modality for therapy delivery. Future research needs to extend beyond testing whether videoconferencing can replicate in-person therapy delivery to consider unique therapeutic affordances of the videoconferencing modality.

PRACTITIONER POINTS

Videoconferencing is an efficacious means of delivering behavioural and cognitive therapies to adults with mental health problems. Trial evidence has established it is no less efficacious than in-person therapy for prolonged exposure, cognitive processing therapy, and behavioural activation. While therapists report nonverbal feedback being harder to judge, and clients can take time to adapt to videoconferencing, clients rate the therapeutic alliance and satisfaction similarly to therapy in-person. Videoconferencing provides opportunities to integrate therapeutic exercises within the person's day-to-day environment.

Clinical features and presentation of cervicofacial infection: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management, and clinical features of patients hospitalised with CFI. Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis, and presenting clinical features. One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median (range) age was 34 (1-94) years. The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%). Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team, and members of the OMFS team.

A65 ENDOSCOPIST-TARGETED INTERVENTIONS TO OPTIMIZE ADENOMA DETECTION RATE - A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Adenoma detection rate (ADR) has emerged as the strongest quality assurance metric that has consistently been shown to be inversely associated with the development of colorectal cancer after colonoscopy. Unfortunately, marked variability in ADR exists among endoscopists. A multitude of interventions targeted at endoscopists to optimize their ADR have been reported, including but not limited to withdrawal time, in room observers, physician report cards, and quality improvement and training programs. However, it is unclear which of them are truly effective.

Aims

We performed a systematic review and meta-analysis of the literature to evaluate the effectiveness of endoscopist-targeted interventions to improve adenoma detection rate (ADR) or polyp detection rate (PDR).

Methods

Systematic searches of major databases were conducted through to March 2018 to identify potentially relevant studies. Both randomized controlled trials and observational studies were included. Data for ADR and PDR were analyzed on the log-odds scale using a random-effects meta-analysis model using restricted maximum likelihood (with Mantel-Haenszel fixed-effect meta-analysis used for fewer than 4 studies). Statistical effect-size heterogeneity was assessed using a Chi2 test and quantifying the relative proportion of variation using the I2 statistic. Publication bias was assessed by the Harbord regression test.

Results

From 4299 initial studies, 24 were included in the systematic review and 13 were included in the meta-analysis representing a total of 55,090 colonoscopies. Physician report card interventions (7 studies) and withdrawal time focused interventions (6 studies) were meta-analyzed. The pooled odds ratio for ADR for report card interventions was 1.31 (95% CI: 1.15, 1.50; p&lt;0.0001), favoring report cards to detect more adenomas. Statistical heterogeneity was detected with substantial relative effect-size variability (Chi2, p&lt;0.0001; I2=80.1%). No statistical evidence of publication bias was found. 6 studies reported data for PDR using withdrawal time focused interventions, with 3 of these reporting data on ADR. The pooled odds ratio for ADR was 1.02 (95% CI: 0.86, 1.22; p=0.81) and for PDR was 1.07 (95% CI: 0.88, 1.31; p=0.51) which were not statistically significant. Statistical heterogeneity was detected in both groups (Chi2, p&lt;0.001; I2=82.2% for ADR and I2=89.4% for PDR) and there was statistical evidence of publication bias. Figures 1 and 2 represent Forest plots for the effect of pre-and post-report card and withdrawal time focused interventions on ADR.

Conclusions

Our study provides evidence that the distribution of colonoscopy quality report cards to physicians significantly improves overall ADR and should strongly be considered as part of quality improvement programs aimed at optimizing colonoscopy performance.

Funding Agencies

None

A134 A MULTI-CENTRE RANDOMIZED CONTROLLED TRIAL TO COMPARE TWO BOWEL CLEANSING REGIMENS AFTER A COLONOSCOPY WITH INADEQUATE BOWEL PREPARATION

Aims

Failed bowel preparation is common during colonoscopy, yet the optimal purgative regimen to use for the next attempt is unknown. The objective of this study was to compare the efficacy, tolerability, and safety of two regimens at supratherapeutic doses for use after failed bowel preparation.

Methods

A multi-centre phase III endoscopist blinded randomized controlled trial (NCT02976805) was conducted in patients who failed bowel preparation, using the US Multi-Society Task Force (USMSTF) definition of inability to exclude polyps &gt;5 mm in size and requiring a shortened interval to next colonoscopy. Regimen A consisted of 15 mg of bisacodyl and 2 + 2 L of split dose polyethylene glycol electrolyte solution (PEG) and Regimen B consisted of 15 mg of bisacodyl and 4 + 2 L of split dose PEG. The primary outcome was adequate bowel preparation, defined as a Boston Bowel Preparation Scale (BBPS) total score ≥ 6 with all segment scores ≥ 2. Secondary outcomes were adequate bowel preparation using the USMSTF definition, median BBPS, adenoma detection (ADR), advanced adenoma detection (aADR), sessile serrated polyp detection (SSPDR), and cecal intubation (CIR). Adverse events were assessed at the time of the colonoscopy and 14 days later.

Results

Between February 2017 and December 2019, 250 subjects were screened at four academic centres in Canada, of which 195 were randomized: 96 to Regimen A and 99 to Regimen B. The mean (SD) age was 60.6 (11.4) years, 87 (45.1%) were female, and the median (IQR) total BBPS score at previous failed colonoscopy was 3 (1,4). Regimen B was not superior to Regimen A in achieving adequate bowel preparation using the BBPS definition (87.6% vs. 91.1%, p=0.45) or the USMSTF definition (85.4% vs 91.1%, p=0.24), nor was it superior with respect to the median BBPS score (7 vs 7, p=0.50), mean ADR (31.5% vs 37.8%, p=0.37), aADR (11.2% vs 18.9%, p=0.15), SSPDR (5.6% vs 8.9%, p=0.40) or CIR (92.1% vs 96.7%, p=0.19). Regimen A had a higher adherence rate (88.2% vs. 74.7%, p=0.02) and greater willingness to undergo the bowel preparation again (91.2% vs. 66.2%, p&lt;0.001). The only serious adverse event occurred in a patient randomized to Regimen B who was admitted to hospital for vomiting after colonoscopy.

Conclusions

Split dose 4L PEG with 15mg of bisacodyl is highly efficacious, well tolerated, and can be used for patients who previously failed first line bowel preparations. The additional 2L of PEG in Regimen B did not improve bowel preparation and was not as well tolerated.

Funding Agencies

AMOSO Opportunities Grant, Pharmascence Inc.

A108 ARE INPATIENTS STILL MORE LIKELY TO FAIL BOWEL PREPARATION IN THE SPLIT-DOSE ERA? FINDINGS FROM 47, 292 COLONOSCOPIES IN THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

Prior studies before the widespread use of split-dose bowel preparation have shown a high rate of inadequate bowel preparation in hospitalized patients. Whether this is still true in the era of split-dose bowel preparation is unknown.

Aims

To determine the impact of inpatient status on bowel preparation quality in the contemporary era of split-dose bowel preparation.

Methods

The Southwest Ontario Colonoscopy cohort consists of all inpatient and outpatient colonoscopies performed between April 2017 and Oct 2018 at 21 hospitals serving a large geographic health region. Procedures done in patients &lt; 18 years of age or by an endoscopist performing &lt;50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed. The primary outcome was adequate bowel preparation, defined on an ordinal scale as “good” or “fair” rather than “poor”. Secondary outcomes included adenoma detection rate (ADR), sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), and cecal intubation rate (CIR).

Results

A total of 47,292 colonoscopies were performed by 75 physicians (36.2% by gastroenterologists, 60% by general surgeons, 4% others), of which 1,690 were inpatients (3.6%). Inpatients were older (mean 66.8 years vs 60.2 years, p&lt;0.0001), more co-morbid (≥ASA grade 3, 53.6% vs 23.7%, p&lt;0.0001), performed for symptomatic indications (95.7% vs 48.6%, p&lt; 0.0001), have trainee involvement (47% vs 11.6% p&lt;0.001), and less likely to receive split-dose bowel preparation (71.7% vs 91.6% p&lt;0.001). On crude analysis, inpatients were less likely to have adequate bowel preparation (86.2% vs 97.6% p&lt;0.001). On multi-variable analysis, inpatients had lower odds of achieving adequate bowel preparation (OR=0.41, 95% CI 0.33 - 0.50, p&lt;0.001), lower ADR (OR=0.47, 95% CI 0.40 - 0.55, p&lt;0.001), lower PDR (OR=0.54, 95% CI 0.47 - 0.61 p&lt;0.001) and lower CIR (OR = 0.43, 95% CI 0.35 - 0.54, p&lt;0.001).

Conclusions

In the era of split-dose bowel preparation, inpatient status is still an important predictor of inadequate bowel preparation with resultant lower quality outcome metrics.

Funding Agencies

None

A113 ANNUAL COLONOSCOPY VOLUME IS NOT PREDICTIVE OF COLONOSCOPY QUALITY - FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

Performing a minimum number of colonoscopies annually has been proposed by some jurisdictions as a requirement for maintaining privileges. However, this practice is supported by limited evidence.

Aims

The objective of this study was to determine if annual colonoscopy volume was associated with colonoscopy quality metrics.

Methods

A population-based study was performed using the Southwest Ontario Colonoscopy cohort, which consists of all adult patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 academic and community hospitals within the health region. Data were collected through a mandatory quality assurance form completed after each procedure and pathology reports were manually reviewed. Physician annualized colonoscopy volumes were compared by correlation analysis to each quality-related outcome, by means of the area under the receiver operating characteristics curve (AUROC), and logistic regression. The prognostic value of colonoscopy volume was also adjusted for case-mix and potential confounders in separate regression analyses for each outcome. The primary outcome was ADR. Secondary outcomes were polyp detection rate (PDR), sessile serrated polyp detection rate (SSPDR), and cecal intubation.

Results

A total of 47,195 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others). There were no clear relationships between annual colonoscopy volumes and study outcomes. Colonoscopy volume was not associated with ADR (OR 1.03, 95% CI 0.96–1.10, p=0.48) and corresponded to an AUROC not significantly different from the null (AUROC 0.52, 95% CI 0.43–0.61, p=0.65). Multi-variable regression adjusting for case-mix also demonstrated no predictive value of annual colonoscopy volume for the primary outcome (OR 1.03, 95% CI 0.94–1.12, p=0.55). Similarly, analyses of secondary outcomes failed to find an association between colonoscopy volume and PDR, SSPDR, or cecal intubation (Table 1).

Conclusions

Annual colonoscopy volumes do not predict ADR, PDR, SSPDR, or cecal intubation rate.

Results of unconditional and conditional approaches for examining the predictive value of annual colonoscopy volume for quality related outcomes.

Funding Agencies

None

A117 PROPOFOL SEDATION DOES NOT IMPROVE MEASURES OF COLONOSCOPY QUALITY – FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

The use of propofol during colonoscopy has gained increased popularity due to deeper anesthesia compared to conscious sedation. Prior studies examining the use of propofol sedation during colonoscopy have primarily focused on anesthesia outcomes. Whether propofol sedation is associated with improvements in colonoscopy outcomes is uncertain.

Aims

The primary outcome was adenoma detection rate (ADR). Secondary outcomes were the detection of any adenoma (conventional adenoma, sessile serrated polyp, and traditional serrated adenoma), sessile serrated polyp detection rate, polyp detection rate, cecal intubation rate, and perforation rate.

Methods

The Southwest Ontario Colonoscopy cohort consists of all patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 hospitals serving a large geographic area in Southwest Ontario. Procedures performed in patients less than 18 years of age or by endoscopist who perform &lt;50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed.

Results

A total of 46,634 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others) of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation (e.g. combination of a benzodiazepine and a narcotic). Patients who received propofol were likely to have a screening indication (49.2% vs 45.5%, p&lt;0.0001), not have a trainee endoscopist present and be performed at a non-academic centre (32.2% vs 44.6%, p&lt;0.0001). Compared to conscious sedation, use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p&lt;0.0001) and detection of any adenoma (27.7% vs. 29.8%, p&lt;0.0001); no difference was observed in the detection ofsessile serrated polyps (5.0% vs. 4.7%, p=0.26), polyp detection rate (41.2% vs 41.2%, p=0.978), cecal intubation rate (97.1% vs. 96.8%, p=0.15) or perforation rate (0.04% vs. 0.06%,p=0.45). On multi-variable analysis, the use of propofol was not significantly associated with any improvement in ADR (RR=0.90, 95% CI 0.74–1.10, p=0.30), detection of any adenoma (RR=0.93, 95% CI 0.75–1.14, p=0.47), sessile serrated polyp detection rate (RR=1.20, 95%CI 0.90–1.60, p=0.22), polyp detection rate (RR=1.00, 95% CI 0.90–1.11, p=0.99), or cecal intubation rate (RR=1.00, 95%CI 0.80–1.26, p=0.99).

Conclusions

The use of propofol sedation does not improve colonoscopy quality metrics.

Funding Agencies

None