247 QUALITY IMPROVEMENT IN DEMENTIA CARE: STREAMLINING CARE PATHWAYS IN A PSYCHIATRY OF OLD AGE SERVICE

Background

Dementia is increasingly considered a public health priority worldwide in the context of predicted increased prevalence. In Ireland, there are an estimated 67,000 persons living with dementia and by 2041 it is expected to rise to 145,000 persons. Challenges in dementia care have been highlighted in health services across Europe and the ineffective structure of dementia care with fragmented non-person-centred pathways has been identified.

Methods

An initial review of the existing cognitive impairment diagnostic pathways in our specialised Psychiatry of Old Age (POA) Service was undertaken. This included surveying the multidisciplinary team to identify challenges, clinical chart review and audit of physical examination equipment. Diagnostic pathway was updated based on findings and informed by the developing national ‘Model of Care for Dementia in Ireland’ and best practice.

Results

Review findings included lack of standardisation of memory assessment, delays in accessing neuroimaging and laboratory results, gaps in staff training. A care pathway document was developed detailing requirements for care from the point of referral through to cognitive impairment diagnosis. Staff training was completed to accompany the introduction of standardised dementia assessment scales. Access to laboratory/radiology booking was enhanced. A cognitive remediation group was developed by Occupational Therapy as part of post-diagnostic supports for service users. Preliminary data indicates improvements in satisfaction of those attending the group. Physical examination equipment audit resulted in quality improvements.

Conclusion

We demonstrate that a quality improvement approach can be implemented to enhance assessment, diagnosis and care provided to support diagnosis of cognitive impairment and dementia in POA service. The enhanced diagnostic care pathways will be assessed over time to assess impact on care of service users. Preliminary findings are positive and it is an approach that can be adopted in other services and inform development of national memory service developments.

Profiles of visuospatial memory dysfunction in opioid-exposed and dependent populations

BACKGROUND

Chronic opioid exposure is common world-wide, but behavioural performance remains under-investigated. This study aimed to investigate visuospatial memory performance in opioid-exposed and dependent clinical populations and its associations with measures of intelligence and cognitive impulsivity.

METHODS

We recruited 109 participants: (i) patients with a history of opioid dependence due to chronic heroin use (n = 24), (ii) heroin users stabilised on methadone maintenance treatment (n = 29), (iii) participants with a history of chronic pain and prescribed tramadol and codeine (n = 28) and (iv) healthy controls (n = 28). The neuropsychological tasks from the Cambridge Neuropsychological Test Automated Battery included the Delayed Matching to Sample (DMS), Pattern Recognition Memory, Spatial Recognition Memory, Paired Associate Learning, Spatial Span Task, Spatial Working Memory and Cambridge Gambling Task. Pre-morbid general intelligence was assessed using the National Adult Reading Test.

RESULTS

As hypothesised, this study identified the differential effects of chronic heroin and methadone exposures on neuropsychological measures of visuospatial memory (p < 0.01) that were independent of injecting behaviour and dependence status. The study also identified an improvement in DMS performance (specifically at longer delays) when the methadone group was compared with the heroin group and also when the heroin group was stabilised onto methadone. Results identified differential effects of chronic heroin and methadone exposures on various neuropsychological measures of visuospatial memory independently from addiction severity measures, such as injecting behaviour and dependence status.

Evidence of opioid-induced hyperalgesia in clinical populations after chronic opioid exposure: a systematic review and meta-analysis

BACKGROUND

Opioid-induced hyperalgesia (OIH) is well documented in preclinical studies, but findings of clinical studies are less consistent. The objective was to undertake a systematic review and meta-analysis of studies examining evidence for OIH in humans after opioid exposure.

METHODS

Systematic electronic searches utilised six research databases (Embase, Medline, PubMed, CINAHL Plus, Web of Science, and OpenGrey). Manual 'grey' literature searches were also undertaken. The Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework was used to develop search strategies, and findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Data synthesis and subgroup analyses were undertaken using a random effects model (DerSimonian-Laird method).

RESULTS

A total of 6167 articles were identified. After abstract and full-text reviews, 26 articles (involving 2706 participants) were included in the review. There was evidence of OIH, assessed by pain tolerance, in response to noxious thermal (hot and cold) stimuli, but not electrical stimuli. There was no evidence of OIH when assessing pain detection thresholds. OIH was more evident in patients with opioid use disorder than in patients with pain, and in patient groups treated with N-methyl-d-aspartate receptor antagonists (primarily evidenced in methadone-maintained populations).

CONCLUSIONS

OIH was evident in patients after chronic opioid exposure, but findings were dependent upon pain modality and assessment measures. Further studies should consider evaluating both pain threshold and pain tolerance across a range of modalities to ensure assessment validity. Significant subgroup findings suggest that potential confounders of pain judgements, such as illicit substance use, affective characteristics, or coping styles, should be rigorously controlled in future studies.

Testing General Relativity with Stellar Orbits around the Supermassive Black Hole in Our Galactic Center

We demonstrate that short-period stars orbiting around the supermassive black hole in our Galactic center can successfully be used to probe the gravitational theory in a strong regime. We use 19 years of observations of the two best measured short-period stars orbiting our Galactic center to constrain a hypothetical fifth force that arises in various scenarios motivated by the development of a unification theory or in some models of dark matter and dark energy. No deviation from general relativity is reported and the fifth force strength is restricted to an upper 95% confidence limit of |α|<0.016 at a length scale of λ=150 astronomical units. We also derive a 95% confidence upper limit on a linear drift of the argument of periastron of the short-period star S0-2 of |ω[over ˙]_{S0-2}|<1.6×10^{-3}  rad/yr, which can be used to constrain various gravitational and astrophysical theories. This analysis provides the first fully self-consistent test of the gravitational theory using orbital dynamic in a strong gravitational regime, that of a supermassive black hole. A sensitivity analysis for future measurements is also presented.

Abstract B64: Impact of neighborhood effects on a multi-approach Colorectal Cancer screening navigation program in an urban federally qualified health center

Purpose.

Mortality and morbidity disparities exist in Colorectal Cancer (CRC). CRC screening rates differs among race/ethnicity, which contribute to these existing disparities. In response, multiple interventions have been developed and assed to address these gaps. Little is known about how efficacy varies across patient populations. In response, multiple interventions have been developed and assessed, including patient navigation. Little is known about how efficacy varies across socioenvironmental contexts.

Objective.

The study sought to examine the interactive effects of patient navigation and provider navigation with contextual factors (facility and residential neighborhood characteristics) on CRC screening uptake among a Chicago-based sample population.

Methods.

Two evidence-based CRC screening interventions were implemented at University of Illinois Mile Square Health Center (MSHC) clinics. The study eligible population was those: 1) Ages 50-75; 2) Had an appointment in 2014 or 2015; and 3) Not up-to-date on CRC screening. The controls were matched by clinic, race/ethnicity, and sex. An individual-level database for the retrospective evaluation of comparative effectiveness of patient navigation-based versus provider-based navigation was created. This database included all patients ages 50-75 who completed at least one patient visit in MSHC in 2015. The database includes patients navigated by the patient navigator, and patients navigated by the provider. The following information was collected from electronic medical record (EMR) data: 1) age; 2) race/ethnicity; 3) insurance status; 4) date mailed birthday reminder was sent; 5) type of one-on-one navigation (CHW, provider, or both); 6) date navigation was administered; 7) patient full address, including zip code; 8) date FOBt given to patient during 2015; 9) date FOBt returned; 10) date colonoscopy scheduled; 11) date colonoscopy completed;12) FOBt result; 13) Screening colonoscopy result; 14) Diagnostic colonoscopy date; 15) Diagnostic colonoscopy date; 16) Cancer Diagnosis date; 17) provider name; and 18) clinic site. The neighborhood characteristics of interest were median household income, poverty, percent black, percent white, and percent of Latino residents based on American Community Survey 2007-2011 data.

Results.

A preliminary analysis was conducted on the database, n= 340. There were significant differences in clinic using Chi-Square statistic (X= 10.7, p = .005). When looking at individual clinics, for the Englewood and Main clinic, patients responded better to provider navigation (20% and 21%) compared to patient navigation (8% and 15%), respectively. Whereas, the Back of the Yards clinic had patients respond better to provider navigation versus patient navigation, 56% versus 14%. Adjusted for clinic, gender, and race/ethnicity, patient navigation was most strongly associated with CRC completion (OR = 5.5, 95% CI:3.1-9.8, p = &lt;.0001). Provider navigation was associated with CRC completion (OR = 1.81, p = .04).

The next steps in the study analysis will be to complete the data abstraction with matched-controls and conduct multivariable spatial logistic and Cox regression models to compare the different types of navigation on a) date patient received FOBt and b) days to FOBt returned since date of navigation c) days to completed colonoscopy since date of navigation. Second, multiple effect modification analyses will be conducted to examine interactive effects by 1) race/ethnicity; 2) clinic site; and 3) neighborhood factors (concentrated disadvantage and racial/ethnic composition).

Conclusions.

In this sample, patient navigation as an intervention was most strongly associated with CRC completion, relative to those who received the standard CRC screening recommendations (controls). CRC screening can lead to increases early detection and improved outcomes. Navigation programs that are tailored to address specific populations can increase uptake and compliance and have far reaching implications in FQHC populations who carry some of the largest burden of cancer morbidity and mortality.

Citation Format: Yazmin San Miguel, Yamile Molina, L. San Miguel, Scott Grumeretz, K. Matthews, Robert Winn, Karriem Watson. Impact of neighborhood effects on a multi-approach Colorectal Cancer screening navigation program in an urban federally qualified health center. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B64.

The consequences of self-reported vision change in later-life: evidence from the English Longitudinal Study of Ageing

OBJECTIVES

Using longitudinal data, we investigate whether deterioration and improvement in self-reported vision among people aged 50 years and older in England experience subsequent changes in various aspects of economic, psychological and social well-being.

STUDY DESIGN

Longitudinal random effects modelling.

METHODS

We used six waves of the biennial English Longitudinal Study of Ageing spanning 2002-2012. Self-reported vision change was classed as an increase or decrease in self-reported level of vision between each wave and effects on depression, satisfaction with life, quality of life, social engagement and equivalized income were examined. Models were adjusted for health, employment and wealth.

RESULTS

All well-being outcomes worsened among respondents experiencing deterioration in self-reported vision, and declined most among individuals with the poorest self-reported vision at baseline and follow-up. Results were significant in fully adjusted models for those deteriorating from optimal to suboptimal vision levels. Improvement in self-reported vision was associated with significantly better satisfaction with life, quality of life and social engagement when the improvement was from suboptimal to optimal vision levels.

CONCLUSIONS

Preventing deterioration in vision is the best means of ensuring well-being is not negatively affected by changes to sight. In addition, ensuring vision problems are corrected where possible may lead to improvements in well-being.

Multifaceted impairments in impulsivity and brain structural abnormalities in opioid dependence and abstinence

BACKGROUND

Chronic opioid exposure, as a treatment for a variety of disorders or as drug of misuse, is common worldwide, but behavioural and brain abnormalities remain under-investigated. Only a small percentage of patients who receive methadone maintenance treatment (MMT) for previous heroin misuse eventually achieve abstinence and studies on such patients are rare.

METHOD

The Cambridge Neuropsychological Test Automated Battery and T1 weighted magnetic resonance imaging (MRI) were used to study a cohort of 122 male individuals: a clinically stable opioid-dependent patient group receiving MMT (n = 48), an abstinent previously MMT maintained group (ABS) (n = 24) and healthy controls (n = 50).

RESULTS

Stable MMT participants deliberated longer and placed higher bets earlier in the Cambridge Gambling Task (CGT) and showed impaired strategic planning compared with healthy controls. In contrast, ABS participants showed impairment in choosing the least likely outcome, delay aversion and risk adjustment on the CGT, and exhibited non-planning impulsivity compared with controls. MMT patients had widespread grey matter reductions in the orbitomedial prefrontal cortex, caudate, putamen and globus pallidus. In contrast, ABS participants showed midbrain-thalamic grey matter reductions. A higher methadone dose at the time of scanning was associated with a smaller globus pallidus in the MMT group.

CONCLUSIONS

Our findings support an interpretation of heightened impulsivity in patients receiving MMT. Widespread structural brain abnormalities in the MMT group and reduced brain structural abnormality with abstinence suggest benefit of cessation of methadone intake. We suggest that a longitudinal study is required to determine whether abstinence improves abnormalities, or patients who achieve abstinence have reduced abnormalities before methadone cessation.

Impulsivity and opioid drugs: differential effects of heroin, methadone and prescribed analgesic medication

BACKGROUND

Previous studies have provided inconsistent evidence that chronic exposure to opioid drugs, including heroin and methadone, may be associated with impairments in executive neuropsychological functioning, specifically cognitive impulsivity. Further, it remains unclear how such impairments may relate of the nature, level and extent of opioid exposure, the presence and severity of opioid dependence, and hazardous behaviours such as injecting.

METHOD

Participants with histories of illicit heroin use (n = 24), former heroin users stabilized on prescribed methadone (methadone maintenance treatment; MMT) (n = 29), licit opioid prescriptions for chronic pain without history of abuse or dependence (n = 28) and healthy controls (n = 28) were recruited and tested on a task battery that included measures of cognitive impulsivity (Cambridge Gambling Task, CGT), motor impulsivity (Affective Go/NoGo, AGN) and non-planning impulsivity (Stockings of Cambridge, SOC).

RESULTS

Illicit heroin users showed increased motor impulsivity and impaired strategic planning. Additionally, they placed higher bets earlier and risked more on the CGT. Stable MMT participants deliberated longer and placed higher bets earlier on the CGT, but did not risk more. Chronic opioid exposed pain participants did not differ from healthy controls on any measures on any tasks. The identified impairments did not appear to be associated specifically with histories of intravenous drug use, nor with estimates of total opioid exposure.

CONCLUSION

These data support the hypothesis that different aspects of neuropsychological measures of impulsivity appear to be associated with exposure to different opioids. This could reflect either a neurobehavioural consequence of opioid exposure, or may represent an underlying trait vulnerability to opioid dependence.

Abnormal brain responses to social fairness in depression: an fMRI study using the Ultimatum Game

BACKGROUND

Depression is a prevalent disorder that significantly affects the social functioning and interpersonal relationships of individuals. This highlights the need for investigation of the neural mechanisms underlying these social difficulties. Investigation of social exchanges has traditionally been challenging as such interactions are difficult to quantify. Recently, however, neuroeconomic approaches that combine multiplayer behavioural economic paradigms and neuroimaging have provided a framework to operationalize and quantify the study of social interactions and the associated neural substrates.

METHOD

We investigated brain activation using functional magnetic resonance imaging (fMRI) in unmedicated depressed participants (n = 25) and matched healthy controls (n = 25). During scanning, participants played a behavioural economic paradigm, the Ultimatum Game (UG). In this task, participants accept or reject monetary offers from other players.

RESULTS

In comparison to controls, depressed participants reported decreased levels of happiness in response to 'fair' offers. With increasing fairness of offers, controls activated the nucleus accumbens and the dorsal caudate, regions that have been reported to process social information and responses to rewards. By contrast, participants with depression failed to activate these regions with increasing fairness, with the lack of nucleus accumbens activation correlating with increased anhedonia symptoms. Depressed participants also showed a diminished response to increasing unfairness of offers in the medial occipital lobe.

CONCLUSIONS

Our findings suggest that depressed individuals differ from healthy controls in the neural substrates involved with processing social information. In depression, the nucleus accumbens and dorsal caudate may underlie abnormalities in processing information linked to the fairness and rewarding aspects of other people's decisions.

Agreement between student dietitians' identification of refeeding syndrome risk with refeeding guidelines, electrolytes and other dietitians: a pilot study

BACKGROUND

Limited research exists concerning how consistently and accurately student and newly-graduated dietitians are identifying refeeding syndrome risk in hospitalised patients. The present study aimed to determine the consistency of students' and newly-graduated dietitians' classification of refeeding syndrome risk, as well as agreement with the application of comparison tools such as the National Institute for Health and Care Excellence guidelines, patients' electrolytes and supplementation, and clinical dietitians previously surveyed.

METHODS

Recently-graduated and final-year Griffith University dietetics students were invited to complete an online survey. The survey questioned demographics and asked respondents to classify the level of refeeding syndrome risk (i.e. none, some, high, unsure) in 13 case studies. Electrolytes and supplementation data were sourced from electronic patient records. Chi-squared tests, t-tests and linear regression analyses were conducted.

RESULTS

Fifty-three eligible people responded [n = 53 of 112, mean (SD) age 26 (4) years, 89% female, 34% graduates]. Respondents' answers were generally more consistent and more likely to agree with comparison tools when two tools showed the same level of refeeding syndrome risk (49-98%, β = 0.626-1.0994, P < 0.001) than when they differed (11-49%). Respondents' level of agreement with refeeding identification guidelines, electrolyte levels, supplementation and dietitians previously surveyed did not differ by graduate status, degree level, clinical placement status or having read refeeding syndrome guidelines recently (P > 0.05).

CONCLUSIONS

Students' and new graduates' identification of refeeding syndrome risk improved when there was consistency between guidelines, electrolytes and dietitians' responses. More research is needed to improve the evidence behind refeeding guidelines, with the aim of enhancing the accuracy and consistency of assessment.

A comprehensive assessment of memory, delay aversion, timing, inhibition, decision making and variability in attention deficit hyperactivity disorder: advancing beyond the three-pathway models

BACKGROUND

Although attention deficit hyperactivity disorder (ADHD) has been associated with a broad range of deficits across various neuropsychological domains, most studies have assessed only a narrow range of neuropsychological functions. Direct cross-domain comparisons are rare, with almost all studies restricted to less than four domains. Therefore, the relationships between these various domains remain undefined. In addition, almost all studies included previously medicated participants, limiting the conclusions that can be drawn. We present the first study to compare a large cohort of medication-naive boys with ADHD with healthy controls on a broad battery of neuropsychological tasks, assessing six key domains of neuropsychological functioning.

METHOD

The neuropsychological functioning of 83 medication-naive boys with well-characterized ADHD (mean age 8.9 years) was compared with that of 66 typically developing (TYP) boys (mean age 9.0 years) on a broad battery of validated neuropsychological tasks.

RESULTS

Data reduction using complementary factor analysis (CFA) confirmed six distinct neuropsychological domains: working memory, inhibition, delay aversion, decision making, timing and response variability. Boys with ADHD performed less well across all six domains although, for each domain, only a minority of boys with ADHD had a deficit [effect size (% with deficit) ADHD versus TYP: working memory 0.95 (30.1), inhibition 0.61 (22.9), delay aversion 0.82 (36.1), decision making 0.55 (20.5), timing 0.71 (31.3), response variability 0.37 (18.1)].

CONCLUSIONS

The clinical syndrome of ADHD is neuropsychologically heterogeneous. These data highlight the complexity of the relationships between the different neuropsychological profiles associated with ADHD and the clinical symptoms and functional impairment.

A longitudinal examination of neuropsychological and clinical functioning in boys with attention deficit hyperactivity disorder (ADHD): improvements in executive functioning do not explain clinical improvement

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) often, but not always, persists into adulthood. Investigations of the associations between clinical and biological markers of persistence can shed light on causal pathways. It has been proposed that compensatory improvements in executive neuropsychological functioning are associated with clinical improvements. This is the first study to test this hypothesis prospectively.

METHOD

The clinical and neuropsychological functioning of 17 boys with ADHD (mean age 10.45 years at time 1; 14.65 years at time 2) and 17 typically developing (TYP) boys (mean age 10.39 years at time 1; 14.47 years at time 2) was tested on two occasions, 4 years apart. This was done using a battery of standardized neuropsychological tests that included tasks with high and low executive demands.

RESULTS

Clinical improvements were observed over time. Neuropsychological performance improvements were also evident, with ADHD boys developing with a similar pattern to TYP boys, but with a developmental lag. Whilst there was an association between reduced symptoms and superior performance at retest for one task with a high executive demand (spatial working memory), this was not seen with two further high executive demand tasks [Stockings of Cambridge and intra-dimensional extra-dimensional (ID/ED) set shifting]. Also, there was no association between change in executive functioning and change in symptoms. Baseline performance on the ID/ED set-shifting task predicted better clinical outcome. Only change in performance on the low executive demand delayed matching-to-sample task predicted better clinical outcome.

CONCLUSIONS

These data highlight the importance of longitudinal measurements of cognition, symptoms and treatment response over time in children and adolescents with ADHD.

Predictive classification of individual magnetic resonance imaging scans from children and adolescents

Neuroimaging techniques are increasingly being explored as potential tools for clinical prediction in psychiatry. There are a wide range of approaches which can be applied to make individual predictions for various aspects of disorders such as diagnostic status, symptom severity scores, identification of patients at risk of developing disorders and estimation of the likelihood of response to treatment. This selective review highlights a popular group of pattern recognition techniques, support vector machines (SVMs) for use with structural magnetic resonance imaging scans. First, however, we outline various practical issues, limitations and techniques which need to be considered before SVM's can be applied. We begin with a discussion on the practicalities of scanning children and adolescent participants and the importance of acquiring high quality images. Scan processing required for inter-subject comparisons is then discussed. We then briefly discuss feature selection and other considerations when applying pattern recognition techniques. Finally, SVMs are described and various studies highlighted to indicate the potential of these techniques for child and adolescent psychiatric research.

Effect of dietary chicory on boar taint

Following preliminary screening and feeding trials on farms supplying a commercial abattoir, 360 entire male pigs were used to evaluate the effects of different percentages of chicory (Cichorium intybus L.) on levels of boar taint compounds and sensory aspects in backfat. Pigs were fed 0, 3, 6 or 9% chicory in the diet, 30 pigs being sampled at 3 different times: initially to measure basal levels of skatole and androstenone and after 1 and 2 weeks on the test diets. Cooked samples of backfat were presented to a trained sensory panel for "sniff" tests. Chicory fed at 9% for 2 weeks reduced skatole levels significantly (P<0.001), with 0.55 of pigs below 0.05 μg/g, typical of levels in castrated males. Abnormal odour scores were significantly lower for pigs in this group compared with 0% pigs (P<0.001), however, androstenone concentration was significantly higher in this group after the 2 week feeding period (P<0.005). Thus, feeding 9% chicory for 2 weeks was effective in reducing backfat skatole concentrations and abnormal odour scores of cooked fat but not androstenone concentration.

SU-E-T-588: A Treatment Planning Comparison of Dual-Arc VMAT Vs. Helical Tomotherapy for Post-Mastectomy Radiotherapy

PURPOSE

To investigate the feasibility of volumetric modulated arc therapy (VMAT) for post-mastectomy radiotherapy (PMRT) and to compare dual- arc VMAT treatment plans to helical tomotherapy (HT) plans on the basis of dosimetric quality, radiobiological calculations and delivery efficiency.

METHODS

Dual-arc VMAT and HT treatment plans were created for fifteen patients previously treated at our clinic. Planning target volumes (PTV) included the chest wall (CW) and regional lymph nodes. The following metrics were used to compare treatment plans for each patient: dose homogeneity index (DHI) and conformity index (CI); coverage of the PTV; dose to organs at risk (OAR); tumor control probability (TCP), normal tissue complication probability (NTCP) and secondary cancer complication probability (SCCP); and treatment delivery time. Differences between treatment plans were tested for significance using the paired Student's t-test.

RESULTS

Both modalities produced clinically acceptable PMRT plans. VMAT plans showed better CI (p < 0.01), and better OAR sparing at low doses than HT plans. For example, VMAT plans showed a 26% (p < 0.01) and 9% (p < 0.01) decrease in V5Gy in the lungs and heart respectively. On the other hand, HT plans showed better DHI (p < 0.01) and PTV coverage (p < 0.01). HT plans also showed slightly better OAR sparing at higher doses, including 8% (p < 0.01) and 9% (p < 0.01) lower maximum doses to the lungs and heart, respectively. Both modalities achieved nearly 100% tumor control and approximately 1% NTCP in the lungs and heart, with VMAT showing lower SCCP (p < 0.01). VMAT plans also required 66.2% less time to deliver.

CONCLUSIONS

Both VMAT and HT are suitable treatment options for PMRT. Our study showed that VMAT"'in addition to being significantly faster'"achieved better CI and low dose OAR sparing while HT achieved better DHI. This work was supported in part by a research support from Elekta, Ltd. However, Elekta, Ltd., did not participate in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit.

Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'

OBJECTIVES

To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease.

METHODS

As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status.

RESULTS

3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)).

CONCLUSIONS

New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

227 THE EFFECTS OF SEXED SEMEN ON EMBRYONIC DEVELOPMENT TO THE BLASTOCYST STAGE

Sexed semen (SS) exhibits approximately 80% of the fertilizing ability of conventional semen (CS), and studies have shown that this continues through the 8-cell stage of bovine embryo development. At the time of this study, no information could be found that, when used for IVF and intracytoplasmic sperm injection (ICSI) development, had been carried to the blastocyst stage. In addition, questions have arisen regarding which of the measured sperm parameters are responsible for the difference between the SS and CS and contribute to this decline in fertility. The goals of this project were to evaluate the effects of using sexed sperm as it relates to embryonic development and to determine if any of the differences in sperm parameters affect embryonic development. A preliminary project evaluated SS and CS from 5 bulls for IVF and ICSI. One bull was selected to provide the sperm (both SS and CS) for the trial, and 1752 oocytes were assigned to either IVF or ICSI. The SS and CS were divided among the available oocytes used for IVF and ICSI. Straws were thawed for 30 s at 37°C, and sperm were then evaluated for motility (provided by CASA, SpermVision, MiniTube of America, Verona, WI), morphology, acrosomal integrity (Coomassie and Pope stains), viability, and nuclear decondensation (SYBR Green and HALO). Results for SS v. CS were as follows: motility, 8 v. 26%; viability, 40.6 v. 30%; nuclear decondensation, 40 v. 30%; normal morphology and acrosomal integrity, no differences. Oocytes were obtained from Applied Reproductive Technologies, LLC (Madison, WI). The fertilization rate was consistently lower (Table 1) for both IVF and ICSI when SS were used (Z = 3.65; P = 0.0003), and there was no evidence that this decline in fertilization rate differed for the 2 methods (Z = 0.18; P = 0.86). Nor was there any evidence that the method affected the fertilization rate in general (Z = 0.75; P = 0.45). Thus, the difference was specific for fertilization rate and had no effect on Day 3 cells or Day 7 blastocysts. A higher fertility rate using ICSI would have indicated that a surface membrane factor may have been decreasing the fertility rate with SS because of the elimination of binding factors associated with ICSI. Thus, it may not be the sperm surface membrane that is distorted in the sexing procedure, but likely the integrity of the spermal DNA, as indicated by the increased nuclear decondensation of SS. Table 1.Comparison of sexed sperm with conventional sperm when used for IVF and intracytoplasmic sperm injection (ICSI) Partial funding for this project was made available by the California State University Agricultural Research Institute (ARI). Appreciation is extended to Sexing Technologies, Inc. (Navasota, TX) for donating the semen.

Hypercytokinaemia accompanies HIV-tuberculosis immune reconstitution inflammatory syndrome

Increased access to combination antiretroviral therapy in areas co-endemic for tuberculosis (TB) and HIV-1 infection is associated with an increased incidence of immune reconstitution inflammatory syndrome (TB-IRIS) whose cause is poorly understood. A case-control analysis of pro- and anti-inflammatory cytokines in TB-IRIS patients sampled at clinical presentation, and similar control patients with HIV-TB prescribed combined antiretroviral therapy who did not develop TB-IRIS. Peripheral blood mononuclear cells were cultured in the presence or absence of heat-killed Mycobacterium tuberculosis for 6 and 24 h. Stimulation with M. tuberculosis increased the abundance of many cytokine transcripts with interleukin (IL)-1β, IL-5, IL-6, IL-10, IL-13, IL-17A, interferon (IFN)-γ, granulocyte-macrophage colony-stimulating factor (GM-CSF) and tumour necrosis factor (TNF) being greater in stimulated TB-IRIS cultures. Analysis of the corresponding proteins in culture supernatants, revealed increased IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12p40, IFN-γ, GM-CSF and TNF in TB-IRIS cultures. In serum, higher concentrations of TNF, IL-6, and IFN-γ were observed in TB-IRIS patients. Serum IL-6 and TNF decreased during prednisone therapy in TB-IRIS patients. These data suggest that cytokine release contributes to pathology in TB-IRIS. IL-6 and TNF were consistently elevated and decreased in serum during corticosteroid therapy. Specific blockade of these cytokines may be rational approach to immunomodulation in TB-IRIS.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

BACKGROUND

Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.

METHOD

The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later.

RESULTS

The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome.

CONCLUSIONS

Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.