Pandemic impacts and experiences after disaster in Australia: qualitative study of compound impacts following the Black Summer bushfires

BACKGROUND

The first cases of the COVID-19 pandemic in Australia were recorded in January 2020, which was during the 'Black Summer' bushfires of 2019-20 and prior to additional disasters in some regions. Few studies have considered the compound impact of disasters and the pandemic.

AIMS

To improve understanding of the impact on mental health and well-being of the pandemic in disaster-affected communities.

METHOD

We conducted semi-structured interviews (n = 18) with community members and online focus groups (n = 31) with help providers from three regions of rural Australia affected by bushfires and the pandemic.

RESULTS

Six themes were produced: (a) 'Pulling together, pulling apart', describing experiences after bushfires and prior to impacts of the pandemic; (b) 'Disruption of the 'normal response', encompassing changes to post-disaster recovery processes attributed to the pandemic; (c) 'Escalating tensions and division in the community', describing impacts on relationships; (d) 'Everywhere you turn you get a slap in the face', acknowledging impacts of bureaucratic 'red tape'; (e) 'There are layers of trauma', highlighting intersecting traumas and pre-existing vulnerabilities; and (f) 'Where does the help come from when we can't do it?', encompassing difficulties accessing services and impacts on the helping workforce.

CONCLUSIONS

This study furthers our understanding of compound disasters and situates pandemic impacts in relation to processes of adjustment and recovery from bushfires. It highlights the need for long-term approaches to resilience and recovery, investment in social infrastructure, multi-component approaches to workforce issues, and strategies to increase mental health support and pathways across services.

232 WORKING-UP DEMENTIA, A RETROSPECTIVE COHORT STUDY OF REFERRALS TO A SPECIALIST DEMENTIA SERVICE

Background

Rates of dementia in Ireland are rapidly increasing in line with our ageing population. Cases are predicted to more than double in the next 30 years from a prevalence of 55,000 in 2018, to 141,000 in 2050. Dementia services will be placed under significant pressure. It is essential that patients referred to specialist memory services are appropriately worked-up prior to referral, to ensure efficiency and optimise the running of these services, and also to improve patient experience.

Methods

We carried out a retrospective review of patients referred to the Psychiatry of Later Life Team for specialist dementia care by General Practitioners. We obtained date of referral to the service, and carried out an electronic chart review to evaluate the work-up performed prior to referral. Our standard work-up criteria consisted of neuroimaging (CT brain or MRI brain), and blood tests including B12, folate, and thyroid function tests within 12-months. Results were analysed descriptively.

Results

104 patients were included in the study, from referrals dated Nov 2014-June 2019. Neuroimaging had been performed in 79.8% (n=83) prior to referral- 89.1% CT, 9.6% MRI, 1.2% both CT and MRI. Of those who had neuroimaging, n=37 had been performed in the previous 12-months, representing 35.6% of overall cohort. In terms of blood work-up, 23.1% (n=24) had bloods performed in the 12 months prior to referral- 70.8% B12, folate and thyroid function tests; 20.8% TFTS only; 8.3% B12 and folate levels only).

Conclusion

Referrals to specialist memory services by General Practice often lack the appropriate first line investigations, which introduces delay in review and the need for further assessment once baseline investigations have been done. There is a need for a standardised work-up prior to referral for optimum running of such services.

329 ANTICHOLINERGIC BURDEN IN PEOPLE LIVING WITH DEMENTIA ATTENDING GERIATRIC MEDICINE AND PSYCHIATRY FOR OLDER PERSONS SERVICES

Background

Anticholinergic burden is associated with an increase in cognitive decline, delirium and confusion. We aimed to examine the Anticholinergic Cognitive Burden (ACB) of patients referred to local dementia services, and the prescribing of acetylcholinesterase inhibitors in patients with a significant anticholinergic burden. We also looked at frequency of prescribing of classes of some medications known to increase anticholinergic burden.

Methods

A retrospective chart review was carried out of new referrals attending local Geriatric Medicine and/or Psychiatry For Older Persons outpatient services with a diagnosis of dementia between 2017 and 2018. Medications in use at the time of patient review were obtained. ACB was calculated using ACB score. Results were analysed descriptively.

Results

163 patients over 65 years old were included in this study, 94 (57.6%) were female. 30% (N = 49) had a significant anticholinergic burden (ACB >3). The mean ACB was 1.69 (Range 0 – 8). 38% of all patients (N = 63) were prescribed an acetylcholinesterase inhibitor, and of those, 20% (N = 13) had a significant anticholinergic burden. Polypharmacy (use of 5 medications or more) was evident with 76% (N = 124) patients. Regarding groups of medications known to increase ACB, 35.5% (N = 58) were prescribed antipsychotics and 18.4% (30) were prescribed benzodiazepines.

Conclusion

There is a significant anticholinergic burden among people living with dementia attending the geriatric medicine and psychiatry of later life services. Some patients with a significant anticholinergic burden were being prescribed acetylcholinesterase inhibitors. This suggests acetylcholinesterase inhibitors may be prescribed without also discontinuing inappropriate medications that are contributing to the anticholinergic burden. We should look to further reduce the anticholinergic burden of patients attending the dementia services by avoiding these medications or using alternatives where available.

311 FROM ONE FRONT DOOR TO ANOTHER: OUTCOMES OF PATIENTS DIRECTLY DISCHARGED FROM THE FRAILTY AT THE FRONT DOOR SERVICE

Background

The Frailty at the Front Door service is a novel service that provides comprehensive geriatric assessment in the emergency department for older adults who have an unplanned emergency presentation to hospital. It is important to monitor outcomes of patients discharged by the service to ensure appropriate patient selection.

Methods

Patients over the age of 75 with a Manchester Triage Score of between three and five and a possible frailty syndrome are eligible for review by the service. After initial review patients are either discharged directly or recommended for admission. We reviewed the outcomes of patients who were discharged directly after Emergency Department (ED) assessment by the service.

Results

Discharge disposition was available for review in 413 (95%) of patients since initiation of the service in October 2021. 30% (n= 122) of patients were discharged directly after initial ED review. Elevated 4AT score (p = 0.002) but not frailty (p = 0.80) was associated with decreased chances of direct discharge. Of patients discharged directly from ED 13% were reviewed post discharge by the community integrated care team (GICOP), with 43% of these reviews taking place within 30 days. Overall, 16% of patients discharged directly represented to ED within 30 days. There was a trend towards lower rates of representation to ED among patients who were seen by GICOP after discharge from ED (p = 0.12).

Conclusion

There was a high rate of direct discharge after review by the service, with low rates of representation to hospital. While limited by low numbers there was a trend towards lower representation rates in patients reviewed post-discharge by the integrated care team. Future quality improvement initiatives will aim to improve the integration between the services and highlighting patients who would benefit from more timely reviews.

355 PREDICTORS OF HOME SUPPORT SERVICES AND THE CONSEQUENCES OF MISMATCH BETWEEN ALLOCATED AND RECEIVED SERVICES IN COGNITIVELY-IMPAIRED OLDER ADULTS

Background

Home support services aim to support older people to remain at home. Despite substantial investment in home support hours (€600 million), this has not translated into increased carers on the ground for older people. We aimed to report patterns of home support service utilisation in older patients with memory problems, and identify any mis-matches between allocated and received hours, and the impact on patients and caregivers.

Methods

Retrospective analysis of consecutive patients referred to community geriatric clinic from January 2021 to May 2022. 95/104 patients who were identified were suitable for inclusion.

Results

Participants had a median age of 82 (IQR 78-86) of whom 57% were female (n=54). 80% (n=76) were frail (CFS ≥4), with 82% dependent for IADLs (Lawton-Brody IADL Scale ≤6). Median MOCA score was 18, with 44% having moderate to severe cognitive impairment (MOCA ≤17). 40% of patients lived with alone (n=38). 52% (n=49) received formal home supports while 80% (n=76) had an informal carer. 37% (n=18) had a mismatch between hours allocated and hours received. There was a significant difference between median hours of care allocated (7) and median hours of care received (5), p <0.001. Increasing age and frailty, worsening cognitive and functional impairment and living status (living alone) predicted allocation of home supports. Patients who lived with family members were 3 times more likely not to receive allocated hours (OR 3.84 (95% CI 1.2–13.7))

Conclusion

In this vulnerable population with cognitive and functional decline, just over half received formal home support hours. A large proportion experienced significant mismatch between allocated and received hours. Family and informal caregivers often have to fill gaps, adding to existing carer strain. Future models of home support should prioritise early intervention for people with IADL loss to remain independent at home and broaden of the scope of practice of carers to facilitate this.

312 DOES EXCLUDING PATIENTS WITH ORTHOSTATIC HYPOTENSION AFFECT SAFETY ESTIMATES IN HYPERTENSION TRIALS? A SYSTEMATIC REVIEW AND COMPARATIVE META-ANALYSIS

Background

In order to apply the findings of antihypertensive randomised controlled trials to older adults, it is important to understand the populations included and consider the generalizability of the results to cohorts that may have been excluded. The purpose of this study was to determine whether participants with orthostatic hypotension were included in randomised controlled trial of antihypertensive therapy and whether adverse event rates of particular importance to this cohort; namely falls or syncope differed based on their exclusion.

Methods

We performed a systematic review and meta-analysis of randomised controlled trials comparing antihypertensives to placebo, combination of antihypertensive agents compared to fewer antihypertensive or higher compared to lower blood pressure targets that reports falls or syncope outcomes. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall in subgroups of trials which excluded patients with orthostatic hypotension and trials which did not exclude patients with orthostatic hypotension. Difference in treatment effect was assessed by testing P for interaction. The primary outcome measure was falls events.

Results

Forty-Seven trials were included, including 18 trials which excluded those with orthostatic hypotension and 29 trials which did not exclude those with orthostatic hypotension. Thirteen trials (n=94,222) reported falls. The baseline incidence of falls in the control group was 4.8% in trials which excluded orthostatic hypotension compared to 8.8% in trials which did not exclude participants with orthostatic hypotension. The association of antihypertensive treatment and falls was similar for trials which excluded those with orthostatic hypotension (OR 1.00; 95%CI, 0.89-1.13) and trials which did not exclude those with orthostatic hypotension (OR, 1.02; 95%CI, 0.88 –1.18).

Conclusion

The exclusion of patients with orthostatic hypotension may under-estimate the event rate of adverse events such as falls but does not appear to affect relative risk estimates associated with antihypertensives.

279 INCLUSION OF OLDER PATIENTS IN CLINICAL TRIALS: A REVIEW OF A SINGLE, HIGH IMPACT, MEDICAL JOURNAL OVER A 2-YEAR PERIOD

Background

Older patients have the highest rates of multimorbidity and prescription drug use. Despite this, previous research has found that these patients are not well represented in Randomised-Control Trials (RCTs), limiting external validity. In recent years many guidelines have been issued to help facilitate the inclusion of older patients in RCTs. We aimed to explore the inclusion of older patients in recent RCTs publications.

Methods

A single, high impact, medical journal was systematically reviewed, with all full text publications between March 2019 and March 2021 being screened. All adult, Phase III, RCTs were selected. The age descriptors of controls were extracted, in addition to information on eligibility criteria that could lead to exclusion based on age, comorbidity, or cognition.

Results

Of 123 RCT publications, the mean age was ≥65 in 42.1% and ≥75 in 8.3%, while the 75th centile age was ≥65 in 72% and ≥75 in 25%. An explicit capacity requirement was present in 41.5% and those with cognitive impairment were excluded in 15.4%. Eligibility determined at the discretion of the investigator and a life-expectancy exclusion criteria were present in 33.3% and 36.6%, respectively. A maximum age limit was present in 18.7%. No RCTs excluded on the basis of polypharmacy. The mean/75th centile age differed significantly by speciality (p<0.05), oldest in cardiovascular and medical RCTs. Having a maximum age limit was significantly associated with a lower mean/75th centile age (p<0.01), while having a life-expectancy exclusion criteria was associated with a higher mean/75th centile age (p<0.05). The age did not differ significantly between pre/post-COVID-19 RCTs, or for other eligibility criteria studied.

Conclusion

While those ≥65 were well represented, those ≥75 were not. Eligibility criteria that could potentially lead to exclusion based on age, comorbidity, or cognition were also common, although the majority did not significantly affect age.

310 A COMPARATIVE ANALYSIS OF THE IRISH POST-GRADUATE GERIATRIC TRAINING SCHEME WITH THE EUROPEAN POST-GRADUATE CURRICULUM IN GERIATRIC MEDICINE

Background

Minimum training recommendations to become a specialist geriatrician in the EU have been published. In this study we sought to evaluate the curriculum of the higher specialist training scheme in Geriatric Medicine in Ireland and examine how it compares with the knowledge recommendations from the European post-graduate curriculum in Geriatric medicine, which is endorsed by both the European Geriatric Medicine Society (EuGMS) and the European Academy of Medicine of Ageing (EAMA).

Methods

In this study we examined the content of didactic study-day lectures given over a five-year rolling period which is the minimum duration of the higher specialist training programme in Geriatric medicine in Ireland. We also examined the published Irish curriculum and compared how both the Irish curriculum and content of the study-days matches up with the 36 items that are identified as the core knowledge content in the European post-graduate curriculum.

Results

There were 24 study days delivered over a five-year time period. The Irish geriatric medicine curriculum formally outlined that 30 of the 36 knowledge areas proposed in the European curriculum should be formally covered during post-graduate geriatric training in Ireland. The European curriculum recommended formal teaching in sarcopenia, sleep disorders, tissue viability, iatrogenic care delivered disorders, sexuality in older adults and geron-technology/e-health, none of which were referred to in the Irish curriculum. However, despite this discrepancy, formal teaching was delivered on 92% (n = 33) of proposed areas. Pain assessment, sleep disorders and tissue viability were areas not covered in Irish didactic study-days. 24 of 36 topics were covered at least twice.

Conclusion

There was high concordance between the content of the Irish and European post-graduate curriculum in Geriatric medicine. Benchmarking against European training standards is an opportunity to ensure that parity of education and training is achieved across the EU.

A randomised placebo-controlled trial of the effectiveness of early metformin in addition to usual care in the reduction of gestational diabetes mellitus effects (EMERGE): study protocol

Background

Pregnancies affected by gestational diabetes mellitus (GDM) are associated with an increased risk of adverse maternal and foetal outcomes. Current treatments for GDM involve initial medical nutritional therapy (MNT) and exercise and pharmacotherapy in those with persistent hyperglycaemia. Insulin is considered first-line pharmacotherapy but is associated with hypoglycaemia, excessive gestational weight gain (GWG) and an increased caesarean delivery rate. Metformin is safe in selected groups of women with GDM but is not first-line therapy in many guidelines due to a lack of long-term data on efficacy. The EMERGE trial will evaluate the effectiveness of early initiation of metformin in GDM.

Methods

EMERGE is a phase III, superiority, parallel, 1:1 randomised, double-blind, placebo-controlled trial comparing the effectiveness of metformin versus placebo initiated by 28 weeks (+6 days) plus usual care.

Women aged 18–50 years will be recruited. Women with established diabetes, multiple pregnancies, known major congenital malformation or small for gestational age (<10th centile), intolerance or contraindication to the use of metformin, shock or sepsis, current gestational hypertension or pre-eclampsia, significant gastrointestinal problems, congestive heart failure, severe mental illness or galactose intolerance are excluded.

Intervention

Immediate introduction of metformin or placebo in addition to MNT and usual care. Metformin is initiated at 500mg/day and titrated to a maximum dose of 2500mg over 10 days. Women are followed up at 4 and 12 weeks post-partum to assess maternal and neonatal outcomes.

The composite primary outcome measure is initiation of insulin or fasting blood glucose ≥ 5.1 mmol/L at gestational weeks 32 or 38. The secondary outcomes are the time to insulin initiation and insulin dose required; maternal morbidity at delivery; mode and time of delivery; postpartum glucose status; insulin resistance; postpartum body mass index (BMI); gestational weight gain; infant birth weight; neonatal height and head circumference at delivery; neonatal morbidities (neonatal care unit admission, respiratory distress, jaundice, congenital anomalies, Apgar score); neonatal hypoglycaemia; cost-effectiveness; treatment acceptability and quality of life determined by the EQ5D-5L scale.

Discussion

The EMERGE trial will determine the effectiveness and safety of early and routine use of metformin in GDM.

Trial registration

EudraCT Number 2016-001644-19l; NCT NCT02980276. Registered on 6 June 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06694-y.

90 IMPACT OF AN INTEGRATED CARE MODEL FOR OLDER PERSONS: EVALUATING A PILOT PROGRAMME

Background

In September 2019 Sláintecare helped establish an Integrated Care team for Older People. The aim of this service was to provide a Comprehensive Geriatric Assessment (CGA) to older people within a community network. Service user experience/feedback are critically important for development of a team and a service. To give service users a platform to evaluate the service a patient experience survey was conducted.

Methods

The survey was designed by the multidisciplinary team, consisting of 13 closed/3 open questions. A Likert scale was utilised for closed questions and thematic analysis for open questions. A question on impact of COVID-19 was also included.

150 of the 950 service users who received a CGA from June 2020 to June 2021 were selected randomly and invited to participate in the postal survey. All participants received a covering letter, questionnaire and a stamped address envelope to return their completed surveys.

Results

47% response rate (71/150). 77% were aged ≥75. 52% completed the survey themselves, 48% required assistance. 61% attended more than twice and most would prefer to attend a local spoke clinic. 96% agreed/strongly agreed that they were satisfied with the service. 99% felt they were treated with dignity/respect and had confidence in the service. 93% agreed that they were involved in care decisions. 82% reported their carers had the opportunity to discuss concerns. Themes emerging included importance of care close to home, avoiding acute hospital, difficulty parking at tertiary centres. 42% highlighted isolation and loneliness due to COVID-19 as a major issue.

Conclusion

Service users had an overwhelmingly positive experience especially when care was delivered in clinics close to their homes. Development of the hub and spoke model is acceptable and feasible to older people and their carers’ in this region and will be the focus for expansion of this service.

33 ARE CLINICAL TRIALS RANDOMISING HOUSEHOLDS TO LIFESTYLE INTERVENTIONS FOR THE PREVENTION OF COGNITIVE DECLINE FEASIBLE?

Background

Dementia is increasing in prevalence worldwide. Several lifestyle factors have been identified as targets for dementia prevention, which may be more effective if targeted at households instead of an individual. To date there have been no clinical trials randomising households to lifestyle interventions of sleep, diet and/or physical activity to prevent cognitive decline. To inform future studies, qualitative approaches can give valuable in-depth insights into the values and beliefs of all household members towards behavioural change.

Methods

Semi structured interviews were carried out among eight households affected by cognitive impairment. Interview content was analysed, and important themes identified.

Results

Eighteen participants were interviewed within household pods. Among those, eight had cognitive impairment and the remainder were spouses or first-degree relatives living in the same home. Several themes of interest emerged including household members without dementia were more likely to report poor sleep habits; sleep was perceived the hardest behaviour to change; although most participants had healthy diets, most were interested in making a change and felt there was a strong link with nutrition and cognition; physical activity is challenging to adapt due to lack of motivation and focus when individuals are cognitively impaired and motivation to pursue physical activity in households centred on relaxation and social interaction.

Conclusion

This study identified beliefs and preferences of households towards lifestyle intervention trials. Barriers to study participation including risk of harm, complexity of intervention and deviation from routine emerged during discussions. Findings from this study should be used to inform future clinical trial protocols and future qualitative studies should explore acceptability and feasibility of digital intervention applications.

112 INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE (ICPOP) IN A RURAL SETTING—ROLE OF ADVANCED NURSE PRACTITIONER (ANP)

Background

Sláintecare advocates for right care, in the right place at the right time. ANPs for Older Persons in the community are uniquely placed to deliver care as close as possible to the older person’s home and to lead a holistic, flexible model of care minimising admission to acute care and maximising existing local resources. A pilot programme aimed at providing ANP led comprehensive geriatric assessment (CGA) (with Geriatrician support) to older people in a defined area commenced in June 2019. This pilot was part of a larger Hub and Spoke model funded by Sláintecare which gave additional MDT support.

Methods

A referral template was designed. Criteria for referral included; age &gt; 75 years, Rockwood Frailty Scale 4–6 (focusing on Falls, Cognitive Impairment and Complex Frailty). Older people on the cusp of requiring long term care (LTC) were also prioritised. A prospective database of patients was maintained by the ANP to evaluate the service.

Results

From June 2019 to August 2021, 156 patients received an ANP led CGA, mostly conducted in the home. 247 reviews were conducted at the local spoke clinic and 46 joint ANP/Geriatrician home visits. Majority of referrals were from GP (n = 69), hospital (n = 30), LTC reviews (n = 22) and Community Nursing Units (CNUs) (n = 19). 449 outpatient appointments have been removed from the tertiary referral centre. Independent case load management from the ANP includes further appointments, telephone follow up/advice and she is a point of contact where crises arise before referral to acute services. 99% of patients surveyed reported satisfaction with the service especially the ease of local access and home visits.

Conclusion

Older Persons’ ANP can provide longitudinal care pathways for older adults in the community in conjunction with ICPOP and local CNUs, intervening before crises emerge and providing continuity of care and an alternative to acute care.

102 PROMOTING BRAIN HEALTH IN AN INTEGRATED CARE OUTREACH PROGRAMME

Background

Lifestyle modifications, in older at risk populations, may prevent or slow the rate of cognitive decline. Promotion of brain health has been recommended by the WHO and other governing bodies. Supporting patients in making these lifestyle changes, however, can be complex. Generic guidance may not apply to all in a heterogenous and frail patient cohort, when physical mobility may be limited and weight loss/nutrition a concern. We sought to review current practices and barriers to brain health guidance in a regional integrated care outreach programme (ICOP).

Methods

From March–June’21 the comprehensive geriatric assessment (CGA) of consecutive patients were reviewed. Those presenting with cognitive complaints, for their first assessment, were included. Demographic data and data on screening for hearing impairment and sleep disturbance were collected, in addition to information on physical activity and nutritional risk. Whether information and guidance on aspects of brain health was given was also assessed.

Results

30 patients met the inclusion criteria. The mean age was 80.3 and the mean clinical frailty scale (CFS) was 4.4. Hearing impairment was present in 20% (n = 6), with no information available in 10% (n = 3). All patients were screened for sleep disturbance, with 13% (n = 4) not fully satisfied with their sleep. Mobility aids, assistance or supervision were required in 40% (n = 12), and 23% (n = 7) were at medium or high malnutrition risk. Only 30% (n = 9) cooked their own meals. Generic brain health advice, or advice about sleep was documented in 30 (n = 9), without hearing impairment advice documented in any patient.

Conclusion

There are several barriers to brain health advice in the ICOP setting, with only 30% of patients having brain health advice documented. We are currently developing patient information leaflets on brain health, that will take potential barriers into account. Dedicated and specific information on local hearing services is also in development, as part of an ongoing quality improvement project.

Interleukin-6, C-reactive protein, fibrinogen, and risk of recurrence after ischaemic stroke: Systematic review and meta-analysis

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in log_e-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Prevalence and implications of gambling problems among firefighters

Firefighting is a high-risk occupation that accounts for vulnerability to a range of mental health problems and addictive behaviours. However, no research has addressed whether this vulnerability extends to gambling problems, and the aim of this study was thus to provide new data on frequency and implications of such problems in this occupational context. The sample consisted of n = 566 career and retained firefighters who participated in a cross-sectional survey of an Australian metropolitan fire service. The Problem Gambling Severity Index (PGSI) was used to operationalise both clinically significant levels of problem gambling (PGSI ≥ 5), and 'at-risk' gambling (PGSI 1-4); alongside measures of major depression (PHQ-9), anxiety (GAD-7), Posttraumatic Stress Disorder (PCL-5) and alcohol problems (AUDIT), as well as other addictive behaviours, wellbeing and psychosocial issues. Results indicated 12.3% of firefighters that reported any gambling problems across a continuum of severity (PGSI ≥ 1), including 2.3% that were problems gamblers, and 10.0% reporting at-risk gambling. The weighted prevalence of problem gambling was comparable to other significant mental health conditions including depression and PTSD, while the rate of any gambling problems was high relative to other addictive behaviours. Gambling problems were associated with poor mental health and wellbeing, but not psychosocial indicators (e.g., financial difficulties). The findings suggest that gambling problems across a spectrum of severity may be significant yet hidden issues among emergency service workers, and thus require increased recognition and responses at the organisational level.

Recurrent Sinopulmonary Infections in a Patient Whose HIV Masked Common Variable Immunodeficiency

It is generally accepted that persons infected with human immunodeficiency virus (HIV) are at an increased risk of infection due to direct destruction of CD4⁺ lymphocytes and subsequently impaired cell-mediated immunity. Typically, HIV infection is associated with immunoglobulin elevations, but quantitative deficiencies in immunoglobulins have also been rarely described. We present an unusual case of common variable immunodeficiency (CVID) in a HIV-positive patient with recurrent severe respiratory infections. We review epidemiology, clinical presentation, and treatment of primary immunoglobulin deficiency. We also review the relationship between immunoglobulin deficiency and HIV and highlight the importance of recognizing the coexistence of two distinct immunodeficiency syndromes.

Barriers and facilitators to attendance at Type 2 diabetes structured education programmes: a qualitative study of educators and attendees

AIMS

Attendance at structured diabetes education has been recommended internationally for all people with Type 2 diabetes. However, attendance rates are consistently low. This qualitative study aimed to explore experiences of attending and delivering Type 2 diabetes structured education programmes in Ireland and barriers and facilitators to attendance.

METHODS

People with Type 2 diabetes who had attended one of the three programmes delivered in Ireland and educators from the three programmes took part in semi-structured telephone interviews. Interviews were audio-taped, transcribed and analysed using inductive thematic analysis.

RESULTS

Twelve attendees and 14 educators were interviewed. Two themes were identified in relation to experiences of programme attendance and delivery: 'Structured education: addressing an unmet need' and 'The problem of non-attendance'. The third theme 'Barriers to attendance: can't go, won't go, don't know and poor system flow' outlined how practicalities of attending, lack of knowledge of the existence and benefits, and limited resources and support for education within the diabetes care pathway impacts on attendance. The final theme 'Supporting attendance: healthcare professionals and the diabetes care pathway' describes facilitators to participants' attendance and the strategies educators perceived to be important in increasing attendance.

CONCLUSIONS

Healthcare professionals have an important role in improving attendance at structured diabetes education programmes. Improving attendance may require promotion by healthcare professionals and for education to be better embedded and supported within the diabetes care pathway.

Effects of a transition home program on preterm infant emergency room visits within 90 days of discharge

OBJECTIVE

To evaluate effects of a transition home program (THP) and risk factors on emergency room (ER) use within 90 days of discharge for preterm (PT) infants <37 weeks gestation.

STUDY DESIGN

This is a prospective 3-year cohort study of 804 mothers and 954 PT infants. Mothers received enhanced neonatal intensive care unit transition support services until 90 days postdischarge. Regression models were run to identify the effects of THP implementation year and risk factors on ER visits.

RESULTS

Of the 954 infants, 181 (19%) had ER visits and 83/181 (46%) had an admission. In regression analysis, THP year 3 vs year 1 and human milk at discharge were associated with decreased risk of ER visits, whereas increased odds was associated with non-English speaking, maternal mental health disorders and bronchopulmonary dysplasia.

CONCLUSION

Enhanced THP services were associated with a 33% decreased risk of all ER visits by year 3. Social and environmental risk factors contribute to preventable ER visits.

Key patterns and predictors of response to treatment for military veterans with post-traumatic stress disorder: a growth mixture modelling approach

BACKGROUND

To determine the patterns and predictors of treatment response trajectories for veterans with post-traumatic stress disorder (PTSD).

METHODS

Conditional latent growth mixture modelling was used to identify classes and predictors of class membership. In total, 2686 veterans treated for PTSD between 2002 and 2015 across 14 hospitals in Australia completed the PTSD Checklist at intake, discharge, and 3 and 9 months follow-up. Predictor variables included co-morbid mental health problems, relationship functioning, employment and compensation status.

RESULTS

Five distinct classes were found: those with the most severe PTSD at intake separated into a relatively large class (32.5%) with small change, and a small class (3%) with a large change. Those with slightly less severe PTSD separated into one class comprising 49.9% of the total sample with large change effects, and a second class comprising 7.9% with extremely large treatment effects. The final class (6.7%) with least severe PTSD at intake also showed a large treatment effect. Of the multiple predictor variables, depression and guilt were the only two found to predict differences in response trajectories.

CONCLUSIONS

These findings highlight the importance of assessing guilt and depression prior to treatment for PTSD, and for severe cases with co-morbid guilt and depression, considering an approach to trauma-focused therapy that specifically targets guilt and depression-related cognitions.

Separation from parents during childhood trauma predicts adult attachment security and post-traumatic stress disorder

BACKGROUND

Prolonged separation from parental support is a risk factor for psychopathology. This study assessed the impact of brief separation from parents during childhood trauma on adult attachment tendencies and post-traumatic stress.

METHOD

Children (n = 806) exposed to a major Australian bushfire disaster in 1983 and matched controls (n = 725) were assessed in the aftermath of the fires (mean age 7-8 years) via parent reports of trauma exposure and separation from parents during the fires. Participants (n = 500) were subsequently assessed 28 years after initial assessment on the Experiences in Close Relationships scale to assess attachment security, and post-traumatic stress disorder (PTSD) was assessed using the PTSD checklist.

RESULTS

Being separated from parents was significantly related to having an avoidant attachment style as an adult (B = -3.69, s.e. = 1.48, β = -0.23, p = 0.013). Avoidant attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, β = 0.31, p = 0.045), avoidance (B = 0.03, s.e. = 0.01, β = 0.30, p = 0.001) and numbing (B = 0.03, s.e. = 0.01, β = 0.30, p < 0.001) symptoms. Anxious attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, β = 0.18, p = 0.001), numbing (B = 0.03, β = 0.30, s.e. = 0.01, p < 0.001) and arousal (B = 0.04, s.e. = 0.01, β = 0.43, p < 0.001) symptoms.

CONCLUSIONS

These findings demonstrate that brief separation from attachments during childhood trauma can have long-lasting effects on one's attachment security, and that this can be associated with adult post-traumatic psychopathology.

Brain antibodies in the cortex and blood of people with schizophrenia and controls

The immune system is implicated in the pathogenesis of schizophrenia, with elevated proinflammatory cytokine mRNAs found in the brains of ~40% of individuals with the disorder. However, it is not clear if antibodies (specifically immunoglobulin-γ (IgG)) can be found in the brain of people with schizophrenia and if their abundance relates to brain inflammatory cytokine mRNA levels. Therefore, we investigated the localization and abundance of IgG in the frontal cortex of people with schizophrenia and controls, and the impact of proinflammatory cytokine status on IgG abundance in these groups. Brain IgGs were detected surrounding blood vessels in the human and non-human primate frontal cortex by immunohistochemistry. IgG levels did not differ significantly between schizophrenia cases and controls, or between schizophrenia cases in 'high' and 'low' proinflammatory cytokine subgroups. Consistent with the existence of IgG in the parenchyma of human brain, mRNA and protein of the IgG transporter (FcGRT) were present in the brain, and did not differ according to diagnosis or inflammatory status. Finally, brain-reactive antibody presence and abundance was investigated in the blood of living people. The plasma of living schizophrenia patients and healthy controls contained antibodies that displayed positive binding to Rhesus macaque cerebellar tissue, and the abundance of these antibodies was significantly lower in patients than controls. These findings suggest that antibodies in the brain and brain-reactive antibodies in the blood are present under normal circumstances.

A systematic review of interventions to improve outcomes for young adults with Type 1 diabetes

BACKGROUND

Many young adults with Type 1 diabetes experience poor outcomes. The aim of this systematic review was to synthesize the evidence regarding the effectiveness of interventions aimed at improving clinical, behavioural or psychosocial outcomes for young adults with Type 1 diabetes.

METHODS

Electronic databases were searched. Any intervention studies related to education, support, behaviour change or health service organizational change for young adults aged between 15-30 years with Type 1 diabetes were included. A narrative synthesis of all studies was undertaken due to the large degree of heterogeneity between studies.

RESULTS

Eighteen studies (of a possible 1700) were selected and categorized: Health Services Delivery (n = 4), Group Education and Peer Support (n = 6), Digital Platforms (n = 4) and Diabetes Devices (n = 4). Study designs included one randomized controlled trial, three retrospective studies, seven feasibility/acceptability studies and eight studies with a pre/post design. Continuity, support, education and tailoring of interventions to young adults were the most common themes across studies. HbA_1c was the most frequently measured outcome, but only 5 of 12 studies that measured it showed a significant improvement.

CONCLUSION

Based on the heterogeneity among the studies, the effectiveness of interventions on clinical, behavioural and psychosocial outcomes among young adults is inconclusive. This review has highlighted a lack of high-quality, well-designed interventions, aimed at improving health outcomes for young adults with Type 1 diabetes.

Investigating the management of diabetes in nursing homes using a mixed methods approach

AIMS

As populations age there is an increased demand for nursing home (NH) care and a parallel increase in the prevalence of diabetes. Despite this, there is growing evidence that the management of diabetes in NHs is suboptimal. The reasons for this are complex and poorly understood. This study aimed to identify the current level of diabetes care in NHs using a mixed methods approach.

METHODS

The nursing managers at all 44 NHs in County Galway in the West of Ireland were invited to participate. A mixed methods approach involved a postal survey, focus group and telephone interviews.

RESULTS

The survey response rate was 75% (33/44) and 27% (9/33) of nursing managers participated in the qualitative research. The reported prevalence of diagnosed diabetes was 14% with 80% of NHs treating residents with insulin. Hypoglycaemia was reported as 'frequent' in 19% of NHs. A total of 36% of NHs have staff who have received diabetes education or training and 56% have access to diabetes care guidelines. Staff education was the most cited opportunity for improving diabetes care. Focus group and interview findings highlight variations in the level of support provided by GPs and access to dietetic, podiatry and retinal screening services.

CONCLUSIONS

There is a need for national clinical guidelines and standards of care for diabetes management in nursing homes, improved access to quality diabetes education for NH staff, and greater integration between healthcare services and NHs to ensure equity, continuity and quality in diabetes care delivery.

The Eukaryotic Replication Machine

The cellular replicating machine, or "replisome," is composed of numerous different proteins. The core replication proteins in all cell types include a helicase, primase, DNA polymerases, sliding clamp, clamp loader, and single-strand binding (SSB) protein. The core eukaryotic replisome proteins evolved independently from those of bacteria and thus have distinct architectures and mechanisms of action. The core replisome proteins of the eukaryote include: an 11-subunit CMG helicase, DNA polymerase alpha-primase, leading strand DNA polymerase epsilon, lagging strand DNA polymerase delta, PCNA clamp, RFC clamp loader, and the RPA SSB protein. There are numerous other proteins that travel with eukaryotic replication forks, some of which are known to be involved in checkpoint regulation or nucleosome handling, but most have unknown functions and no bacterial analogue. Recent studies have revealed many structural and functional insights into replisome action. Also, the first structure of a replisome from any cell type has been elucidated for a eukaryote, consisting of 20 distinct proteins, with quite unexpected results. This review summarizes the current state of knowledge of the eukaryotic core replisome proteins, their structure, individual functions, and how they are organized at the replication fork as a machine.

The impact of sharing personalised clinical information with people with type 2 diabetes prior to their consultation: A pilot randomised controlled trial

AIM

To assess the impact of sharing personalised clinical information with people with type 2 diabetes prior to their out-patient consultation on patient involvement during the consultation, diabetes self-management self-efficacy and glycaemic control.

METHODS

A pilot three-arm randomised controlled trial. The 'intervention booklet' group received a booklet including personalised clinical information, a 'general information booklet' control group received a booklet with no personalised clinical information and a 'usual care' control group received no written information.

RESULTS

136 people took part. The intervention group were significantly more likely to have shown the booklet to a 'significant other', (48% V 23%, p<0.05), brought the booklet with them to the clinic (85% V 35%, p<0.005) and to refer to the booklet during the consultation (45% V 13%, p<0.005). No significant differences in patient involvement during the consultation, diabetes management self-efficacy or glycaemic control were found between the three groups.

CONCLUSIONS

Although participants found it useful to receive their clinical results, no differences were found in the patient outcomes measured.

PRACTICE IMPLICATIONS

Further pilot work on the timing of the intervention, who it is targeted at and what outcomes are measured is warranted before proceeding to a full-scale RCT.

Highly sensitive magneto-motive photoacoustic and ultrasound (PAUS) imaging with cyclic excitations

Highly specific molecular imaging with photoacoustics (PA) must suppress background endogenous signals while maintaining signals from target nanoagents. Magneto-motive PA was introduced to perform motion-based background suppression using a low frequency magnetic field. Previous studies show suppression based on displacement magnitude can suffer if significant physiological motion is present. This limitation can be overcome using cyclic magneto-motive PA (cmmPA), where multiple cycles of an ac magnetic field are used and the coherence of detected displacements is the retrieved information. In this paper, we show a method to enhance the magnetic response of an electromagnet specifically for cmmPA. Several magnetic frequencies were tested and a simple model is proposed to describe displacement frequency dependence. By choosing optimal parameters based on this model, we show that the technique can detect a low number of tagged cells using either US-based or PA-based displacement estimation. In addition, robustness to physiological motion is demonstrated in a moving phantom.

The effects of camicinal, a novel motilin agonist, on gastro-esophageal function in healthy humans-a randomized placebo controlled trial

BACKGROUND

A proportion of patients with foregut dysmotility fail to respond to standard interventions. Motilin agonists may be beneficial in this group. We aimed to determine the effect of camicinal, a novel motilin agonist, on gastrointestinal physiology in healthy volunteers.

METHODS

Healthy male subjects were randomly assigned to receive a single dose of 125 mg camicinal or placebo in a double-blind cross-over design. Esophageal function and reflux indices were assessed using high-resolution manometry (pre and 1.5-h post dose) and 24-h ambulatory multichannel intraluminal impedance/pH. After a standardized meal, subjects ingested a wireless motility capsule from which compartmental transit times and motility indices were derived. Subjects were restudied with the alternate intervention after 7 days.

KEY RESULTS

The study subjects (12 male, mean age 47.4 years, range 22-55) tolerated the drug well, except one who exhibited mild abdominal pain on both placebo and camicinal. In comparison to placebo, gastric emptying time (GET) was accelerated following camicinal (-115.4 min, 95% confidence interval -194.4, -36.4, p = 0.009). No effect was demonstrable on esophageal function, small bowel, colonic, or whole bowel transit times and motility indices. With camicinal, as part of a post hoc analysis, there was a trend association between the percentage reduction in GET and total number of acidic reflux events (r = 0.56, p = 0.09).

CONCLUSIONS & INFERENCES

Camicinal decreases GET and was generally well-tolerated. In health, the direct effects of camicinal are on accelerating GET with a potential secondary benefit of reducing reflux events, which warrant further exploration in patient cohorts.

Familial progressive hyper- and hypopigmentation and malignancy in two families with new mutations in KITLG

BACKGROUND

Familial progressive hyper- and hypopigmentation (FPHH) is an autosomal dominant skin condition presenting in childhood with generalized macular dyspigmentation, usually reported in patients of East Asian origin. It overlaps phenotypically with other dyschromatoses, but can now be distinguished by mutations in the KIT ligand gene (KITLG).

AIM

We report two unrelated white families with similar phenotypic presentations of FPHH developing in early childhood in several generations.

METHODS

Sanger sequencing of the exons and flanking introns of KITLG was performed.

RESULTS

This identified a new heterozygous missense mutation in each family (p.Thr34Asn and p.Val37Gly, respectively). Of the six affected individuals examined by us, two had cancer: a 62-year-old man in family 1 had developed two primary melanomas and a pharyngeal carcinoma, and a 42-year-old woman in family 2 had developed thyroid carcinoma. All had unusually sparse lateral eyebrows, a finding not previously reported in this condition.

CONCLUSIONS

We summarize the genetic spectrum of the dyschromatoses and discuss a possible increased risk of malignancy in FPHH.

Adjunctive raloxifene treatment improves attention and memory in men and women with schizophrenia

There is increasing clinical and molecular evidence for the role of hormones and specifically estrogen and its receptor in schizophrenia. A selective estrogen receptor modulator, raloxifene, stimulates estrogen-like activity in brain and can improve cognition in older adults. The present study tested the extent to which adjunctive raloxifene treatment improved cognition and reduced symptoms in young to middle-age men and women with schizophrenia. Ninety-eight patients with a diagnosis of schizophrenia or schizoaffective disorder were recruited into a dual-site, thirteen-week, randomized, double-blind, placebo-controlled, crossover trial of adjunctive raloxifene treatment in addition to their usual antipsychotic medications. Symptom severity and cognition in the domains of working memory, attention/processing speed, language and verbal memory were assessed at baseline, 6 and 13 weeks. Analyses of the initial 6-week phase of the study using a parallel groups design (with 39 patients receiving placebo and 40 receiving raloxifene) revealed that participants receiving adjunctive raloxifene treatment showed significant improvement relative to placebo in memory and attention/processing speed. There was no reduction in symptom severity with treatment compared with placebo. There were significant carryover effects, suggesting some cognitive benefits are sustained even after raloxifene withdrawal. Analysis of the 13-week crossover data revealed significant improvement with raloxifene only in attention/processing speed. This is the first study to show that daily, oral adjunctive raloxifene treatment at 120 mg per day has beneficial effects on attention/processing speed and memory for both men and women with schizophrenia. Thus, raloxifene may be useful as an adjunctive treatment for cognitive deficits associated with schizophrenia.

Advance preferences regarding thrombolysis in patients at risk for stroke: a cross-sectional study

BACKGROUND

It is difficult to obtain informed consent for thrombolysis in stroke patients given the emergency setting, the need for a speedy decision and the effects of neurological deficits.

AIM

To determine the advance preferences for thrombolysis of patients at risk for stroke following discussion of the potential risks and benefits.

DESIGN

Cross-sectional survey.

METHODS

Data on benefits and risks of thrombolysis within 3 h and between 3 and 4.5 h after stroke were presented orally, in writing and pictorially to patients attending geriatric and stroke services in a teaching hospital with specified stroke risk factors and preferences for thrombolysis were recorded.

RESULTS

Of the 121 participants, 108 (89.3%; 95% confidence interval [CI] 82.4-93.7) would opt for thrombolysis within the 3-h period and 100 (82.6%; 95% CI 74.9-88.4) within the 3- to 4.5-h period after acute stroke (P = 0.04, McNemar's test for correlated proportions). Previous stroke or transient ischaemic attack was more common among those who agreed to thrombolysis (54.1% vs. 30.4%, P = 0.04) and those who opted for thrombolysis were significantly more likely to agree to have their preferences recorded and used in the event of a stroke than those who refused thrombolysis (88.8% vs. 30.4%, P = 0.002).

CONCLUSION

Advance discussion of the potential risks and benefits of thrombolysis in at-risk patients may improve decision making if thrombolysis is being considered and the patient can no longer make a decision.

Comparing mortality in patients with atrial fibrillation who are receiving a direct-acting oral anticoagulant or warfarin: a meta-analysis of randomized trials

BACKGROUND

In patients with non-valvular atrial fibrillation (AF), direct-acting oral anticoagulants (DOACs) are at least non-inferior to warfarin for the prevention of stroke and systemic embolism. The main objective of this study was to obtain reliable and precise estimates for all-cause mortality, vascular mortality and bleeding mortality in patients with AF receiving a DOAC or warfarin for stroke prevention.

METHODS

A meta-analysis was performed on phase 3 randomized trials that compared a DOAC with warfarin for stroke prevention in AF. Published data were pooled by use of the DerSimonian random-effect model, with revman 5.2 and comprehensive meta analysis software version 2. The results were presented as risk ratios (RRs), absolute risk reduction (ARR), and number-needed-to-treat (NNT).

RESULTS

A total of 71 683 patients were included in this meta-analysis from four randomized controlled trials (median patient follow-up: 1.8-2.8 years) that compared a DOAC with warfarin for stroke prevention in AF. As compared with warfarin, DOACs significantly reduced all-cause mortality (RR 0.89, 95% confidence interval [CI] 0.85-0.94; ARR 0.76%, 95% CI 0.39-1.13%; NNT = 132), vascular mortality (RR 0.88, 95% CI 0.82-0.94; ARR 0.53%, 95% CI 0.23-0.83%; NNT = 189), and bleeding mortality (RR 0.54, 95% CI 0.44-0.67; ARR 0.32%, 95% CI 0.21-0.43%; NNT = 313).

CONCLUSION

As compared with warfarin therapy for stroke prevention in patients with AF, DOACs significantly reduce all-cause mortality, vascular mortality, and bleeding mortality. This mortality benefit appears to be driven by the reduction in vascular-related and bleeding-related mortality, which, in turn, may be related to the reduction in intracranial bleeding.

Serum testosterone levels are related to cognitive function in men with schizophrenia

BACKGROUND

Sex steroids such as oestrogen and testosterone are potent neurodevelopmental hormones that also play a role in neuromodulation and neuroprotection of the mature brain. Sex steroid hormones may also be involved in the pathophysiology of schizophrenia as reduced circulating sex steroid levels and changes in brain sex steroid receptors are found in people with schizophrenia compared to controls. In men with schizophrenia, recent studies have documented an inverse correlation between serum testosterone and negative symptoms. Our study sought to confirm whether men with schizophrenia had lower levels of testosterone relative to controls and to determine whether lower testosterone levels were related to higher symptom severity and impaired cognition.

METHOD

Circulating serum hormone levels (testosterone, oestrogen, and prolactin), cognitive function and symptoms were assessed in 29 chronically ill men with schizophrenia or schizoaffective disorder. Twenty healthy men were recruited as a comparison group. A series of regression analyses were performed to determine the extent to which circulating sex steroid hormone levels predict cognition and symptoms in men with schizophrenia.

RESULTS

We did not find a significant difference in serum testosterone levels between groups. However, circulating testosterone levels significantly predicted performance on verbal memory, processing speed, and working memory in men with schizophrenia. With the exception of an effect of oestrogen on verbal memory, circulating sex steroid levels did not predict cognitive function in healthy men. Testosterone levels were not related to positive or negative symptom severity, but testosterone influenced excitement/hostility levels in our schizophrenia sample.

CONCLUSIONS

The results suggest that circulating sex steroids may modulate cognitive deficits associated with schizophrenia.

Dual skin tests with Mycobacterium avium sensitin and PPD to detect misdiagnosis of latent tuberculosis infection

BACKGROUND

A positive tuberculin skin test (TST) may indicate cross-reacting immunity to non-tuberculous mycobacteria (NTM) and not latent tuberculosis infection (LTBI).

OBJECTIVES

To assess misclassification of LTBI, as assessed by skin testing with Mycobacterium avium sensitin (MaS), and to determine how this misclassification affects the analysis of risk factors for LTBI.

METHODS

In a population-based survey, participants underwent skin testing with M. tuberculosis purified protein derivative (PPD) and MaS. A PPD-dominant skin test was a reaction that was ≥ 3 mm larger than the MaS reaction; a MaS-dominant skin test was a reaction that was ≥ 3 mm larger than the PPD reaction.

RESULTS

Of 447 randomly selected persons, 135 (30%) had a positive PPD test. Of these, 21 (16%) were MaS- dominant, and were therefore attributable to NTM and misclassified as LTBI. PPD reactions of 5-14 mm were more likely to be misclassified than those ≥ 15 mm (OR = 5.0, 95%CI 1.9-13.2). Adjusting for misclassification had only a small impact on the analysis of risk factors for LTBI.

CONCLUSIONS

A substantial number of individuals who are diagnosed with LTBI are actually sensitized to NTM. Using dual skin testing would reduce misdiagnosis and prevent unnecessary treatment.

Heart rate after trauma and the specificity of fear circuitry disorders

BACKGROUND

Fear circuitry disorders purportedly include post-traumatic stress disorder (PTSD), panic disorder, agoraphobia, social phobia and specific phobia. It is proposed that these disorders represent a cluster of anxiety disorders triggered by stressful events and lead to fear conditioning. Elevated heart rate (HR) at the time of an aversive event may reflect strength of the unconditioned response, which may contribute to fear circuitry disorders.

METHOD

This prospective cohort study assessed HR within 48 h of hospital admission in 602 traumatically injured patients, who were assessed during hospital admission and within 1 month of trauma exposure for lifetime psychiatric diagnosis. At 3 months after the initial assessment, 526 patients (87%) were reassessed for PTSD, major depressive disorder, panic disorder, agoraphobia, social phobia, obsessive compulsive disorder and generalized anxiety disorder.

RESULTS

At the 3-month assessment there were 77 (15%) new cases of fear circuitry disorder and 87 new cases of non-fear circuitry disorder (17%). After controlling for gender, age, type of injury and injury severity, patients with elevated HR (defined as ≥96 beats per min) at the time of injury were more likely to develop PTSD [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.32-14.43], panic disorder (OR 3.46, 95% CI 1.16-10.34), agoraphobia (OR 3.90, 95% CI 1.76-8.61) and social phobia (OR 3.98, 95% CI 1.42-11.14). Elevated HR also predicted new fear circuitry disorders that were not co-morbid with a non-fear circuitry disorder (OR 7.28, 95% CI 2.14-24.79).

CONCLUSIONS

These data provide tentative evidence of a common mechanism underpinning the onset of fear circuitry disorders.