Sleep-disordered breathing in severe mental illness: clinical evaluation of oximetry diagnosis and management limitations

BACKGROUND

To describe the diagnosis and management pathway of sleep-disordered breathing (SDB) in a sample of patients with severe mental illness (SMI), and to assess the feasibility and patient acceptability of overnight oximetry as a first-step screening method for detecting severe SDB in this population.

METHODS

The study was a retrospective audit of patients with SMI seen at a Collaborative Centre for Cardiometabolic Health in Psychosis service who were invited for overnight oximetry between November 2015 and May 2018. The adjusted oxygen desaturation index (ODI) was calculated using 4% desaturation criteria. Results were discussed with a sleep specialist and categorized into a 4-level risk probability tool for SDB.

RESULTS

Of 91 adults consenting for overnight oximetry, 90 collected some oximetry data, though 11 of these 90 patients collected technically unsatisfactory oximetry. Thus 79/90 patients (88%) collected adequate oximetry data for at least one night. The oximetry traces suggested likely minimal obstructive sleep apnea (OSA) in 41 cases, moderate to severe OSA in 25 patients, severe OSA in 9 patients and possible obesity hypoventilation syndrome (OHS) in 4 cases. Full polysomnography was recommended for 39 patients but only one-third underwent testing. Nineteen patients were reviewed by a sleep specialist. Of the 10 patients who initiated CPAP, four were considered adherent to treatment.

CONCLUSION

Home oximetry may be a pragmatic option for SDB screening in patients with SMI but reliable full diagnostic and management pathways need to be developed.

OP0163 2019 UPDATE OF THE JOINT EUROPEAN LEAGUE AGAINST RHEUMATISM AND EUROPEAN RENAL ASSOCIATION–EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION (EULAR/ERA-EDTA) RECOMMENDATIONS FOR THE MANAGEMENT OF LUPUS NEPHRITIS

Background:

Up to 40% of systemic lupus erythematosus (SLE) patients develop kidney disease, which represents a major cause of morbidity.

Objectives:

To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN).

Methods:

We followed the EULAR standardised operating procedures for the publication of treatment recommendations. Delphi-based methodology led to 15 questions for systematic literature review (SLR), which was undertaken by three fellows.

Results:

The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNI), and management of end-stage-kidney-disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7gr/24h with [near-]normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3g/day, or mycophenolic acid at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500mg x6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1g/24h despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations.

Conclusion:

The updated recommendations intend to inform rheumatologists, nephrologists, patients, national professional societies, hospital officials, social security agencies and regulators about the treatment of LN based on most recent evidence.

Disclosure of Interests:

Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Myrto Kostopoulou: None declared, Kim Cheema: None declared, Hans-Joachim Anders: None declared, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Ingeborg Bajema Consultant of: GSK, John N. Boletis Grant/research support from: GSK, Pfizer, Paid instructor for: GSK, Abbvie, UCB, Enorasis, Eleni Frangou: None declared, Frederic Houssiau Grant/research support from: UCB, Consultant of: GSK, Jane Hollis: None declared, Alexandre Karras: None declared, Francesca Marchiori: None declared, Stephen Marks: None declared, Gabriela Moroni: None declared, Marta Mosca: None declared, Ioannis Parodis: None declared, Manuel Praga: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Vladimir Tesar: None declared, Maria Trachana: None declared, Ronald van Vollenhoven Grant/research support from: AbbVie, Amgen, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline (GSK), Janssen Research & Development, LLC, Lilly, Pfizer, Roche, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB and Vertex, Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GlaxoSmithKline, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Alexandre Voskuyl: None declared, Y.K. Onno Teng Grant/research support from: GSK, Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, Bernadette van Leeuw: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, Dimitrios Boumpas: None declared

Personality dimensions of people who suffer from visual stress

Personality dimensions of participants who suffer from visual stress were compared with those of normal participants using the Eysenck Personality Inventory. Extraversion-Introversion scores showed no significant differences between the participants who suffered visual stress and those who were classified as normal. By contrast, significant differences were found between the normal participants and those with visual stress in respect of Neuroticism-Stability. These differences accord with Eysenck's personality theory which states that those who score highly on the neuroticism scale do so because they have a neurological system with a low threshold such that their neurological system is easily activated by external stimuli. The findings also relate directly to the theory of visual stress proposed by Wilkins which postulates that visual stress results from an excess of neural activity. The data may indicate that the excess activity is likely to be localised at particular neurological regions or neural processes.

The uninsured and Medicaid Oregon tobacco user experience in a real world, phone based cessation programme

OBJECTIVE

To describe the experience of uninsured and Medicaid Oregon tobacco users who registered in Free & Clear (F&C), a telephone based cessation programme including five scheduled outbound calls.

DESIGN AND SETTING

Using a retrospective cohort design, 1334 (423 uninsured, 806 Medicaid, and 105 commercially insured) Oregon tobacco users who registered in F&C between 18 November 1998 and 28 February 2000 were identified and followed for 12 months post-registration; 648 (48.6%) were successfully contacted at 12 months. Information was collected from the F&C database. Unconditional logistic regression, adjusted for race and education, was used.

RESULTS

The seven day quit rate at 12 months, assuming non-respondents were smokers, was 14.8% (95% confidence interval (CI) 13.0 to 16.9). This rate was significantly higher among commercially insured participants (v Medicaid but not uninsured) and among participants who completed > or = 5 calls (v < 5 calls). The quit rate for those contacted at 12 months was 30.6% (95% CI 27.0% to 34.3%) and varied, however not significantly, by insurance and number of calls. After adjustment, respondents who completed > or = 5 calls were 60% more likely to quit tobacco (odds ratio (OR) 1.6, 95% CI 0.9 to 3.1), and uninsured respondents who completed > or = 5 calls were 70% more likely to quit tobacco (OR 1.7, 95% CI 0.9 to 3.5), relative to those who completed < 5 calls, but the difference was not significant.

CONCLUSIONS

The quit rates are similar to those reported in efficacy trials. The observed variation in quitting tobacco for respondents by number of calls completed and by insurance merits further investigation concentrating on increasing compliance with the call schedule, particularly for the uninsured.

Assessment of Ankle-Subtalar-Joint-Complex Laxity Using an Instrumented Ankle Arthrometer: An Experimental Cadaveric Investigation

OBJECTIVE: To show the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint-complex laxity using a portable ankle arthrometer; to assess within and between-tester measurement reliability; and to determine if the ankle arthrometer can detect increased mechanical laxity of the ankle-subtalar-joint-complex after simulated injury of the lateral ankle ligaments. DESIGN AND SETTING: We used linear regression analysis to examine the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint-complex laxity. An intraclass correlation coefficient (2,1) was calculated to determine intratester and intertester reliability for instrumented measurements of ankle-subtalar-joint-complex laxity. In addition, 2 separate, one-way, repeated-measures analyses of variance were used to compare instrumented measures of anteroposterior displacement and inversion-eversion rotation among the intact ankles after sectioning the anterior talofibular ligament and both the anterior talofibular and calcaneofibular ligaments. Data were collected in a biomechanics laboratory setting. SUBJECTS: Six fresh-frozen human-cadaver ankle specimens were studied. MEASUREMENTS: Testing involved the concurrent measurement of tibial-calcaneal bone motion and ankle-subtalar-joint-complex motion during the application of external loads. An instrumented ankle arthrometer was used to load the ankle in a controlled manner. Two spatial kinematic linkages measured the 3-dimensional motion of the calcaneus relative to the tibia and the motion of the arthrometer's footplate relative to the tibia. RESULTS: The correlation between tibial-calcaneal bone motion and instrumented measurement for anterior-posterior displacement was.878 (P =.0001). Its linear relationship with bone motion accounted for approximately 77% of the variance of the instrumented measurement. The correlation between tibial-calcaneal bone motion and instrumented measurement for inversion-eversion rotation was.858 (P =.0001), with approximately 74% of the variance of the instrumented measurement accounted for by its linear relationship with bone motion. High intratester and intertester reliability coefficients (ICC [2,1] =.80 to.97) were observed for instrumented measurements of ankle-subtalar-joint-complex laxity. In addition, ligamentous sectioning resulted in significantly increased ankle-subtalar-joint-complex laxity. When compared with the intact condition, sectioning both the anterior talofibular and calcaneofibular ligaments produced significant increases in anterior-posterior displacement (P =.0001) and inversion-eversion rotation (P =.002). CONCLUSIONS: We found a strong relationship between tibial-calcaneal bone motion and arthrometric measurements of ankle-subtalar-joint-complex laxity. The instrumented ankle arthrometer may be suitable as a diagnostic tool for the evaluation of lateral ankle-ligament laxity.

Proper-name processing: are proper names pure referencing expressions?

Theoretical models of proper-name processing have been primarily derived from studies of people's names; however, they are thought to generalize to all classes of proper name. Five experiments are reported that use repetition priming to compare different classes of proper names. It was found that for people's names and landmark names, (a) production of a name in response to seeing a picture primed a subsequent familiarity decision to the same item's written name and (b) similarly, making a familiarity decision to an auditory presentation of a name primed a familiarity decision to the same item's written name. No comparable facilitation was found for the country-name stimuli. The presence of this specific facilitation was attributed to the nature of connectivity between conceptual and lexical representations. Theoretical views that proper names are unique, meaningless labels and that they are pure referencing expressions are evaluated.

On the relationship between reading, listening and speaking: it's different for people's names

Two experiments are reported that tested predictions derived from the framework of face, object, and word recognition proposed by Valentine, Brennen, and Brédart (1996). The findings were as follows: (1) Production of a celebrity's name in response to seeing the celebrity's face primed a subsequent familiarity decision to the celebrity's printed name. The degree of repetition priming observed was as great as that observed when a familiarity decision to the printed name was repeated in the prime and test phases of the experiment. (2) Making a familiarity decision to an auditory presentation of a celebrity's name primed a familiarity decision to the same celebrity's name presented visually. The magnitude of cross-modality priming was as great as the magnitude of within-modality repetition priming. This result for people's names contrasted with the effects observed in lexical decision tasks, in which no reliable cross-modality priming was observed. The results cannot be accounted for by previous models of face and name processing. They show a marked contrast between processing people's names and processing words. The results support the framework proposed by Valentine et al. (1996). The implications for models of speech production, perception, and reading are discussed, together with the potential of the methodology to elucidate our understanding of proper name processing.

Deploying an HMO's data warehouse

Kaiser Permanente says it has saved millions of dollars and improved the quality of care with information from its data warehouse. Here's how Kaiser implemented the warehouse four years ago, and how it uses it today.

The role of automated peritoneal dialysis (APD) in an integrated dialysis programme

While there is no doubt that renal transplantation would be the preferred option for all patients suffering from end stage renal disease, this is sadly an unrealistic aim for many patients in the UK. There is a shortage of donor organs and, with the increasing percentage of elderly patients on dialysis, under 50% of all dialysis patients are on the national transplant waiting list. Of the 12,000 or so patients on dialysis in the UK, approximately half receive haemodialysis and half peritoneal dialysis. In the last few years, there has been a resurgence of interest in automated peritoneal dialysis and just under 20% of the peritoneal dialysis population currently receive this mode of therapy. The advantages of automated peritoneal dialysis include the capacity for an increased dialysis prescription, increased freedom and quality of life and a decreased risk of peritonitis and intra peritoneal pressure related problems. These advantages may offset the increased cost of automated peritoneal dialysis and long-term patient morbidity and mortality may be diminished by its provision in an integrated dialysis programme.

The narrative skills of primary school children with a unilateral hearing impairment

The discourse skills of four boys with a unilateral hearing impairment (UHI), aged 7·2-10·7 years, were appraised over a 2-year period by examining their oral narrative use. All subjects exhibited delayed narrative skills, including features typical of children with a language disorder. These findings of language difficulties within this population were at variance with previous findings showing that children with UHI do not experience language problems. The subjects' language skills were discussed in relation to their academic performance. The implications of the findings for the process of narrative assessment were also discussed.

Mental health status as a predictor of morbidity and mortality: a 15-year follow-up of members of a health maintenance organization

OBJECTIVES

This study sought to relate preexisting depression, worries, affect balance, and mental health symptoms to subsequent risk of morbidity and mortality.

METHODS

A random sample of members of a health maintenance organization were interviewed at home in a 1970/71 survey. Baseline psychological measures from that survey were then related to 15-year mortality and first incidence of cancer, heart disease, hypertension, stroke, functional gastrointestinal disease, and hyperimmune diseases.

RESULTS

Baseline depression and the Langner Mental Health Index predicted incidence of functional gastrointestinal and hyperimmune diseases. The relationship of the Langner index to hyperimmune diseases was particularly strong; mortality, cancer, heart disease, hypertension, and stroke incidence were not related to that index. Except for affect balance, which was worst in the elderly, indications of psychological dysfunction were strongest in the young.

CONCLUSIONS

Psychological indices detected increased risk for functional gastrointestinal and hyperimmune diseases but were not related to mortality risk. Further research is needed to disaggregate relationships of the specific conditions that were included in the hyperimmune group. Functional gastrointestinal disease might be preventable with early attention to depressed persons and to those scoring high on the Langner index.

A stop-smoking telephone help line that nobody called

The purpose of this study was to evaluate the reach of a smoker's hotline that provided a variety of services to over 2100 health maintenance organization members. Formative evaluation procedures identified topics of concern, and repeated promotions advertised the service via multiple channels. Excluding a special giveaway promotion, an average of less than three calls per month were made during the 33 months of operation. To be cost-effective, smoker's hotlines should be offered to large populations and should be consistently and intensively publicized.

Baseline characteristics of participants in phase I of the Trials of Hypertension Prevention

Phase I of the Trials of Hypertension Prevention was designed to test the effectiveness and safety of three life-style (weight loss, sodium restriction, and stress management) and four nutrition supplement (calcium, magnesium, potassium, and fish oil) interventions in reducing diastolic blood pressure (DBP) in persons with a high-normal blood pressure. A total of 2182 persons with a DBP between 80 and 89 mm Hg met the eligibility criteria for participation in phase I and were randomized to one of the active intervention or control treatment groups. Most were white (82%), male (70%), married (76%), nonsmoking (88%), college graduate (53%), full-time employees (91%). The average blood pressure prior to entry into the trial was 124.9 mm Hg systolic and 83.8 mm Hg diastolic. A variety of baseline observations, including sociodemographic characteristics, personal and family medical history, health habits, diet, and biologic measurements, were documented before randomization and compared among the seven active intervention and control groups. As might be expected in a randomized trial of this sample size, the distribution of measured baseline characteristics was virtually identical in the treated and control groups. Based on this finding and the knowledge that randomization procedures were implemented without deviation from the phase I protocol, it is probable that unknown potential confounders were also equally distributed at entry into the study. Given the achievement of high rates of follow-up, subsequent differences in blood pressure are unlikely to have been due to baseline differences between the active treatment and control groups, and can probably be attributed to effects of the active interventions.

Smoking cessation and change in diastolic blood pressure, body weight, and plasma lipids. MRFIT Research Group

Cigarette smoking cessation was examined for its impact on diastolic blood pressure, weight, and plasma lipids in 3,470 special intervention males in the Multiple Risk Factor Intervention Trial. Change in smoking status (quitters vs nonquitters) was not independently associated with change in diastolic blood pressure or the subsequent use of antihypertensive medication for smokers who were normotensive at entry. More quitters (35%) became hypertensive than nonquitters (27%, P less than 0.01), although the groups had similar baseline diastolic blood pressure levels. Weight gain subsequent to cessation probably contributed to this excess incidence of hypertension in quitters. Stepped-care antihypertensive therapy lowered diastolic blood pressure similarly for hypertensive quitters and nonquitters. Weight increases of 6 lb or more by the 72-month visit occurred in 47% of quitters vs 25% of nonquitters (P less than 0.01); quitters did not differ from nonquitters in their change in total kilocalories from baseline to the 72-month visit. Quitters who gained 6 lb or more tended to be less obese at baseline, be less physically active, and smoke more cigarettes per day than those who did not gain this amount. Finally, quitters relative to nonquitters experienced an adjusted increase of 2.4 mg/dl high-density lipoprotein cholesterol, but no difference in total or low-density lipoprotein cholesterol. The implications for intervention are discussed as they relate to the common, but not inevitable, increase in weight subsequent to cessation.

Bone mineral status in childhood accidental fractures

We studied the bone mineral and calcium (Ca) status of 17 children who suffered an accidental fracture in 1980. These children were matched by age and sex to a nonfractured control group. Blood was drawn for serum Ca, phosphorus, magnesium, 25-hydroxycholecalciferol ( calcidiol ), alkaline phosphatase, and albumin. Bone mineral content (BMC) was evaluated by photon absorptiometry. There were no differences in serum values between the two groups. Twelve (71%) of the 17 children in the fracture group had a lower BMC than their matched controls. The BMC of the fracture group was lower than their controls, 0.423 +/- 0.042 v 0.461 +/- 0.037 g/cm. Four of the 15 in the fracture group ingested less than 60% of the recommended dietary allowance (RDA) for Ca and P (800 mg/day), while all the controls were ingesting at least 60% of the RDA. Four children of the fracture group who were ingesting less Ca and P than those of the control group also had low BMC.

Decreased bone mineral status in lactating adolescent mothers

To determine the calcium and bone mineral status of lactating adolescents, we compared 12 lactating adolescents with 11 nonlactating adolescents, 11 lactating adults, and 11 nulliparous adolescent control subjects. At two and 16 weeks, there were no differences in maternal serum concentrations of calcium, phosphorus, alkaline phosphatase, or calcidiol (25-hydroxyvitamin D). The bone mineral content at two weeks among the four groups was not different, but at 16 weeks the lactating adolescents' bone mineral content was lower than that in the other groups. The lactating adolescents' bone mineral content was decreased between two and 16 weeks (1.049 +/- 0.088 vs 0.887 +/- 0.054 gm/cm; P less than 0.02). Dietary intakes were similar among the groups for calories, protein, vitamin D, calcium, and phosphorus. However, only three of ten lactating adolescents met the recommended dietary allowance for calcium or phosphorus (1,600 mg/day), whereas eight of ten nonlactating adolescents, six of seven lactating adults, and seven of ten adolescents control subjects met the recommended dietary allowance for calcium or phosphorus (P less than 0.05). Our data suggest that during 16 weeks of lactation, the adolescent mother may be at risk for bone demineralization because of low dietary intakes of calcium or phosphorus.