AB1562-HPR COMPARING THE PROVISION OF SUBCUTANEOUS METHOTREXATE BETWEEN HOMECARE AND OUTPATIENT PHARMACY; WHAT DO PATIENTS PREFER AND IS ONE ROUTE QUICKER?

Background

The provision of subcutaneous methotrexate has historically been through homecare who provide injection training and delivery. In July 2018, subcutaneous methotrexate was accepted for shared care in the Trust’s locality to reduce medication costs but to also improve safety, reducing the risk of concomitant trimethoprim prescribing.

When suitable for shared care, initial injection training is provided by outpatient pharmacists and prescribing and monitoring during the stabilisation period is the responsibility of the rheumatology pharmacy team.

Objectives

The primary aim of this audit was to compare patient satisfaction between these two different routes of injection training and prescription provision. Additionally, the time it took for a patient to receive their first dose following a decision to start treatment, was also compared.

Methods

Patients were identified from databases held within the department, contacted retrospectively via telephone and asked to complete a short questionnaire. Clinic letters and the homecare company provided dates of treatment decision and initiation.

Results

40 patients were contacted, 20 had received treatment via outpatient pharmacy and 20 via homecare.

Table 1.

Patient reported satisfaction following receipt of injection training and prescription provision via outpatient pharmacy and homecare

Outpatient Pharmacy (20)Homecare (20)Not satisfiedSatisfiedVery satisfiedNot satisfiedSatisfiedVery satisfiedTime taken to start treatment25132612Injection training04163512Method for delivery of injection training and initial prescription18113413Process of receiving repeat prescriptions14151316

The mean time taken to start treatment was 30 days in the homecare group and 13 days in the outpatient group. 7 patients (35%) within the outpatient group started treatment within 7 days. The shortest time within the homecare group was 15 days (3 patients).

Conclusion

Reported patient satisfaction between the two routes of treatment provision was similar. Patients commenced treatment significantly quicker via outpatient pharmacy, reporting a high degree of satisfaction with the injection training provided by outpatient pharmacists. This audit has confirmed that shared care provision of methotrexate initially via outpatient pharmacy is a safe, efficient and viable option.

Disclosure of Interests

Rebecca Heaton Speakers bureau: I prepared slides and presented virtually for pharmacists explaining shared care experience (Nordic), Consultant of: Formulating a educational package for rheumatology pharmacists (Galapagos), Jennifer Nasralla: None declared, Charlotte Filer: None declared, Edward Appleby: None declared, Mya Myintzu: None declared

B-15 Engagement in Cognitively-Demanding Activities in Daily Life is Associated with Neurocognitive Test Performance and Perceived Cognitive Difficulties Among Adults With and Without HIV

Objective

Assessing daily activities is important for understanding how cognitive abilities affect everyday functioning. We evaluated a new measure capturing engagement in cognitively-demanding activities among people with and without HIV, and examined associations with neurocognitive test performance and perceived cognitive difficulties.

Method

Participants included 79 adults (59 HIV+, 20 HIV-) enrolled in studies at UCSD (mean age = 55.1; SD = 13.1). Domain-specific composite scaled scores measured neurocognitive functioning as continuous variables. Demographically-corrected global deficit scores determined neurocognitive impairment. Perceived cognitive difficulties were self-reported via the Everyday Cognition scale (ECog). The newly created, self-report Frequency and Difficulty of Activities Scale (FDAS) measured frequency of engagement in 27 cognitively-demanding activities [0 = Never to 10 = Once a day or more] in the last month. FDAS “total frequency score” sums all frequency ratings. Participants also rated difficulty performing each FDAS activity [0 = Not at all to 10 = Extremely]. FDAS “difficult-activity score” sums frequency ratings only for activities that participants identified as difficult for them (i.e., difficulty rating >75th percentile of sample).

Results

Higher FDAS total frequency scores correlated with better verbal fluency (r = 0.26, p = 0.019) and processing speed (r = 0.24, p = 0.030). Multiple regression revealed a significant interaction between cognitive impairment and frequency of engagement in difficult activities (b = 0.34, 95%CI = 0.18-0.50, p < 0.001), such that higher FDAS difficult-activity scores related to more perceived cognitive difficulties only among cognitively impaired participants.

Conclusion

This study explored use of a new measure of complex daily activities to aid neuropsychological interpretation. Results suggest that effects of neurocognitive impairment on perceived cognitive difficulties may only be apparent if individuals are attempting to perform challenging everyday tasks.

A-03 Ethnic/Racial Differences in Longitudinal Neurocognitive Change among People Living with HIV

HIV disproportionately affects Black and Latino people in the United States, but data on longitudinal neurocognitive patterns for these groups are scarce. This study evaluated the incidence and predictors of neurocognitive decline by ethnicity/race in a cohort of Black, Latino, and White people living with HIV (PLWH). Participants included 499 PLWH (43.5% White, 42.7% Black, 13.8% Latino; mean age at baseline = 43.5) from the six-site CNS HIV Anti-Retroviral Therapy Effects Research (CHARTER) study. Participants completed comprehensive neurocognitive and neuromedical evaluations over 3-7 study visits for an average of 2.8 years (SD = 1.1). Interpertation of neurocognitive change was based on published methods using regression-based norms that correct for baseline performance and practice effects. Survival analyses investigated the relationship between ethnicity/race and neurocognitive change, and predictors of neurocognitive decline. In follow-up, 108 participants (21.6%) declined, 311 (62.3%) remained stable, and 80 (16.0%) improved. In Cox proportional hazard models, hazard ratios for neurocognitive decline were increased for Latinos compared to Whites (HR = 2.19, 95%CI = 1.32-3.63, p = .002) and Blacks (HR = 1.87, 95%CI = 1.14-3.04, p = .01). Including significant covariates (baseline nadir CD4, hepatitis C Virus, and VACS Index: a composite marker of physical health among PLWH)did not significantly decrease the elevated risk for decline among Latinos. We found that Latino PLWH appear to have higher risk of neurocognitive decline compared to White and Black PLWH. Traditional markers of HIV disease and physical health at baseline did not explain this elevated risk of neurocognitive decline. Future research examining economic, socio-environmental, and culturally-relevant biomedical factors may help to explain this observed ethnic/racial disparity in longitudinal neurocognitive function in HIV.

B-24 Objective and Subjective Sleep Measures are Associated with Neurocognition in Middle-Aged and Older Adults With and Without HIV

Objective

Poorer sleep quality is related to worse cognitive functioning in the general population and people living with HIV; however, many studies use self-report sleep questionnaires that rely on retrospective recall. This study aimed to examine the relationship between objective (wrist actigraphy) and subjective sleep quality with neurocognitive functioning.

Method

Eighty-five adults aged 50-74 years with and without HIV (HIV+ n = 53, HIV- n = 32) were recruited from the community and ongoing studies at UC San Diego. Participants completed comprehensive neuropsychological testing assessing global and domain-specific cognition. Participants wore actigraphy watches for 14 nights after neuropsychological testing to objectively assess sleep quality (i.e., total sleep time (TST), efficiency, wake after sleep onset, and sleep fragmentation). The Pittsburgh Sleep Quality Index assessed subjective sleep quality.

Results

After adjusting for demographic variables and use of sleep medications, there were no differences in any sleep quality measures by HIV status (p’s>0.05). In separate adjusted linear regression models, lower sleep efficiency (p = 0.02; 95% CI: -9.5, -1.1) and greater sleep fragmentation (p = 0.02; 95% CI: -0.82, -0.09) were associated with worse learning. Less TST was associated with worse working memory (p = 0.02; 95% CI: -9.2, -0.8). In contrast, worse subjective sleep quality was associated with worse executive function (p < 0.01; 95% CI: -1.18, -0.23) and working memory (p = 0.03; 95% CI: -1.22, -0.07).

Conclusion

Both objective and subjective sleep quality were associated with cognition in both persons with and without HIV; however, subjective and objective sleep quality were associated with different cognitive domains. Therefore, both objective and subjective sleep quality are important health behaviors to assess.

Effect of daily supplementation with ubiquinol on muscle coenzyme Q10 concentrations in Thoroughbred racehorses

Coenzyme Q10 (CoQ10) is essential for mitochondrial aerobic production of ATP via oxidative phosphorylation, but has had little study in horses. Its biologically active form is ubiquinol. We evaluated the effects of daily supplementation with ubiquinol on gluteal muscle CoQ10 concentrations and an indicator of phosphorylation status, citrate synthase (CS), in fit Thoroughbreds. Six horses received either 1 g ubiquinol daily for 3 weeks followed by 21 days without supplement, or had a 3 week unsupplemented period followed by 3 weeks of supplementation. A seventh horse received the same diet as the other horses, but no supplement, and served as a negative control. Middle gluteal muscle biopsies were obtained before feeding at day 0 (baseline), and after 10 and 21 days of each period. Muscle CoQ10 concentration was determined by HPLC with UV detection at 275 nm. CS was measured spectrophotometrically at 37 °C and related to mitochondrial CoQ10 concentration. Results (mean ± standard deviation) were analysed by 2-way RM ANOVA for effects of supplementation and time (P<0.05). Muscle baseline and non-supplemented CoQ10 concentrations prior to beginning supplementation were not different (458±156 pmol/mg protein). Values increased from 413±276 (baseline) to 977±227 pmol/mg after 10 days supplementation (P=0.03), but not thereafter (21 days: 867±194 pmol/mg; P=0.31). CS activity increased in concert with CoQ10 concentration (P=0.02; baseline: 67±18, 10 days: 155±68, 21 days: 163±78 nmol/(min.mg)). Muscle CoQ10 concentration was strongly correlated with CS activity (P=0.002; r2=0.53). Discontinued supplementation decreased muscle CoQ10 concentration and tended towards significance (P=0.06). Daily dietary supplementation with 1 g ubiquinol increased gluteal muscle [CoQ10] from day 0 to day 10, but not from days 10 to 21, possibly indicating saturation of mitochondria with ubiquinol. Associated increases in CS activity suggested aerobic metabolic capacity was enhanced with supplementation. Discontinuing supplementation decreased CoQ10 concentration.

Validation of the NIH Toolbox in Individuals with Neurologic Disorders

OBJECTIVE

Individuals with spinal cord injury (SCI), traumatic brain injury (TBI), and stroke experience a variety of neurologically related deficits across multiple domains of function. The NIH Toolbox for the Assessment of Neurological and Behavioral Function (NIHTB) examines motor, sensation, cognition, and emotional functioning. The purpose of this paper is to establish the validity of the NIHTB in individuals with neurologic conditions.

METHODS

Community-dwelling individuals with SCI (n = 209), TBI (n = 184), or stroke (n = 211) completed the NIHTB. Relative risks for impaired performance were examined relative to a matched control groups.

RESULTS

The largest group differences were observed on the Motor domain and for the Fluid Cognition measures. All groups were at increased risk for motor impairment relative to normative standards and matched controls. Fluid cognitive abilities varied across groups such that individuals with stroke and TBI performed more poorly than individuals with SCI; increased relative risks for impaired fluid cognition were seen for individuals in the stroke and TBI groups, but not for those in the SCI group. All three neurologic groups performed normally on most measures in the Sensation Battery, although TBI participants evidenced increased risk for impaired odor identification and the stroke group showed more vision difficulties. On the Emotion Battery, participants in all three groups showed comparably poor psychological well-being, social satisfaction, and self-efficacy, whereas the TBI group also evidenced slightly increased negative affect.

CONCLUSIONS

Data provide support for the validity of the NIHTB in individuals with neurologic conditions.

Quality assurance of electron beams using a Varian electronic portal imaging device

The feasibility of utilizing an electronic portal imaging device (EPID) for the quality assurance of electron beams was investigated. This work was conducted on a Varian 2100iX machine equipped with an amorphous silicon (aS1000) portal imager. The linearity of the imager pixel response as a function of exposed dose was first confirmed. The short-term reproducibility of the EPID response to electron beams was verified. Low (6 MeV), medium (12 MeV) and high (20 MeV) energies were tested, each along with small (6 × 6 cm(2)), medium (10 × 10 cm(2)) and large (20 × 20 cm(2)) applicators. Acquired EPID images were analyzed using an in-house MATLAB code for radiation field size, penumbra, symmetry and flatness. Field sizes and penumbra values agreed with those from film dosimetry to within 1 mm. Field symmetry and flatness constancies were measured over a period of three weeks. The results indicate that EPID can be used for routine quality assurance of electron beams.

Demographic influences and suggested cut-scores for the Beck Depression Inventory in a non-clinical Spanish speaking population from the US-Mexico border region

The Beck Depression Inventory-I (BDI-I) is a self-report measure of depressive symptomatology that is widely used in both research and clinical settings. While the Spanish language version of the BDI-I is frequently used in the USA, there are currently no available guidelines to determine depressive symptomatology base rates in Spanish speaking populations using this instrument. In the present study, base rates of depressive symptoms and demographic influences on the BDI-I were measured in a non-clinical Spanish speaking population from the US-Mexico border region. A sample of 198 neurologically normal Spanish speaking individuals, mostly of Mexican decent, completed the BDI-I as part of a larger neuropsychological norming study. The results indicated that while there were no effects of age or education on overall BDI-I scores, those with lower education tended to report higher severity of individual symptoms. Consistent with findings in other populations, women endorsed a greater number of depressive symptoms. Therefore separate cut-scores were derived for men and women to represent these differences. Future research should assess the impact of acculturation and socioeconomic stressors on the BDI scores in this mostly immigrant population.

Cognitive deficits and degeneration of interneurons in HIV+ methamphetamine users

The cellular basis for cognitive deficits in HIV+ patients with and without a history of methamphetamine (METH) use is unclear. We found that HIV+ METH users had more severe loss of interneurons that was associated with cognitive impairment. Compared with other markers, loss of calbindin and parvalbumin interneurons in the frontal cortex was the most significant correlate to memory deficits, suggesting a role in neurobehavioral alterations of HIV+ METH users.