Home-Monitoring Vision Tests to Detect Active Neovascular Age-Related Macular Degeneration

Importance

Most neovascular age-related macular degeneration (nAMD) treatments involve long-term follow-up of disease activity. Home-monitoring would reduce the burden on patients and their caregivers and release clinic capacity.

Objective

To evaluate 3 vision home-monitoring tests for patients to use to detect active nAMD compared with diagnosing active nAMD at hospital follow-up during the after-treatment monitoring phase.

Design, Setting, and Participants

This was a diagnostic test accuracy study wherein the reference standard was detection of active nAMD by an ophthalmologist at hospital follow-up. The 3 home-monitoring tests evaluated included the following: (1) the KeepSight Journal (KSJ [International Macular and Retinal Foundation]), which contains paper-based near-vision tests presented as word puzzles, (2) the MyVisionTrack (mVT [Genentech]) vision-monitoring mobile app, viewed on an Apple mobile operating system-based device, and (3) the MultiBit (MBT [Visumetrics]) app, viewed on an Apple mobile operating system-based device. Participants were asked to test weekly; mVT and MBT scores were transmitted automatically, and KSJ scores were returned to the research office every 6 months. Raw scores between hospital follow-ups were summarized as averages. Patients were recruited from 6 UK hospital eye clinics and were 50 years and older with at least 1 eye first treated for active nAMD for at least 6 months or longer to a maximum of 42 months before approach. Participants were stratified by time since starting treatment. Study data were analyzed from May to September 2021.

Exposures

The KSJ, mVT, and MBT were compared with the reference standard (in-hospital ophthalmologist examination).

Main Outcomes and Measures

Estimated area under receiver operating characteristic curve (AUROC). The study had 90% power to detect a difference of 0.06, or 80% power to detect a difference of 0.05, if the AUROC for 2 tests was 0.75.

Results

A total of 297 patients (mean [SD] age, 74.9 [6.6] years; 174 female [58.6%]) were included in the study. At least 1 hospital follow-up was available for 312 study eyes in 259 participants (1549 complete visits). Median (IQR) home-monitoring testing frequency was 3 (1-4) times per month. Estimated AUROC was less than 0.6 for all home-monitoring tests, and only the KSJ summary score was associated with lesion activity (odds ratio, 3.48; 95% CI, 1.09-11.13; P = .04).

Conclusions and Relevance

Results suggest that no home-monitoring vision test evaluated provided satisfactory diagnostic accuracy to identify active nAMD diagnosed in hospital eye service follow-up clinics. Implementing any of these evaluated tests, with ophthalmologists only reviewing test positives, would mean most active lesions were missed, risking unnecessary sight loss.

Intraoperative plasma proteomic changes in cardiac surgery: In search of biomarkers of post-operative delirium

PURPOSE

Delirium presents a significant healthcare burden. It complicates post-operative care in up to 50% of cardiac surgical patients with worse outcomes, longer hospital stays and higher cost of care. Moreover, the nature of delirium following cardiac surgery with cardiopulmonary bypass (CPB) remains unclear, the underlying pathobiology is poorly understood, status quo diagnostic methods are subjective, and diagnostic biomarkers are currently lacking.

OBJECTIVE

To identify diagnostic biomarkers of delirium and for insights into possible neuronal pathomechanisms.

EXPERIMENTAL DESIGN

Comparative proteomic analyses were performed on plasma samples from a nested matched cohort of patients who underwent cardiac surgery. Validation by targeted proteomics was performed in an independent set of samples. Biomarkers were assessed for biological functions and diagnostic accuracy.

RESULTS

Forty-seven percent of subjects demonstrated delirium. Of 3803 proteins identified from patient samples by multiplexed quantitative proteomics, 16 were identified as signatures of exposure to CPB, and 11 biomarkers distinguished delirium cases from non-cases (AuROC = 93%). Notable among these biomarkers are C-reactive protein, serum amyloid A-1 and cathepsin-B.

CONCLUSIONS AND CLINICAL RELEVANCE

The interplay of systemic and central inflammatory markers sheds new light on delirium pathogenesis. This work suggests that accurate identification of cases may be achievable using panels of biomarkers.

Mindfulness moments for clinicians in the midst of a pandemic

Clinicians are routinely subjected to intense and stressful working environments, and the current COVID-19 crisis increases their risk of psychological distress. Mindfulness has been shown to improve life satisfaction, resilience to stress, self-compassion, compassion and general well-being in healthcare workers. Based on their clinical experience, the authors present mindfulness moments for clinicians (MMFC), a selection of short, simple and accessible mindfulness practices to promote resilience and compassion among clinicians working in this pandemic. The practices can be used on the job and are accessible to both novice and experienced meditators. Most of these practices are extracted from evidence-based mindfulness programmes. Further research is indicated to assess the effectiveness of using MMFC to support clinicians in their work and to promote resilience.

The Natural Selection of Private and Inner Speech

This article analyzes the emergence of private and inner speech from the perspective of natural selection, arguing that social speech acts as a selection pressure for the emergence of private speech, that private speech acts as a selection pressure that leads to the emergence of inner speech, and that this view of private and inner speech may help to explain the natural selection of a variety of other traits of the human mind in an asymmetric intraspecific evolutionary arms race.

Striatal activity correlates with stimulant-like effects of alcohol in healthy volunteers

Individuals who experience greater stimulation and less sedation from alcohol are at increased risk for alcohol-related problems. However, little is known regarding the neurobiological mechanisms underlying subjective response to alcohol. The current study examined the degree to which alcohol-induced brain activation correlates with ratings of stimulation and sedation, using a within-subjects, double-blind, placebo-controlled design. Participants (N = 34 healthy adults with no history of alcohol use disorder) completed three sessions: a calibration session to determine the duration of infusion needed to bring the breath alcohol to 80 mg/dl for each subject, and two counterbalanced fMRI sessions with placebo and alcohol administration. During the fMRI sessions, participants underwent 50 min scans, which included a 10 min baseline period, the IV infusion period needed to bring breath alcohol concentration (BrAC) to a peak 80 mg/dl (on the alcohol session), followed by a post-peak decline period. Participants rated their subjective stimulation and sedation at regular intervals throughout the scan. A priori VOI analyses showed that the time course of stimulation correlated with BOLD signal in the striatum. The time course of sedation did not correlate with BOLD signal in any VOIs. There were no correlations in primary visual cortex, which served as a control. These findings are the first to show that alcohol effects in the striatum are linked to the positive, stimulant-like effects of the drug and advance our understanding of the neurobiological mechanisms underlying individual differences in subjective responses to alcohol, and more broadly, risk for alcohol use disorders.

Naps Do Not Change Delay Discounting Behavior in Young Adults

When offered a choice of $40 today or $50 later, many would choose the immediate reward over the greater delayed reward. Such behavior is a result of future gains being discounted such that their value is rendered less than that of the immediate gain. Extreme discounting behaviors are associated with impulsivity and addiction. Given recent evidence of sleep's role in decision making, we tested the hypothesis that sleep would reduce delayed discounting behavior. Twenty young adults (M = 20.19 years, SD = 0.98 years; 6 males) performed a hypothetical delay discounting task, making a series of choices between an immediate reward (from $0 to $50) or a larger reward ($50) available at a delay of 2, 4, 8, 14, or 22 weeks. Participants performed the task before and after a mid-day nap, and before and after an equivalent interval of wake (within subject, order counterbalanced, wake, and sleep conditions separated by 1 week). As expected, indifference points decreased with longer delays both prior to and following the nap/wake interval. However, the impact of a nap interval on discounting did not differ from the impact of a wake interval. Thus, while sleep has been shown to play an active role in some financial decision-making tasks, a nap is not sufficient to change delay discounting behavior.

Is Helmet and Faceguard Modification Common in Hurling and Camogie and Why Is It Done?

Aims Despite no previous research, it is anecdotally reported that hurling and camogie players modify their helmet and faceguard, which is against GAA regulations and can potentially increase injury risk. This study aimed to establish the prevalence and rationale behind modifications in hurling and camogie. Methods An online questionnaire was completed by 304 players aged over 18 (62% hurlers, 38% camogie players) which consisted of 27 questions. Results Appearance (43%) was the primary reasons for helmet brand choice, with just 1.6% citing safety as a main reason for choice. Surprisingly, 8% of helmets were already modified when purchased and 31% of participants made further modifications, primarily switching faceguards and removal of bars. Restricted vision, comfort and perceived poor quality of the helmet/faceguard were the most common reasons for modification. Players predominantly (75.8%) agreed that further education on modifications is required. Conclusion Future research on the relationship between helmet/faceguard modification and injury risk is required.

Exposure-Response Relationships during Free-Access Intravenous Alcohol Self-Administration in Nondependent Drinkers: Influence of Alcohol Expectancies and Impulsivity

BACKGROUND

Self-administration is a hallmark of all addictive drugs, including alcohol. Human laboratory models of alcohol self-administration have characterized alcohol-seeking behavior and served as surrogate measures of the effectiveness of pharmacotherapies for alcohol use disorders. Intravenous alcohol self-administration is a novel method that assesses alcohol exposure driven primarily by the pharmacological response to alcohol and may have utility in characterizing unique behavioral and personality correlates of alcohol-seeking and consumption.

METHODS

This study examined exposure-response relationships for i.v. alcohol self-administration, and the influence of impulsivity and alcohol expectancy, in healthy, nondependent drinkers (n=112). Participants underwent a 2.5-hour free-access i.v. alcohol self-administration session using the Computerized Alcohol Infusion System. Serial subjective response measures included the Drug Effects Questionnaire and Alcohol Urge Questionnaire. To characterize the motivational aspects of alcohol consumption prior to potential acute adaptation, the number of self-infusions in the first 30 minutes of the free-access session was used to classify participants as low- and high-responders.

RESULTS

High-responders showed greater subjective responses during i.v. alcohol self-administration compared with low responders, reflecting robust exposure-driven hedonic responses to alcohol. High-responders also reported heavier drinking patterns and lower scores for negative alcohol expectancies on the Alcohol Effects Questionnaire. High-responders also showed higher measures of impulsivity on a delayed discounting task, supporting previous work associating impulsivity with greater alcohol use and problems.

CONCLUSIONS

These findings indicate that early-phase measures of free-access i.v. alcohol self-administration are particularly sensitive to the rewarding and motivational properties of alcohol and may provide a unique phenotypic marker of alcohol-seeking behavior.

Negative urgency, mood induction, and alcohol seeking behaviors

BACKGROUND

Negative urgency, defined as impulsive risk-taking during extreme negative emotional states, is the most important impulsivity-related trait for alcohol-related problems and alcohol dependence. However, how negative urgency imparts risk for alcohol-related problems is not yet well understood. Therefore, the goal of the current study was to examine how negative urgency relates to separable aspects of the emotional experience and alcohol-seeking behaviors.

METHODS

A total of 34 (19 women) community-dwelling, alcohol-using adults aged 21-32 (mean age=24.86, SD=3.40, 74.3% Caucasian) completed two counterbalanced intravenous alcohol self-administration sessions: one during a neutral mood condition and one during a negative mood condition.

RESULTS

Negative urgency was associated with 1) greater mood change following negative mood induction (F=4.38, df=15, p=0.002, η2=0.87), but was unrelated to changes in craving or cortisol release in response to mood induction; 2) greater alcohol craving prior to and after an alcohol prime (F=3.27, p=0.02, η2=0.86), but only in the negative and not the neutral mood condition; and 3) higher peak BrAC (F=2.13, df=42, p=0.02, η2=0.48), continuing to increase intoxication level over a longer period (F=3.77, df=42, p<0.001, η2=0.62), and more alcohol seeking (F=21.73, df=22, p<0.001, η2=0.94) throughout the negative session. Negative urgency was associated with overall lower cortisol release.

CONCLUSIONS

These results highlight the importance of assessing behavioral indicators of negative urgency under mood condition, and suggest that negative urgency may amplify alcohol self-administration through increased negative emotional reactivity to mood events and increased alcohol craving after initial alcohol exposure, leading to maintenance of alcohol related behavior.

Gender-Specific Effects of Mood on Alcohol-Seeking Behaviors: Preliminary Findings Using Intravenous Alcohol Self-Administration

BACKGROUND

Although negative mood has long been implicated in differences in alcohol seeking by men and women, little research has used precise, well-controlled laboratory experiments to examine how negative mood affects alcohol-seeking behaviors.

METHODS

A total of 34 (19 women) community-dwelling, alcohol-using adults aged 21 to 32 (mean age = 24.86, SD = 3.40, 74.3% Caucasian; Alcohol Use Disorders Identification Test [AUDIT] = 10.1, SD = 3.4) completed 2 counterbalanced intravenous alcohol self-administration sessions: one under negative mood and one under neutral mood. Fourteen individuals (9 women; mean age = 25.00, SD = 2.77) participated in an alcohol "liking" experiment (i.e., free access [FA] drinking) and 20 individuals (10 women; mean age = 24.77, SD = 3.73) participated in an alcohol "wanting" experiment, in which gaining access to alcohol required progressively effortful work. There was no significant difference between men and women on the AUDIT, t(32) = -0.38, p = 0.71.

RESULTS

Priming with negative mood induction caused a significant decrease in self-reported mood (mean change = -1.85, t(32) = -6.81, p < 0.001), as intended. In FA, negative mood was associated with a significantly increased peak breath alcohol concentration (BrAC; F = 9.41, p = 0.01), with a trend toward a greater effect in men than in women (F = 2.67, p = 0.13). Negative mood also had a significant effect on peak BrAC achieved in the progressive work paradigm (F = 5.28, p = 0.04), with a significantly stronger effect in men (F = 5.35, p = 0.03) than women; men also trended toward more consistent work for alcohol across both neutral and negative sessions.

CONCLUSIONS

These preliminary findings demonstrate a gender-specific response on how mood affects alcohol seeking and suggest gender-specific interventions to prevent mood-based alcohol consumption.

Offspring of parents with an alcohol use disorder prefer higher levels of brain alcohol exposure in experiments involving computer-assisted self-infusion of ethanol (CASE)

RATIONALE

Acute alcohol effects may differ in social drinkers with a positive family history of alcohol use disorders (FHP) compared to FH negative (FHN) controls.

OBJECTIVES

To investigate whether FHP subjects prefer higher levels of brain alcohol exposure than do FHN controls.

MATERIALS AND METHODS

Twenty-two young healthy nondependent social drinkers participated in two identical sessions of computer-assisted self-infusion of ethanol (CASE); the first for practicing the procedures, the second to test hypotheses. All 12 FHP (four women) and ten FHN (three women) participants received a priming exposure, increasing arterial blood alcohol concentration (aBAC) to 30 mg% at 10 min and decreasing it to 15 mg% at 25 min. A 2-h self-administration period followed, during which only the subjects could increase their aBAC by pressing a button connected to a computer controlling the infusion pump. Infusion rate profiles were calculated instantaneously to increase aBAC by precisely 7.5 mg% within 2.5 min after each button press, followed by a steady descent. Subjects were instructed to produce the same alcohol effects as they would do at a weekend party.

RESULTS

The mean and maximum aBAC during the self-administration period and the number of alcohol requests (NOAR) were significantly higher in the FHP vs. FHN participants.

CONCLUSIONS

This is the first laboratory experiment demonstrating higher alcohol self-administration in FHP compared to FHN subjects. A practice session increases the sensitivity of CASE experiments for detection of subtle differences in human alcohol self-administration.

Computer-assisted Self-infusion of Ethanol (case): New Outcome Measures may Contain Unseful Information

Oral alcohol self-administration studies limit the range of arterial blood alcohol concentrations (aBAC) due to the combination of IRB-constraints on the maximum aBAC allowed and substantial variability in idiosyncratic enteral absorption. 25 healthy young adults participated in a preliminary assessment of the influence of familial alcoholism on alcohol self-administration using CASE. CASE automates the i.v. infusion of 6% ethanol, using an individualized kinetic model to achieve identical incremental aBAC in all subjects.

In two CASE sessions, the subject was instructed to request infused “drinks” in order to emulate his/her perceptions of alcohol effects obtained at a weekend party. Conventional outcome measures all correlated closely with each other, so we evaluated the basic shape of the time course of aBAC achieved and the latency to peak aBAC (Tpk).

Tpk correlated with maximum aBAC on the 1st (p= 0.029), but not 2nd session. Further, Tpk did not correlate with mean aBAC on either day, but did correlate well with the number of drink requests on both days (p< 0.001). In 33 out of 47 experiments, subjects achieved and maintained stable plateaus of aBAC for at least 30 minutes during the self-infusion. Both latency to peak aBAC and the shape of the subject’s preferred time course of aBAC may represent informative new ways of examining styles of alcohol self-administration of alcohol using CASE. The additions may enrich studies of the influence of factors such as familial alcoholism on the vulnerability for alcohol future alcohol dependence.