OP0286 CHARACTERISTICS ASSOCIATED WITH SEVERE COVID-19 OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE (COVID-19 GRA)

Background:

An increased risk of severe COVID-19 outcomes may be seen in patients with autoimmune diseases on moderate to high daily doses of glucocorticoids, as well as in those with comorbidities. However, specific information about COVID-19 outcomes in SLE is scarce.

Objectives:

To determine the characteristics associated with severe COVID-19 outcomes in a multi-national cross-sectional registry of COVID-19 patients with SLE.

Methods:

SLE adult patients from a physician-reported registry of the COVID-19 GRA were studied. Variables collected at COVID-19 diagnosis included age, sex, race/ethnicity, region, comorbidities, disease activity, time period of COVID-19 diagnosis, glucocorticoid (GC) dose, and immunomodulatory therapy. Immunomodulatory therapy was categorized as: antimalarials only, no SLE therapy, traditional immunosuppressive (IS) drug monotherapy, biologics/targeted synthetic IS drug monotherapy, and biologic and traditional IS drug combination therapy. We used an ordinal COVID-19 severity outcome defined as: not hospitalized/hospitalized without supplementary oxygen; hospitalized with non-invasive ventilation; hospitalized with mechanical ventilation/extracorporeal membrane oxygenation; and death. An ordinal logistic regression model was constructed to assess the association between demographic characteristics, comorbidities, medications, disease activity and COVID-19 severity. This assumed that the relationship between each pair of outcome groups is of the same direction and magnitude.

Results:

Of 1069 SLE patients included, 1047 (89.6%) were female, with a mean age of 44.5 (SD: 14.1) years. Patient outcomes included 815 (78.8%) not hospitalized/hospitalized without supplementary oxygen; 116 (11.2) hospitalized with non-invasive ventilation, 25 (2.4%) hospitalized with mechanical ventilation/extracorporeal membrane oxygenation and 78 (7.5%) died. In a multivariate model (n=804), increased age [OR=1.03 (1.01, 1.04)], male sex [OR =1.93 (1.21, 3.08)], COVID-19 diagnosis between June 2020 and January 2021 (OR =1.87 (1.17, 3.00)), no IS drug use [OR =2.29 (1.34, 3.91)], chronic renal disease [OR =2.34 (1.48, 3.70)], cardiovascular disease [OR =1.93 (1.34, 3.91)] and moderate/high disease activity [OR =2.24 (1.46, 3.43)] were associated with more severe COVID-19 outcomes. Compared with no use of GC, patients using GC had a higher odds of poor outcome: 0-5 mg/d, OR =1.98 (1.33, 2.96); 5-10 mg/d, OR =2.88 (1.27, 6.56); >10 mg/d, OR =2.01 (1.26, 3.21) (Table 1).

Table 1.

Characteristics associated with more severe COVID-19 outcomes in SLE. (N=804)

OR (95% CI)Age, years1.03 (1.01, 1.04)Sex, Male1.93 (1.21, 3.08)Race/Ethnicity, Non-White vs White1.47 (0.87, 2.50)RegionEuropeRef.North America0.67 (0.29, 1.54)South America0.67 (0.29, 1.54)Other1.93 (0.85, 4.39)Season, June 16th 2020-January 8th 2021 vs January-June 15th 20201.87 (1.17, 3.00)Glucocorticoids0 mg/dayRef.0-5 mg/day1.98 (1.33, 2.96)5-10 mg/day2.88 (1.27, 6.56)=>10 mg/day2.01 (1.26, 3.21)Medication CategoryAntimalarial onlyRef.No IS drugs2.29 (1.34, 3.91)Traditional IS drugs as monotherapy1.17 (0.77, 1.77)b/ts IS drugs as monotherapy1.00 (0.37, 2.71)Combination of traditional and b/ts IS1.00 (0.55, 1.82)Comorbidity BurdenNumber of Comorbidities (excluding renal and cardiovascular disease)1.39 (0.97, 1.99)Chronic renal disease2.34 (1.48, 3.70)Cardiovascular disease1.93 (1.34, 3.91)Disease Activity, Moderate/ high vs Remission/ low 2.24 (1.46, 3.43)

IS: immunosuppressive. b/ts: biologics/targeted synthetics

Conclusion:

Increased age, male sex, glucocorticoid use, chronic renal disease, cardiovascular disease and moderate/high disease activity at time of COVID-19 diagnosis were associated with more severe COVID-19 outcomes in SLE. Potential limitations include possible selection bias (physician reporting), the cross-sectional nature of the data, and the assumptions underlying the outcomes modelling.

Acknowledgements:

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR) the UK National Health Service, the National Institute for Health Research (NIHR), or the UK Department of Health, or any other organization.

Disclosure of Interests:

Manuel F. Ugarte-Gil Grant/research support from: Pfizer, Janssen, Graciela S Alarcon: None declared, Andrea Seet: None declared, Zara Izadi: None declared, Cristina Reategui Sokolova: None declared, Ann E Clarke Consultant of: AstraZeneca, BristolMyersSquibb, GlaxoSmithKline, Exagen Diagnostics, Leanna Wise: None declared, Guillermo Pons-Estel: None declared, Maria Jose Santos: None declared, Sasha Bernatsky: None declared, Lauren Mathias: None declared, Nathan Lim: None declared, Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum unrelated to this work., Grant/research support from: Amgen and Bristol-Myers Squibb, Zachary Wallace Consultant of: Viela Bio and MedPace, Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: MS, UCB, and Pfizer, Anja Strangfeld Speakers bureau: AbbVie, MSD, Roche, BMS, Pfizer, Grant/research support from: AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, Grant/research support from: Lilly, Mylan, Pfizer, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: Pfizer, Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Pfizer outside the submitted work, Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000), Milena Gianfrancesco: None declared, Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project

OP0006 ASSOCIATIONS OF BASELINE USE OF BIOLOGIC OR TARGETED SYNTHETIC DMARDS WITH COVID-19 SEVERITY IN RHEUMATOID ARTHRITIS: RESULTS FROM THE COVID-19 GLOBAL RHEUMATOLOGY ALLIANCE

Background:

Targeted DMARDs may dampen the inflammatory response in COVID-19, perhaps leading to a less severe clinical course. However, some DMARD targets may impair viral immune defenses. Due to sample size limitations, previous studies of DMARD use and COVID-19 outcomes have combined several heterogeneous rheumatic diseases and medications, investigating a single outcome (e.g., hospitalization).

Objectives:

To investigate the associations of baseline use of biologic or targeted synthetic (b/ts) DMARDs with a range of poor COVID-19 outcomes in rheumatoid arthritis (RA).

Methods:

We analyzed voluntarily reported cases of COVID-19 in patients with rheumatic diseases in the COVID-19 Global Rheumatology Alliance physician registry (March 12, 2020 - January 6, 2021). We investigated RA treated with b/tsDMARD at the clinical onset of COVID-19 (baseline): abatacept (ABA), rituximab (RTX), Janus kinase inhibitors (JAK), interleukin-6 inhibitors (IL6i), or tumor necrosis factor inhibitors (TNFi). The outcome was an ordinal scale (1-4) for COVID-19 severity: 1) no hospitalization, 2) hospitalization without oxygen need, 3) hospitalization with any oxygen need or ventilation, or 4) death. Baseline covariates including age, sex, smoking, obesity, comorbidities (e.g., cardiovascular disease, cancer, interstitial lung disease [ILD]), concomitant non-biologic DMARD use, glucocorticoid use/dose, RA disease activity, country, and calendar time were used to estimate propensity scores (PS) for b/tsDMARD. The primary analysis used PS matching to compare each drug class to TNFi. Ordinal logistic regression estimated ORs for the COVID-19 severity outcome. In a sensitivity analysis, we used traditional multivariable ordinal logistic regression adjusting for covariates without matching.

Results:

Of the 1,673 patients with RA on b/tsDMARDs at the onset of COVID-19, (mean age 56.7 years, 79.6% female) there were n=154 on ABA, n=224 on RTX, n=306 on JAK, n=180 on IL6i, and n=809 on TNFi. Overall, 498 (34.3%) were hospitalized and 112 (6.7%) died. Among all patients, 353 (25.3%) were ever smokers, 197 (11.8%) were obese, 462 (27.6%) were on glucocorticoids, 1,002 (59.8%) were on concomitant DMARDs, and 299 (21.7%) had moderate/high RA disease activity. RTX users were more likely than TNFi users to have ILD (11.6% vs. 1.7%) and history of cancer (7.1% vs. 2.0%); JAK users were more likely than TNFi users to be obese (17.3% vs. 9.0%). After propensity score matching, RTX was strongly associated with greater odds of having a worse outcome compared to TNFi (OR 3.80, 95% CI 2.47, 5.85; Figure). Among RTX users, 42 (18.8%) died compared to 27 (3.3%) of TNFi users (Table). JAK use was also associated with greater odds of having a worse COVID-19 severity (OR 1.52, 95%CI 1.02, 2.28). ABA or IL6i use were not associated with COVID-19 severity compared to TNFi. Results were similar in the sensitivity analysis and after excluding cancer or ILD.

Table 1.

Frequencies for the ordinal COVID-19 severity outcome for patients with RA on biologic or targeted synthetic DMARDs (n=1673).

COVID-19 outcomes by severity scale (n,%)ABAn=154RTXn=224JAKn=306IL6in=180TNFi n=8091)Not hospitalized113 (73.3%)121 (54.0%)220 (71.9%)150 (83.3%)666 (82.3%)2)Hospitalization without oxygenation10 (6.5%)14 (6.2%)11 (3.6%)9 (5.0%)53 (6.5%)3)Hospitalization with any oxygenation or ventilation16 (10.4%)47 (21.0%)52 (17.0%)16 (8.9%)63 (7.8%)4)Death15 (9.7%)42 (18.8%)23 (7.5%)5 (2.8%)27 (3.3%)

Conclusion:

In this large global registry of patients with RA and COVID-19, baseline use of RTX or JAK was associated with worse severity of COVID-19 compared to TNFi use. The very elevated odds for poor COVID-19 outcomes in RTX users highlights the urgent need for risk-mitigation strategies, such as the optimal timing of vaccination. The novel association of JAK with poor COVID-19 outcomes requires replication.

Acknowledgements:

The views expressed here are those of the authors and participating members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the ACR, EULAR, the UK National Health Service, the National Institute for Health Research, the UK Department of Health, or any other organization.

Disclosure of Interests:

Jeffrey Sparks Consultant of: Bristol-Myers Squibb, Gilead, Inova, Janssen, and Optum, unrelated to this work, Grant/research support from: Amgen and Bristol-Myers Squibb, unrelated to this work, Zachary Wallace Consultant of: Viela Bio and MedPace, outside the submitted work., Grant/research support from: Bristol-Myers Squibb and Principia/Sanofi, Andrea Seet: None declared, Milena Gianfrancesco: None declared, Zara Izadi: None declared, Kimme Hyrich Speakers bureau: Abbvie unrelated to this study, Grant/research support from: BMS, UCB, and Pfizer, all unrelated to this study, Anja Strangfeld Paid instructor for: AbbVie, MSD, Roche, BMS, Pfizer, outside the submitted work, Grant/research support from: grants from a consortium of 13 companies (among them AbbVie, BMS, Celltrion, Fresenius Kabi, Lilly, Mylan, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis, and UCB) supporting the German RABBIT register, outside the submitted work, Laure Gossec Consultant of: Abbvie, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sanofi-Aventis, UCB, unrelated to this study, Grant/research support from: Lilly, Mylan, Pfizer, all unrelated to this study, Loreto Carmona: None declared, Elsa Mateus Grant/research support from: grants from Abbvie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal S.A., MSD, Celgene, Medac, Pharmakern, GAfPA; grants and non-financial support from Pfizer, outside the submitted work, Saskia Lawson-Tovey: None declared, Laura Trupin: None declared, Stephanie Rush: None declared, Gabriela Schmajuk: None declared, Patti Katz: None declared, Lindsay Jacobsohn: None declared, Samar Al Emadi: None declared, Leanna Wise: None declared, Emily Gilbert: None declared, Ali Duarte-Garcia: None declared, Maria Valenzuela-Almada: None declared, Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Philippe Dieudé Consultant of: Boerhinger Ingelheim, Bristol-Myers Squibb, Lilly, Sanofi, Pfizer, Chugai, Roche, Janssen unrelated to this work, Grant/research support from: Bristol-Myers Squibb, Chugaii, Pfizer, unrelated to this work, Elena Nikiphorou: None declared, Vanessa Kronzer: None declared, Namrata Singh: None declared, Manuel F. Ugarte-Gil Grant/research support from: Janssen and Pfizer, Beth Wallace: None declared, Akpabio Akpabio: None declared, Ranjeny Thomas: None declared, Suleman Bhana Consultant of: AbbVie, Horizon, Novartis, and Pfizer (all <$10,000) unrelated to this work, Wendy Costello: None declared, Rebecca Grainger Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, Cornerstones, Jonathan Hausmann Consultant of: Novartis, Sobi, Biogen, all unrelated to this work (<$10,000), Jean Liew Grant/research support from: Yes, I have received research funding from Pfizer outside the submitted work., Emily Sirotich Grant/research support from: Board Member of the Canadian Arthritis Patient Alliance, a patient run, volunteer based organization whose activities are largely supported by independent grants from pharmaceutical companies, Paul Sufka: None declared, Philip Robinson Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Consultant of: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer and UCB (all < $10,000), Pedro Machado Speakers bureau: Yes, I have received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Consultant of: Yes, I have received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this study (all < $10,000)., Jinoos Yazdany Consultant of: Eli Lilly and AstraZeneca unrelated to this project

"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life

BACKGROUND

Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL.

METHODS

Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently.

RESULTS

Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers.

CONCLUSIONS

Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

Effect of Color on Reported Autokinetic Movement

Ss reported autokinetic movement under 1 of 4 color conditions (red, green, violet, and yellow). The over-all main effect of color on magnitude of reported movement was not significant. The interaction between color and trials was significant.

Four-Year Prospective Audit of Tonsillectomy Practice in Argyll and Clyde

Abstract Objective: To assess the practice of tonsillectomy in Inverclyde and Renfrewshire area of Argyll and Clyde Health Board. Design: an audit Setting: Royal Alexandra Hospital, Paisley Subjects: all patients undergoing tonsillectomy were prospectively audited over a four year period. Information audited included: age, sex, length of stay, operator grade, complications, readmissions and prophylactic antibiotic use. Results: 1582 cases were audited. 64% were women. The mean age of the patients was 16.76% of patients were discharged on the first post operative day. The majority of operations were carried out by staff grades and associate specialists. The primary complication rate was very low (1.33%). 3% of patients were readmitted, mostly because of secondary haemorrhage. Prophylactic post operative antibiotics were used in 39% of cases. Conclusions: it is safe to discharge patients on the first day post tonsillectomy, even if they live some distance from the hospital. Prophylactic post operative antibiotic use does not decrease the rate of readmission. Tonsillectomy is carried out safely in Argyll and Clyde.

Genes Responsible for Size Reduction of Marine Vibrios during Starvation Are Located on the Chromosome

In a survey of 21 marine Vibrio spp., all responded to nutrient deprivation by undergoing a reduction in size (dwarfing). However, only 43% of these strains possessed one or more plasmids, suggesting that the genes responsible for dwarfing were located on the chromosome rather than on the plasmids. This conclusion was confirmed by the observation that fragmentation and subsequent size reduction occurred in three strains from which the plasmids had been removed by curing. The cured strains lost certain characteristics, such as resistance to some heavy metals and antibiotics, that were restored when the plasmids were reintroduced by either transformation or electroporation.

Cartilage loss occurs in the same subregions as subchondral bone attrition: a within-knee subregion-matched approach from the Multicenter Osteoarthritis Study

OBJECTIVE

By magnetic resonance imaging (MRI), subchondral bone attrition (SBA) can be seen in early osteoarthritis (OA), but the significance of this is unknown. We therefore evaluated whether SBA was associated with cartilage loss within the same subregion of the knee.

METHODS

The Multicenter Osteoarthritis Study is a cohort of individuals who have or are at high risk for knee OA. At baseline and 30 months, participants' knee MRIs were graded using the Whole-Organ Magnetic Resonance Imaging Score in the 10 subregions of the tibiofemoral joint for cartilage morphology and SBA. We conducted analyses within a knee to eliminate between-person confounding, using an M:N (cases:controls) matched case-control approach with the 10 subregions of a person's knee forming a matched set. Cases within a knee were defined as subregions with cartilage loss, while controls were subregions in that same knee without cartilage loss. We evaluated the association of cartilage loss over 30 months with the presence of baseline SBA in the same subregion within that knee using conditional logistic regression.

RESULTS

SBA was associated with an odds ratio of 7.5 (95% confidence interval 5.6-9.9, P < 0.0001) for cartilage loss in the same subregion compared with subregions without any baseline SBA in our sample of 459 knees from participants, 64% of whom were women, with a mean age of 63 years and a mean body mass index of 30.5 kg/m(2).

CONCLUSION

SBA is strongly associated with cartilage loss within the same subregion of a knee. SBA may directly influence overlying cartilage loss or serve as a marker of an area undergoing great compressive stress and in which cartilage loss is inevitable.

Deep brain stimulation of the subthalamic nucleus in Parkinson's Disease 1993 – 2003: where are we 10 years on?

Since its advent in 1993, high frequency stimulation (HFS) of the subthalamic nucleus (STN) has rapidly developed into the most commonly practiced surgical procedure for the treatment of Parkinson's Disease (PD). Although its exact mechanism of action, be it through an inhibitory depolarization block, desynchronization of neuronal circuits or other means, is not clear, the efficacy and safety of the technique are now well established. HFS of the STN improves the motor function by at least 60%, drastically reduces the levodopa requirement and significantly improves the quality of life in PD. This review updates the recent concepts on the pathophysiology of PD and analyses the basic science principles underlying the clinical practice of the STN HFS. The evolution of the surgical technique and long-term patients' outcome are further discussed.

Surgical therapy for Parkinson's disease

High frequency stimulation (HFS) has become the main alternative to medical treatment, due to its reversibility, adaptability, and low morbidity. Initiated in the thalamus (Vim) for the control of tremor, HFS has been applied to the Pallidum (GPi), and then to the subthalamic nucleus (STN), suggested by experiments in MPTP monkeys. STN-HFS is highly efficient on tremor, rigidity and bradykinesia and is now widely applied. Criteria for success are correct patient selection and precise electrode placement. The best outcome predictor is the response to Levodopa. The mechanisms of action might associate inhibition of cell firing, jamming of neuronal message and exhaustion of synaptic neurotransmitter release. The inhibition of glutamate STN release could be neuroprotective on nigral cells. Animal experiments support this hypothesis, not contradicted by the long-term follow up of patients. Neuroprotection might have considerable impact on the management of PD patient and warrants clinical trials.

Adaptive coordination and alignment of eye and hand

Under spatial misalignment of eye and hand induced by laterally displacing prisms (11.4 degrees in the rightward direction), subjects pointed 60 times (once every 3 s) at a visually implicit target (straight ahead of nose, Experiment 1) or a visually explicit target (an objectively straight-ahead target, Experiment 2). For different groups in each experiment, the hand became visible early in the sagittal pointing movement (early visual feedback). Adaptation to the optical misalignment during exposure (direct effects) was rapid, especially with early feedback; complete compensation for the misalignment was achieved within about 30 trials, and overcompensation occurred in later trials, especially with an explicit target. In contrast, adaptation measured with the misalignment removed and without visual feedback after blocks of 10 pointing trials (aftereffects) was slow to develop, especially with delayed feedback and an implicit target; at most, about 40% compensation for the misalignment occurred after 60 trials. This difference between direct effects and aftereffects is discussed in terms of separable adaptive mechanisms that are activated by different error signals. Adaptive coordination is activated by error feedback and involves centrally located, strategically flexible, short-latency processes to correct for sudden changes in operational precision that normally occur with short-term changes in coordination tasks. Adaptive alignment is activated automatically by spatial discordance between misaligned systems and involves distributed, long-latency processes to correct for slowly developing shifts in alignment among perceptual-motor components that normally occur with long-term drift. The sudden onset of misalignment in experimental situations activates both mechanisms in a complex and not always cooperative manner, which may produce overcompensatory behavior during exposure (i.e., direct effects) and which may limit long-term alignment (i.e., aftereffects).

Evidence for social learning in the self-presentation of alcohol problems

AIMS

To examine the extent to which problem alcohol users' self reports of drinking pattern and symptomatology derive primarily from a functional, learned social-cognitive schema (referred to as a 'script' in this paper), rather than from acts of recall or memory.

METHODS

Using a between-groups design with one repeated (within-subjects) measure, problem drinkers and non-problem drinkers were asked to complete a questionnaire about drinking behaviour and symptoms. Each group filled in the questionnaire twice, under both of two conditions. In condition one, they used the questionnaire to describe their own drinking and in condition two they were asked to describe the drinking of the other group (i.e. the problem drinkers filled out the questionnaire to describe non-problem drinking and the non-problem drinkers described problem drinking).

RESULTS

Using analyses of variance for the different sub-scales of the questionnaire, no overall differences were found between the two groups on four of the five subscales. However, clear and significant differences were found between the two conditions. That is, both groups were able to produce clearly differentiated scripts for both problem drinking and non-problem drinking.

CONCLUSIONS

These data, together with related data from other sources, suggest that 'scripts' for problem drinking and for non-problem drinking can be elicited from both problem-drinking and non-problem-drinking groups. The data support conclusions from an earlier study, suggesting that subjects may use learned 'scripts' rather than recall when responding to certain types of questionnaire instruments.

Effects on prism adaptation of duration and timing of visual feedback during pointing

In two experiments, we investigated the effects of duration of visual feedback of the pointing limb and the time (early to late) in the movement when the limb first becomes visible (timing of visual feedback). Timing, rather than duration of visual feedback, proved to have the greater effect on the relative magnitude of visual and proprioceptive adaptation. Visual adaptation increased smoothly with feedback delay, but corresponding decreases in proprioceptive adaptation underwent an additional sharp change when feedback was delayed until about three-fourths of the way to the terminal limb position. These results are consistent with the idea that visual and proprioceptive adaptation are mediated by exclusive processes. Change in the limb position sense (i.e., proprioceptive adaptation) may be produced by visual guidance of the pointing limb, and view of the limb early in the pointing movement seems to be critical for such visual guidance. The limb may be ballistically released as it nears the terminal position, and, thereafter, any opportunity for visual guidance (i.e., view of the limb) is not effective. On the other hand, change in the eye position sense (i.e., visual adaptation) may be mediated by proprioceptive guidance of the eye; the eyes may track the imaged position of the nonvisible limb. Such proprioceptive guidance seems to be solely a function of the distance moved before the limb becomes visible.

User satisfaction with rehabilitation services delivered using Internet video

Rehabilitation services to four remote sites in New Brunswick were delivered via PC-based videoconferencing equipment, using ADSL connections to the Internet. Approximately 40 people used the equipment over 18 months. There were 32 videoconference sessions. A total of 60 questionnaires were returned (a 94% response rate). In 31 of the 32 videoconferences, a connection was successfully established between the computers. The videoconferences lasted on average 20 min. The most frequent applications were viewing of rehabilitative equipment and video communication. The technology was found to be useful and provided an enhanced form of communication from the video component. There were some problems with the stability and reliability of the equipment.

Calibration and alignment are separable: evidence from prism adaptation

In 2 prism adaptation experiments, the authors investigated the effects of limb starting position visibility (visible or not visible) and visual feedback availability (early or late in target pointing movements). Thirty-two students participated in Experiment 1 and 24 students participated in Experiment 2. Independent of visual feedback availability, constant error was larger and variable error was smaller for target pointing when limb starting position was visible during prism exposure. Independent of limb starting position visibility, aftereffects of prism exposure were determined by visual feedback availability. Those results support the hypothesis that calibration is determined by limb starting position visibility, whereas alignment is determined separately by visual feedback availability.

The tumescent technique to significantly reduce blood loss during burn surgery

INTRODUCTION

Burn surgery is complicated by blood loss. The tumescent technique of subdermal injection of epinephrine has been utilized to decrease intraoperative blood loss. We hypothesized that this would safely decrease blood loss during burn surgery.

METHODS

Twenty patients utilized the tumescent technique. The tumescent group had subdermal injections of epinephrine beneath the excision and donor site plus thrombin spray and warm saline soaked laparotomy pads. Ten patients grafted prior to adopting the tumescent technique utilized thrombin spray and warm saline soaked laparotomy pads for hemostasis. Blood loss was determined by operative estimation and calculation. Data were analyzed by Student's t-test and paired t-test.

RESULTS

The two groups were demographically similar. The tumescent group had significantly less total blood loss and blood loss per unit area excised. There were no clinically detectable arrythmias, changes in heart rate or blood pressure noted.

CONCLUSIONS

The tumescent technique significantly reduced intraoperative blood loss. It is safe, inexpensive and easy to use. The subdermal epinephrine/saline injection creates a smooth, tense surface which assists with debridement and donor harvest.

Preoperative duplex ultrasonography evaluation for deep venous thrombosis in revision hip arthroplasty patients

In a prospective consecutive series, 53 revision hip arthroplasties were performed in 51 patients. Pre- and postoperative Duplex ultrasonography examinations were reviewed by an independent, experienced radiologist. Three of 51 patients (53 procedures) had evidence of chronic deep venous thrombosis (DVT) or other venous abnormality preoperatively, yielding an incidence of 5.6%. One (1.9%) patient developed an acute DVT postoperatively despite pharmacological and mechanical preventative measures. These results indicate the use of preoperative ultrasonography as a screening tool prior to revision hip arthroplasty is not warranted based on the low incidence of acute or chronic DVT detected preoperatively. Long-term anticoagulation, when necessary, can be based on the findings of a postoperative scan.

Day persons, night persons, and time of birth: preliminary findings

The authors conducted 2 surveys to determine the relationship between time of birth and being a day person or a night person. Day persons are most alert during daylight hours; night persons are most alert during hours of darkness. In Survey 1, the authors asked U.S. high school students to complete the Alertness Questionnaire (B. Wallace, 1993) and to respond to other items related to daytime or nighttime activity. In Survey 2, the authors administered the same items to a U.S. college population. In both surveys, time of birth was significantly related to being a day person or a night person. The results suggest that a critical period for setting the biological clock for alertness may be the moment of birth.

Preliminary evidence for diurnal fluctuations in visual imagery

In a repeated measures design, the Vividness of Visual Imagery Questionnaire (VVIQ; Marks, 1973) was administrated to 10 participants each half hour in a single day between 8:00 and 20:00. The questionnaire was also administrated on four consecutive days following the original administration at 8:00, 14:00 and 20:00. These results were then fitted to a model with the superposition of two cosinusoidal functions. An analysis of the results suggested the coexistence of ultradian and circadian cycles in the determination of the vividness of visual imagery.

Prism exposure aftereffects and direct effects for different movement and feedback times

The effects of movement time and time to visual feedback (feedback time) on prism exposure aftereffects and direct effects were studied. In Experiment 1, the participants' (N = 60) pointing limb became visible early in the movement (.2-s feedback time), and eye-head aftereffects increased with increasing movement time (.5 to 3.0 s), but larger hand-head aftereffects showed little change. Direct effects (terminal error during exposure) showed near-perfect compensation for the prismatic displacement (11.4 diopters) when movement time was short but decreasing compensation with longer movement times. In Experiment 2, participants' (N = 48) eye-head aftereffects increased and their larger hand-head aftereffects decreased with increasing movement time (2.0 and 3.0 s), especially when feedback time increased (.25 and 1.5 s). Direct effects showed increasing overcompensation for longer movement and feedback times. Those results suggest that aftereffects and direct effects measure distinct adaptive processes, namely, spatial realignment and strategic control, respectively. Differences in movement and feedback times evoke different eye-hand coordination strategies and consequent direct effects. Realignment aftereffects also depend upon the coordination strategy deployed, but not all strategies support realignment. Moreover, realignment is transparent to strategic control and, when added to strategic correction, may produce nonadaptive performance.

An action plan for tobacco control at regional level

Smoking is the single biggest preventable cause of death in the UK; killing over 120 000 people each year, contributing to inequalities in health, exacerbating and causing poverty. Smoking has increased steadily among children since 1988 and more recently, among young adults. The current context in the UK is highly favourable for introducing comprehensive tobacco control measures. This paper summarises a regional action plan for tobacco control. Actions at district and regional levels are outlined to establish a comprehensive local tobacco control framework and complement national tobacco control measures. Measures include: a 'SWOT' analysis of current activity; systematic monitoring of smoking prevalence, attitudes to smoking, and the impact of tobacco control interventions; provision of effective smoking cessation support to a minimum standard throughout the health service; increased coverage of smoke-free public places and workplaces; enforcement of legislation on illegal sales to children and against smuggling and selling illegally imported tobacco; paid and unpaid mass media campaigns; and systematic lobbying for fiscal and legislative measures. One of the key components of the plan is the introduction of evidence-based tobacco control strategies at district levels. These should include a performance framework with clear organisational and managerial accountability and employ a co-ordinated, multiagency, partnership approach. Priority groups should be identified. Strategies should seek to engage the public to build support for tobacco control measures. Sufficient time, staff, resources and training must be allocated to tobacco control work and progress towards objectives monitored.

Deja vu: nosocomial hepatitis B virus transmission and fingerstick monitoring

PURPOSE

Three patients with acute hepatitis B virus infection were identified who had been hospitalized on the same medical ward during a 19-day period several months earlier. An investigation was undertaken to determine if nosocomial transmission had occurred.

SUBJECTS AND METHODS

A cohort study of patients admitted to the medical ward during the 19-day period in 1995 was conducted. In addition, we reviewed medical charts and laboratory records of all patients with acute hepatitis B virus infection who had been admitted to the hospital from 1992 through October 1996 to identify other cases with possible nosocomial acquisition.

RESULTS

The 3 patients who had developed acute hepatitis B infection 2 to 5 months after hospitalization on the same medical ward had diabetes mellitus but no identified risk factors for hepatitis B infection. A source patient with diabetes mellitus and hepatitis B "e" antigenemia also was present on the same medical ward at the same time; all 4 patients were infected with the same viral subtype (adw2). Diabetes mellitus and fingerstick monitoring were associated with illness (P <0.001). Through the review of medical charts and laboratory records, 11 additional cases of suspected nosocomial acquisition via fingersticks were identified in 1996, including two clusters involving an unusual subtype of hepatitis B virus (adw4). The fingerstick device employed had a reusable base onto which disposable lancet caps were inserted. There was ample opportunity for cross-contamination among patients because deficiencies in infection control practices, particularly failure to change gloves between patients, were reported by nurses and patients with diabetes mellitus.

CONCLUSION

Transmission during fingerstick procedures was the most likely cause of these cases of nosocomial hepatitis B infection. Contamination probably occurred when healthcare workers failed to change gloves between patients undergoing fingerstick monitoring, although other means of contamination cannot be ruled out.

Nutrition and obesity in the chronic mentally ill

OBJECTIVE

The aim of this study was to determine the need for nutrition intervention in a group of people living in mental health residential houses in the Northern Sydney Area.

METHOD

A nutrition assessment was conducted by the researcher using a face-to-face interview with mental health residents and a survey on medical background completed by case managers.

RESULTS

The prevalence of overweight and obesity was significantly greater than that reported for the general population. Respondents also had a significantly higher prevalence of abdominal obesity than the general population. No respondent met the minimum core food group requirements as outlined in the 12345+ Food and Nutrition Plan.

CONCLUSIONS

The needs assessment has shown that nutrition promotion is required in this group. The task ahead is to motivate the group to change their food and nutrition behaviours, where many barriers to a healthy lifestyle exist.

Prism Adaptation During Target Pointing From Visible and Nonvisible Starting Locations

The performance of subjects whose starting limb location was visible when pointing to a sagittal target during exposure to prismatic displacement showed immediate target acquisition, but aftereffects of exposure were absent. When starting limb location was not visible, accurate exposure performance was slow to develop, but aftereffects were substantial. Visible starting location evoked a zeroing-in control strategy on the basis of relative-location coding, which rapidly reduced performance error but disabled detection of spatial misalignment between sensorimotor systems. When starting location was not visible, absolute-location coding of the displaced target initiated movement that had to be corrected subsequently by visual feedback. In this case, comparison of the initial erroneous movement code with the limb location that achieved the target enabled misalignment detection and consequent realignment.

Adaptive spatial alignment and strategic perceptual-motor control

When starting limb and target locations were simultaneously visible in a visuomotor task, performance during prism exposure was nearly perfect, but aftereffects were absent. When starting limb location was not visible, accurate exposure performance was slow to develop, but aftereffects were substantial. Adaptive spatial alignment of sensorimotor spaces and strategic perceptual-motor control to coordinate sensorimotor systems are distinct processes. However, realignment is dependent on whether the exposure task evokes control strategies that enable detection of misalignment. If the task can be performed solely by coding the visible difference between limb and target locations, misalignment detection is disabled. If movement is initiated by target location and then the limb is controlled by the visible difference between target and limb, the discordance between initialized and terminal locations enables misalignment detection and realignment.

Hypnotic susceptibility, imaging ability, and anagram-solving activity

Anagram-solving activity was examined as a function of hypnotic susceptibility level and imaging ability. In Experiment 1, anagrams that were composed of sets of letters that formed actual words (word anagrams), but when unscrambled formed other words, were compared to sets of letters that formed nonwords (nonsense anagrams). Word anagrams required more time to solve than nonsense anagrams. Also, fewer word anagrams were correctly solved compared to nonsense anagrams. Those individuals judged both high in hypnotic susceptibility and vivid in imaging ability demonstrated the best performance. In Experiment 2, anagrams that when unscrambled formed high-imagery words were compared to those that formed low-imagery words. High-imagery-word anagrams were solved more quickly and correctly than low-imagery-word anagrams. Such activity was best demonstrated by individuals who were judged to be both high in hypnotic susceptibility and vivid in imaging ability. These results are discussed in terms of strategies for solving anagrams and the individual differences that appear to be associated with using such strategies.