The impact of fluphenazine withdrawal: a mirror-image study

BACKGROUND

Fluphenazine decanoate licenced as a long-acting injectable (LAI) first-generation antipsychotic (FGA) was withdrawn from sale in 2018. This study evaluates if its withdrawal resulted in increased relapse rates of psychosis in an Irish patient cohort and examines which prescribed alternative antipsychotic medications were associated with more optimal outcomes.

METHODS

Fifteen participants diagnosed with a psychotic disorder were included. A mirror-image study over 24-months' pre-and post-withdrawal of fluphenazine was conducted. Kaplan-Meier survival and proportional hazards analyses were conducted. The impact of alternate antipsychotic agents (LAI flupenthixol compared to other antipsychotic medications) was evaluated. Semi-structured interviews with participants examined subjective opinions regarding the change in their treatment.

RESULTS

Seven participants (46.7%) relapsed in the 24-month period subsequent to fluphenazine discontinuation compared to one individual (6.7%) in the previous identical time-period (p = 0.035). Flupenthixol treatment was associated with reduced relapse rates compared to other antipsychotics (χ2 = 5.402, p = 0.02). Thematic analysis revealed that participants believed that the discontinuation of fluphenazine deleteriously impacted the stability of their mental disorder.

CONCLUSION

The withdrawal of fluphenazine was associated with increased relapse rate in individuals previously demonstrating stability of their psychotic disorder. While acknowledging the limitation of small sample size, preliminary evidence from this study suggests that treatment with the first-generation antipsychotic (FGA) flupenthixol was associated with a lower risk of relapse compared to SGAs. Reasons for this lower risk of relapse are not fully clear but could be related to dopamine hypersensitivity with this treatment change.

Temporal Trends in Severe Brain Injury and Associated Outcomes in Very Preterm Infants

INTRODUCTION

Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited.

METHODS

Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born <32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed.

RESULTS

Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71).

CONCLUSION

Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants.

Opinions of key stakeholders regarding the inpatient Individual Care Plan

OBJECTIVES

In Ireland, regularly reviewed Individual Care Plans (ICPs) for inpatients at all acute psychiatric inpatient units are a requirement of the Mental Health Act . In this study, we comprehensively evaluated and compared opinions of key stakeholders in relation to the ICP as a care delivery tool.

METHODS

We employed a descriptive survey design. Questionnaires were distributed to 123 stakeholders (patients and mental health professionals (MHPs)) to evaluate and compare opinions regarding the impact of the ICP in relation to healthcare delivery and health outcomes, and regarding the structure and frequency of use of the ICP.

RESULTS

Ninety-eight stakeholders (80%) completed study questionnaires. Stakeholders (patients (58%) and MHPs (85%)) reported that the ICP assisted in healthcare delivery. However, different attitudes between groups were noted in relation to whether the ICP contributed towards healthcare outcomes, with 64% of patients, but only 41% of MHPs reporting that the ICP positively contributed to mental healthcare outcomes. Some free-text comments described patient dissatisfaction with the role of the ICP for healthcare delivery, and MHP dissatisfaction that the ICP was time-consuming and did not significantly enhance standard patient care.

CONCLUSION

Whilst the implementation of the ICP is generally viewed positively by both patients and MHPs, considerable dissatisfaction by MHPs was also noted with certain aspects of how the ICP was delivered in practice. Practical adjustments to the implementation of ICP in order to build more positive stakeholder experiences appear warranted and worthy of further research.

Dose-Response Effect of Mental Health Diagnoses on Concussion Recovery in Children and Adolescents

BACKGROUND

Pre-existing mental health diagnoses may contribute to greater emotional symptom burden and prolonged recovery after concussion.

HYPOTHESIS

Youth with pre-existing mental health diagnoses will have greater emotional symptom burden, greater risk for delayed return to exercise, and more prolonged recovery from concussion than those without those diagnoses.

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 3.

METHODS

A prospective registry of youth concussion was examined for differences in emotional symptom burden after injury to develop a predictive risk model for prolonged recovery. The impact of individual and total number of pre-existing mental health diagnoses (0, 1, 2, and 3+) was assessed, and multivariable logistic regression was performed to identify factors associated with prolonged recovery.

RESULTS

Among a cohort of 3105 youth with concussion, those with a history of mental health diagnoses, in a dose-response fashion, had greater postinjury emotional symptom burden (7 emotional symptoms vs 4; P < 0.01), visio-vestibular dysfunction (65% abnormal vs 56% abnormal; P < 0.01), later return to symptom-limited exercise (23 vs 21 days; P < 0.01), and overall longer concussion recovery (38 days, interquartile range [IQR] 18, 80) versus 25 days (IQR 13, 54; P < 0.01). Boys with prolonged recovery after concussion had greater emotional symptom burden than girls (5 emotional symptoms vs 3; P < 0.01).

CONCLUSION

Pre-existing mental health diagnoses are associated with greater postinjury emotional symptom burden and longer concussion recovery in a dose-response fashion. Visiovestibular deficits and delayed return to exercise are also associated with pre-existing mental health diagnoses and prolonged recovery. Boys with prolonged recovery from concussion experience greater emotional symptom burden than girls.

CLINICAL RELEVANCE

Addressing pre-existing mental health diagnoses is essential to concussion management. Boys with prolonged recovery from concussion may particularly benefit from interventions to address their higher emotional symptom burden. Interventions, including a home visio-vestibular exercise program and symptom-limited exercise, may contribute to improving time to concussion recovery.

A comparison of rate and methods of probable suicide for 2 years pre and post the onset of the COVID-19 pandemic

OBJECTIVES

To examine and compare rates and methods of probable suicide in a Western region of Ireland during a 24 month period since the onset of the COVID-19 pandemic compared with a similar period immediately prior to the pandemic onset.

METHODS

Post-mortem reports between March 1st 2018 and February 29th 2020 were reviewed and compared with data from March 1st 2020 to February 28th 2022. Relevant demographic data, rates and methods of probable suicide and lifetime engagement with mental health services were compared across the two time points.

RESULTS

Identical rates of probable suicide (85 individuals at both time points) were demonstrated with no difference evident in the utilisation of violent compared to non-violent methods.

CONCLUSIONS

This study demonstrates that despite previous reports of increased rates of self-harm and some evidence of increased mental distress since the onset of the COVID-19 pandemic, no change in rates of or methods employed by individuals who died by probable suicide were evident in this geographical region.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Feasibility of Cognitive-Sparing Stereotactic Radiosurgery for Brain Metastases: Initial Report of Phase II COG-SRS Trial

PURPOSE/OBJECTIVE(S)

Radiotherapy at high doses leads to white matter (WM) and hippocampal injury which can cause cognitive decline. We designed the first, to our knowledge, evidence-based cognitive sparing brain SRS trial for patients with limited brain metastases. In this report we analyze feasibility of cognitive-sparing SRS, utilizing dose constraints for eloquent WM tracts and bilateral hippocampi.

MATERIALS/METHODS

This is a single-institution phase II NCI-funded clinical trial (NCT04343157) of cognitive-sparing brain SRS; eloquent regions of interest (ROI) and associated cognitive domains are outlined in Table 1. Patients underwent high-resolution quantitative diffusion and volumetric MRI at baseline and post-SRS follow-up. Comprehensive neurocognitive assessment was performed at baseline and 3 months post-SRS by a neuropsychologist evaluating different neurocognitive domains (Table 1). Clinical processing/workflow was largely automated with robust, validated segmentation tools of eloquent WM tracts and the hippocampi. Single fraction dose constraints to WM tracts were 12 Gy Dmax and 8.4 Gy to hippocampi with 3 and 5 fraction equivalent doses, based on our prior NTCP studies. Patient accrual, follow up imaging and neurocognitive testing is still active.

RESULTS

To date, n = 59 patients and 114 lesions have been treated with cognitive-sparing Linac-based SRS on trial. Median age is 63 years. Lung cancer was the most common primary (35.6%), along with breast cancer (23.7%) and melanoma (15.3%). Patients had 1-4 brain metastases; median prescription dose was 24 Gy/1, 27 Gy/3, or 30 Gy/5 depending on target volume. Most patients were treated < 7 business days from MRI. Cognitive endpoints have been collected on 89.5% of patients. Cognitive sparing constraints were met in 79.3% of plans while maintaining standard clinical SRS plan indices and coverage benchmarks. 38.9% of the plans that failed to meet the Dmax constraint kept D0.03cc under constraints. Plans going over constraints had tumors overlying or within 1 mm of eloquent ROIs. Local control for treated lesions at 6 months was 97.9% and 95.7% at 12 months. Distant intracranial control was 68.1% at 6 and 12 months. Median OS was 18 months.

CONCLUSION

Cognitive-sparing SRS treatment planning was successfully implemented for the majority of treated lesions with excellent local control. Mitigation of damage to eloquent structures has potential to further reduce cognitive decline after SRS. Full neurocognitive outcomes will be reported after accrual and testing are complete.

Quantitative Analysis of BrainAge using Neuroimaging Data to Estimate Radiation-Induced Brain Aging and Associations with Cognitive Changes in Brain Metastases Patients

PURPOSE/OBJECTIVE(S)

Radiotherapy is critical in brain tumor management yet causes accelerated aging via irreparable damage to white matter, cortex, and subcortical areas. BrainAGE is an open-source machine learning tool that analyses morphology from raw quantitative structural MRI to generate a predictive 'BrainAge' value, enabling analyses of patients with neurodegenerative diseases. We assessed the utility of this algorithm in measuring brain age morphology in brain metastases patients on a clinical trial, analyzed differences in BrainAge and chronological age, and explored associations with cognitive performance.

MATERIALS/METHODS

We analyzed pre-SRS high-resolution T1-weighted noncontrast volumetric MRI in patients with brain metastases (n = 57, median age 63 years, range 20-87) treated on a prospective clinical trial of cognitive-sparing SRS. The BrainAGE machine learning tool processed images to derive a BrainAge; it reliably generates this value using a Gaussian Processes regression, with a robust neurotypical training cohort. We examined correlations between BrainAge and chronological age with regression. Brain-predicted age gap (Brain-Gap) was calculated, defined as the difference between a patient's BrainAge and chronological age. We assessed cognitive function at baseline pre-SRS with a comprehensive battery of validated tests across multiple domains performed by a neuropsychologist, including memory (HVLT total), executive function (COWAT category fluency), and language (COWAT letter fluency). Raw test scores were scaled to T-scores adjusting for age, sex, and education level per testing norms. We examined if Brain-Gap was associated with cognitive performance pre-SRS.

RESULTS

BrainAGE software was robust, estimating a BrainAge for all input MRI sequences. We found a strong correlation between BrainAge and chronological age (r-squared = 0.82). The Brain-Gap median value was 0.84 and the mean was -0.90, in years (range -18.30-11.36 years). Brain-Gap was not significantly associated with cognitive performance across the three tests at the pre-SRS timepoint. Among patients with impaired cognition (T<35), there was no significant difference in BrainAge relative to chronological age.

CONCLUSION

To our knowledge, this is the first study utilizing the BrainAGE model as a biomarker of neuroanatomical age for brain tumors patients. Existing publications had lesion-free cohorts. Our results show that BrainAge was reliably associated with chronologic age in brain metastases patients pre-SRS. The Brain-Gap difference was minimal at baseline, and we found no significant association with pre-SRS cognitive performance. Future studies will examine this biomarker after SRS to look for individual aging radiation effects and prediction for cognitive changes after therapy.

Evidence-Based Multivariate Normal Tissue Complication Probability (NTCP) Study of Domain-Specific Cognitive Decline after Partial Brain RT

PURPOSE/OBJECTIVE(S)

Beyond the hippocampus, there are no evidence-based dose constraints for eloquent brain structures which subserve memory and attention/processing speed. We performed a multivariate normal tissue complication probability analysis of post-RT neurocognitive decline, examining dosimetric predictors of eloquent brain regions.

MATERIALS/METHODS

Data were analyzed from a prospective longitudinal clinical trial. Patients (n = 78) with primary brain tumors receiving fractionated RT complete a comprehensive neurocognitive evaluation and high-resolution volumetric and diffusion MRI at baseline and 6 months post-RT. Image processing using robust, validated automated segmentation parcellated individual WM tracts, cortical regions, and hippocampi. Well-validated neurocognitive tests including Delis-Kaplan Executive Function System and Wechsler Adult Intelligence Scale-IV coding (attention/processing), Boston Naming Test (language) and Hopkins Verbal Learning Test and Brief Visuospatial Memory Test (verbal/visuospatial memory) were assessed. Reliable change indices adjusted for practice effects (RCI-PE) were calculated for each patient between baseline and 6 months; a negative RCI-PE was scored as decline. Univariate logistic regression was performed with mean and max dose to structures of interest as well as clinical variables. Multivariate model building was performed using automated bootstrapped logistic regression, LASSO and random forest modeling.

RESULTS

On univariate analysis mean and max dose to multiple regions of the corpus callosum (CC) were correlated with attention/processing speed decline; most significantly in WAIS coding, including Dmax to the anterior CC (p = 0.011) and central CC (p = 0.010), and Dmax and Dmean to the mid anterior CC (p = 0.006 and 0.010). Mean dose to the left fornix was associated with decline in memory (p = 0.023, cutoff 12.9 Gy), as were increasing age and both concurrent and adjuvant chemotherapy. On multivariate analysis for attention, automated bootstrapped logistic regression showed the most frequently selected variable was mean dose to the mid anterior CC. Performance at nested cross-validation by AUC was 0.80 (0.75-0.84); LASSO model performance by AUC was 0.76 (0.72-0.81) with Dmean to the mid anterior CC being the most frequent variable. The top five most important variables in the Random Forest as ranked by mean decrease in Gini coefficient were mean dose to mid anterior CC, all white matter, combined CC and max dose to CC and posterior CC. Model performance by AUC was 0.66 (0.60-0.71).

CONCLUSION

Here, we present the first, to our knowledge, NTCP model for decline in attention/processing speed, along with dosimetric predictors of memory decline beyond the hippocampus. We found that after partial brain RT, dose to several ROIs significantly correlated with post-RT impairment. These data can guide future cognitive-sparing strategies for brain RT.

A 2-year longitudinal evaluation of the impact of the COVID-19 pandemic on individuals with pre-existing anxiety disorders

OBJECTIVES

To examine if the COVID-19 pandemic is associated with a differential effect over a 2-year time period in relation to its psychological and social impact on patients with established anxiety disorders.

METHODS

Semi-structured interviews were conducted with 21 individuals attending the Galway-Roscommon Mental Health Services in Ireland with an ICD-10 diagnosis of an anxiety disorder. Interviews occurred at three time-points over a 2-year period to determine the impact of the COVID-19 pandemic and associated restrictions on anxiety and depressive symptoms, social and occupational functioning, and quality of life.

RESULTS

No statistical difference in symptomatology was noted between the three time-points in relation to anxiety symptoms as measured utilising psychometric rating scales (Beck Anxiety Inventory (BAI), Hamilton Anxiety Rating Scale (HARS) or Likert Scale measures). The greatest impact of COVID-19 at all time-points related to social functioning and quality of life. Significant variability was noted for individual participants. Qualitative analysis noted a tentative optimism for the future in the setting of vaccination and societal re-opening. Fear of re-emerging anxiety symptoms with the removal of societal restrictions was noted.

CONCLUSIONS

No significant overall change in symptomatology or functioning over time was noted for individuals with pre-existing anxiety disorders, however variability was demonstrated, with some individuals describing ongoing anxiety, social isolation and concern for their future. A strong theme of hope for the future and less concern regarding the COVID-19 pandemic was evident; however tailored supports including the utilisation of tele-psychiatry is suggested, particularly for those experiencing increased anxiety with the removal of societal restrictions.

A cluster of acute thebaine poisonings from non-food grade poppy seeds in the Australian food supply

INTRODUCTION

Poppy seed tea is used for its opioid effects and contains multiple opium alkaloids, including morphine, codeine, papaverine, and thebaine. Animal studies indicate thebaine has strychnine-like properties, but there is limited literature describing human thebaine poisoning. We describe a cluster of acute thebaine poisoning in people ingesting tea made using poppy seeds with high thebaine content that entered the Australian food supply chain.

METHODS

This is an observational study of patients poisoned after drinking poppy seed tea. Cases were identified by three prospective toxicovigilance systems: the Emerging Drug Network of Australia collaboration, the New South Wales Prescription, Recreational and Illicit Substance Evaluation program, and the Emerging Drugs Network of Australia Victoria study. We report characteristics of clinical toxicity in cases with reported ingestion of poppy seed tea and analytical confirmation of thebaine exposure.

RESULTS

Forty cases presenting with multi-system toxicity following poppy seed tea ingestion were identified across seven Australian states/territories from November 2022 to January 2023. Blood testing in 23 cases confirmed high thebaine concentrations. All 23 were male (median age 35, range 16-71 years). All patients experienced muscle spasms. Rigidity was described in nine, convulsions in six, while rhabdomyolysis, acute kidney injury, and metabolic acidosis occurred in five patients. There were two cardiac arrests. The thebaine median admission blood concentration was 1.6 mg/L, with a range of 0.1-5.6 mg/L, and was the dominant opium alkaloid in all samples. Convulsions, acute kidney injury, metabolic acidosis, and cardiac arrest were associated with increasing median thebaine concentrations. Four patients were managed in the Intensive Care Unit, with two receiving continuous kidney replacement therapy (one also received intermittent haemodialysis) for kidney injury. There was one death.

CONCLUSIONS

Thebaine toxicity, like strychnine poisoning, resulted in neuromuscular excitation characterized by muscle spasm, rigidity, and convulsions. Severe toxicity, including acute kidney injury, metabolic acidosis, and cardiac arrest, appears dose-dependent.

Toxicokinetics of thebaine in those consuming non-food grade poppy seeds as a tea

INTRODUCTION

Thebaine is an alkaloid in poppy seeds that is neurotoxic to animals. Data on its clinical effects and toxicokinetics in people are minimal. In 2022, poppy seeds high in thebaine entered the Australian food market, and people consuming tea made from these poppy seeds developed poisoning.

METHODS

Three patients who drank poppy seed tea and developed neuromuscular toxicity consented for thebaine to be quantitated in serial blood samples. Blood samples were analyzed by liquid chromatography with high-resolution mass spectrometry.

RESULTS

Case 1: A man in his 60s presented with drowsiness, vomiting, malaise and myoclonus. He developed metabolic acidosis with hyperlactataemia, acute kidney injury requiring haemodialysis, convulsions, rhabdomyolysis, and was in the hospital for 18 days. The admission thebaine blood concentration was 2.1 mg/L, and the apparent elimination half-life was 14.8 h. Case 2: A man in his 30s presented with myoclonus, rigidity, vomiting, and dizziness. He developed metabolic acidosis with hyperlactataemia, acute kidney injury, and myalgias. The admission thebaine blood concentration was 4.1 mg/L, and the apparent elimination half-life was 11.6 h. Case 3: A man in his 30s presented with myoclonus, rigidity, clonus, diaphoresis, and abdominal pain. The admission thebaine blood concentration was 2.2 mg/L, and the apparent elimination half-life was 8.3 h.

DISCUSSION

Neuromuscular toxicity, metabolic acidosis with hyperlactataemia, acute kidney injury, and gastrointestinal symptoms were prominent clinical features in these patients after drinking poppy seed tea. Effects persisted for days, and all survived, despite thebaine concentrations far exceeding those in published forensic reports, although human data are sparse. Compared to rats, the thebaine apparent elimination half-life is much longer in humans who develop symptoms at lower concentrations.

CONCLUSIONS

Despite relatively high thebaine blood concentrations and moderate to severe poisoning, outcomes were favourable with early presentations. It is possible that acute kidney injury prolongs the apparent elimination half-life of thebaine.

Proximal humerus fractures: A review of current practice

The management of proximal humeral fractures (PHF) remains controversial. Its incidence is increasing. Patients should be meticulously assessed clinically for co-morbidities and neuro-vascular injuries. Radiological investigation helps provide information on the fracture configuration and dislocations. Enhanced by 3-dimensional CT scanning, these further help in decision making and operative planning. PHF classifications have been demonstrated to have poor intra-observer and inter-observer reliability. Research has identified some radiographic predictive factors for humeral head ischaemia and likely failure of surgical fixation. The range of management options include non-operative treatment, operative fixation, intramedullary nailing and arthroplasty (hemiarthroplasty, reverse shoulder replacement). The majority of PHFs are stable injuries and non-operative management is usually successful. Some degree of malunion is readily tolerated especially by elderly patients. Surgical management of significantly displaced, unstable proximal humerus fractures should aim to stabilise the fracture adequately and provide satisfactory function for the long term. Management of the greater tuberosity is pivotal for the eventual outcome. When fixation may appear to be compromised by poor bone quality, likely poor function, age related rotator cuff degeneration or likely humeral head ischaemia clinicians may opt for arthroplasty. Successful hemiarthroplasty outcomes are dependent on sufficient healing of the tuberosity and recovery of the rotator cuff integrity. Reverse shoulder replacement can predictably deliver good functional outcomes for the shoulder in elderly patients, where rotator cuff dysfunction is suspected or as a revision procedure following failure of other surgical interventions. As opposed to hemiarthroplasty, which has shown a downward trend, there has been an increasing trend towards the use of reverse shoulder replacement in proximal humeral fractures. The management of PHFs should be patient specific, fracture specific and meet the functional demands and needs of the individual patient. The surgeon's skill set and clinical experience also plays an important role in the options of management available.

Kynanthropic and vampirism delusions: a case report and review of the literature

Zooanthropy (delusional beliefs of turning into an animal) is a rare but well recognised psychiatric phenomenon. This case describes the presence of kynanthropic delusions (delusional beliefs of turning into a dog). Multiple other psychotic symptoms were also evident including unusually the additional presence of delusions of vampirism. Delusional beliefs in this case were associated with behavioural changes including growling and barking, and less commonly an expressed craving for biting people's necks to suck human blood. Symptom intensity was associated with increased psychosocial stressors for this patient, with some benefit noted from very high doses of anti-psychotic medications. Brief admissions to the acute psychiatric inpatient unit and thus removal from environmental stressors has been associated with an amelioration in symptomatology.

Evaluation of adherence monitoring in buprenorphine treatment: A pilot study using timed drug assays to determine accuracy of testing

AIMS

Buprenorphine is effective at reducing relapse to opioid misuse, morbidity and mortality in opioid-dependent patients. Urine drug screening (UDS) to assess adherence is used routinely in opioid agonist treatment (OAT). The primary aim of this study was to determine factors which may be associated with a negative qualitative urine drug screen for buprenorphine in OAT patients.

METHODS

This prospective pilot study was conducted at a tertiary addiction medicine centre. Twenty participants on stable treatment underwent supervised administration of sublingual buprenorphine. Matched urine and blood samples were collected prior to and 2, 4 and 6 hours after buprenorphine administration. Qualitative urine drug screen results were obtained using gas chromatography-mass spectrometry (GC-MS), while quantitative blood and urine results were obtained using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS).

RESULTS

Qualitative urine assay yielded a negative result for buprenorphine in 57% of tested samples. The median concentration of urinary buprenorphine was 167 mcg/L (range: 2-1730 mcg/L). Thirty percent of all blood samples did not detect buprenorphine (range 0-18 mcg/L). Positive qualitative urine drug screen results were associated with higher urine (343 mcg/L compared with 75 mcg/L; P < .05) and blood (4 mcg/L compared with 2 mcg/L; P < .05) buprenorphine concentrations. Median urine concentrations of buprenorphine were highest at 2 hours and were higher in participants receiving CYP3A4 inhibitors.

CONCLUSION

Interpretation of qualitative urine drug screens to assess adherence in OAT is complex. Poor adherence with treatment cannot be assumed in patients returning a negative qualitative GC-MS urine drug screen.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 10⁹/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Effectiveness of a Text Message Intervention to Reduce Texting While Driving Among Targeted Young Adults: A Randomized Controlled Trial

PURPOSE

This randomized clinical trial tested the efficacy of a 6-week text message program to reduce texting while driving (TWD) for young adults.

METHODS

Eligible individuals recruited from four emergency departments from December 2019 to June 2021 were aged 18-25 years who reported TWD in the past 2 weeks. Participants were randomly assigned 1:1 to intervention:assessment control. The intervention arm (n = 57) received an automated interactive text message program, including weekly queries about TWD for 6 weeks with feedback and goal support to promote cessation of TWD. The assessment control arm (n = 55) received identical weekly TWD queries but no additional feedback. Outcomes were collected via web-based self-assessments at 6- and 12 weeks and analyzed under intent-to-treat models, presented as adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The mean (SD) age was 21.7 (2.1) years, 73 (65%) were female, and 40 (36%) were White. The 6-week follow-up rate was 77.7% (n = 87) and 12-week follow-up rate was 64.3% (n = 72). At 6 weeks, 52.6% (95% CI, 39.0%-66.0%) of intervention participants reported TWD versus 63.6% (95% CI, 49.6%-76.2%) of control participants (adjusted OR, 0.71; 95% CI, 0.32-1.59). At 12 weeks, 38.2% (95% CI, 22.8%-53.5%) of intervention participants reported TWD versus 69.3% (95% CI, 53.8%-84.7%) of control participants (adjusted OR, 0.29; 95% CI, 0.11-0.80).

DISCUSSION

An interactive text message intervention was more effective at reducing self-reported TWD among young adults than assessment control at 12 weeks.

Effectiveness of a Text Message Intervention Promoting Seat Belt Use Among Young Adults: A Randomized Clinical Trial

IMPORTANCE

Approximately 1 in 10 adults do not always wear a seat belt, with the lowest use rates reported among young adults.

OBJECTIVE

To determine the efficacy of a 6-week automated behavioral text message program promoting seat belt use compared with an attention control.

DESIGN, SETTING, AND PARTICIPANTS

This parallel, 2-group, single-blind, individually randomized clinical trial included a convenience sample of patients recruited from 4 emergency departments in 2 cities in Pennsylvania from December 2019 to September 2021, with follow-ups at 6 and 12 weeks after randomization. Patients in stable condition aged 18 to 25 years who, in standardized screening, reported driving or being a passenger in a car without always using a seat belt in the past 2 weeks were eligible for recruitment. Participants who completed a 2-week trial run-in phase were randomly assigned 1:1 to the intervention or the assessment control. Data were analyzed from October 2019 to January 2020.

INTERVENTIONS

The intervention group received Safe Vehicle Engagement (SAVE), a 6-week automated interactive text message program, including weekly seat belt use queries with feedback and goal support to promote consistent use of a seat belt. The control group received identical weekly seat belt use queries but no additional feedback.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of young adults reporting always wearing a seat belt over the past 2 weeks, collected at 6 weeks (after a 2-week run-in) via web-based self-assessments and analyzed under intent-to-treat models using multiple imputation procedures. Sensitivity analyses included complete-case analyses of ordered categorical outcomes by vehicle seat position. Secondary outcomes included seatbelt use at 12 weeks and select cognitive constructs related to seat belt use.

RESULTS

A total of 218 participants (mean [SD] age, 21.5 [2.1] years; 139 [63.8%] women) were randomized, with 110 randomized to SAVE and 108 randomized to the control group. A total of 158 individuals (72.4%) were included in the 6-week follow-up. The rate of always using a seat belt over the past 2 weeks at the 6-week follow-up was 41.3% (95% CI, 30.6%-52.0%) among SAVE participants and 20.0% (95% CI, 10.6%-29.3%) among control participants (odds ratio [OR], 2.8; 95% CI, 1.4-5.8; P = .005). A total of 140 individuals (64.2%) participated in the 12-week follow-up. At 12 weeks, the rate of always using a seat belt over the past 2-weeks was 42.8% (95% CI, 31.2%-54.2%) among SAVE participants and 30.7% (95% CI, 19.6%-41.6%) among control participants (OR, 1.7; 95% CI, 0.9-3.4; P = .13). When examining ordered categories of seat belt use by seat position, there were significantly greater odds of wearing a seat belt at 6 and 12 weeks among SAVE participants vs control participants (eg, 6 weeks for driver: OR, 5.2; 95% CI, 2.6-10.5; 6 weeks for front passenger: OR, 4.3; 95% CI, 2.2-8.2; 6 weeks for back passenger: OR, 4.3; 95% CI, 2.2-8.2).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, an interactive text message intervention was more effective at promoting seat belt use among targeted young adults than an attention control at 6 weeks. There was no significant difference between groups in always wearing a seat belt at 12 weeks. These findings, if replicated in a larger sample, suggest a scalable approach to improve seat belt use.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03833713.

Quality of life after involuntary psychiatric admission

Studies seeking predictors of outcomes after involuntary admission, including quality of life (QoL), are limited and results inconsistent. We aimed to describe QoL 3 months after involuntary psychiatric admission and to investigate associated factors. One hundred and fifty-three involuntarily admitted inpatients were assessed for a range of sociodemographic and clinical variables. Structured scales included the Brief Psychiatric Rating Scale (BPRS), the MacArthur Admission Experience Survey, the Heinrichs Quality of Life Scale and the World Health Organisation Quality of Life Brief Assessment (WHOQOL-BREF, n = 124). The mean total score on the Heinrichs QoL scale at 3 months was 69.3 (SD = 24.1). Predictors of higher 3 month QoL after involuntary admission in a multiple regression model (adjusted R² = 0.37, F = 7.1 (14, 138), p ≤0.001) were less severe negative symptoms on the BPRS at baseline (B = -4.56, p < 0.001), improvement in negative symptom scores between baseline and follow up (B = 4.58, p < 0.001) and higher current social class (B = -14.31, p = 0.001). Events during involuntary admission, such as being subject to coercive experiences, were not significantly associated with QoL after admission. The results suggest that a core determinant of service users' QoL after involuntary admission is negative symptom severity and change over time.

Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R): protocol for a pilot randomised controlled study

BACKGROUND

Psychosis, even in its early stages, is associated with significant disability, causing it to be ranked ahead of paraplegia and blindness in those aged 18-35 in terms of years lived with disability. Current pharmacological and psychological interventions intervention have focused primarily on the reduction of positive symptoms (hallucinations and delusions), with little benefit to domains of psychosis such as cognitive difficulties and social and occupational functioning.

METHODS/DESIGN

The CReSt-R intervention trial is a single center, pilot randomised controlled study based at the National University of Ireland (NUI), Galway. The trial will recruit participants from four clinical sites with assessment and intervention completed by the primary NUI Galway team. The trial will explore the feasibility, acceptability, and effectiveness of a novel psychosocial intervention for early psychosis based on a combined cognitive remediation training and cognitive behavioural therapy approach focused on social recovery. Participants, aged 16-35 within the first 5 years of a diagnosed psychotic disorder, will be recruited from the Children and Adolescent Mental Health Service and the Adult Mental Health Services in the region.

DISCUSSION

Cognitive remediation training (for improving cognition) and social recovery focused cognitive behavioural therapy, have both separately demonstrated effectiveness. This trial will evaluate the feasibility, acceptability, and explore the efficacy of a treatment approach that combines both approaches as part of an integrated, multicomponent intervention.

TRIAL REGISTRATION

Cognitive Remediation & Social Recovery in Early Psychosis (CReSt-R): ClincialTrials.gov Identifier NCT04273685. Trial registered Feb 18th, 2020. Last updated April 14th, 2021.

A191 PERSISTENT BENEFIT OF DIETITIAN-LED GLUTEN-FREE DIET EDUCATION AT CD DIAGNOSIS ON DIETARY ADHERENCE IN CHILDREN AND ADULTS WITH TYPE 1 DIABETES AND CELIAC DISEASE

Background

Celiac disease (CD) is a common autoimmune comorbidity of type 1 diabetes (T1D) with a gluten-free diet (GFD) being the current gold standard treatment for this condition. Adherence to a GFD can be impacted by several factors including dietetic counselling, yet little is known about the impact of clinic-based interventions on long-term GFD adherence in this population.

Aims

To prospectively evaluate the impact of a dietitian-led GFD education intervention on adherence to a GFD in children and adults with T1D and CD over a 3-year period.

Methods

A cohort of N=62 pediatric and adult subjects who screened seropositive for CD as part of the CD-DIET clinical trial were followed over a 3-year period post-CD diagnosis and assessed on the basis of the GFD education regimen they received at initial CD diagnosis. This included 3 groups: 1) intensive dietitian training (IDT = 5 dietitian visits over 1 year while following GFD), 2) single dietitian training (SDT = 1 GFD training session after 1 year of following GCD) and 3) no dietitian training (NDT) at CD diagnosis. Annual visits included serologic testing of TTG-IgA titres, anthropometric assessments and the completion of questionnaires evaluating diet and adherence to a GFD. Data was analysed longitudinally using linear mixed effects and generalized estimating equations (GEE) regression modeling adjusting for the fixed effects of age, sex, duration of diabetes and time.

Results

At baseline, participants who received IDT (n=15), SDT (n=16) and NDT (n=31) represented 24.2%, 25.8%, and 50.0% of the cohort, respectively. Over the 3-year study period, participants in the IDT group had the greatest odds of self-reporting being a GFD, with odds 4.3 (95%CI: 1.1 to 16.4; P=0.033) and 9.5 (95%CI: 2.7 to 33.7; P&lt;0.001) greater than the SDT and NDT groups, respectively. The assessment of daily gluten intakes less than 10mg, as recommended for a GFD, revealed a lack of differences between the IDT and SDT groups. In contrast, the NDT group had significantly lower odds of meeting this threshold relative to those who received IDT (OR=0.2; 95%CI: 0.04 to 0.56; P=0.004). No longitudinal differences in TTG-IgA levels were seen between groups over the 3-year period.

Conclusions

In diabetes patients greater contact with a dietitian at CD diagnosis was associated with higher levels of GFD adherence over time, which was not reflected in follow-up Serologic evaluation. These findings highlight the importance of nutritional support in patients with both diabetes and celiac disease at the time of CD diagnosis. In addition, following TTG-IgA alone does not fully inform dietary compliance to a GFD.

Diet teaching stratification

Funding Agencies

Juvenile Diabetes Research Foundation / PSI

Psychiatric and psycho-social characteristics of suicide completers: a 13-year comprehensive evaluation of psychiatric case records and post-mortem findings

Currently, there are limited data comparing demographic and clinical characteristics of individuals who died by probable suicide and who did and did not previously attend mental health services (MHSs). This study compared demographic and clinical factors for both groups, in a Western region of Ireland over a 13-year period. Postmortem reports between January 1, 2006 and March 31, 2019 were reviewed for 400 individuals who died by probable suicide. Relevant sociodemographic and clinical data were extracted from individuals’ lifetime case notes. One hundred and fifty nine individuals (40%) had attended MHSs at some stage (“attendee”). Hanging was the most common method of suicide (61%), followed by drowning (18%) for both attendees and nonattendees of MHSs, with more violent methods utilized overall by nonattendees (p = 0.028). Sixty-eight percent of individuals who previously attempted hanging subsequently died utilizing this method. A higher proportion of attendees were female compared to nonattendees of MHSs (28.9 vs. 14.5%, p = 0.001). Recurrent depressive disorder (55%) was the most common diagnosed mental health disorder. For individuals with a diagnosis of schizophrenia, 39% had antipsychotic medications detectable in their toxicology reports. In conclusion, the majority of people who died by probable suicide had never had contact with MHSs, and nonattendees overall were more likely to utilize violent methods of suicide. Nonconcordance with psychotropic medications in psychotic patients and previous hanging attempt were highlighted as potential risk factors for death by probable suicide.

Objective Eye Tracking Metrics of Vision and Autonomic Dysfunction Distinguish Adolescents With Acute Concussion and Those with Persistent Post-Concussion Symptoms from Uninjured Controls

OBJECTIVE

To explore the utility of an eye-tracking assessment in distinguishing binocular alignment, saccadic movement, and pupillary dynamics among uninjured adolescents, acute cases (= 28 days since concussion), and persistent cases (>28 days since concussion).

BACKGROUND

Visual and autonomic system disturbances are common sequelae of concussion. Quantification of visual and autonomic dysfunction via an eye tracking device could provide an objective method of acute diagnosis and subacute identification of ongoing injury.

DESIGN/METHODS

We compared 347 eye tracking metrics, derived from a 220 seconds eye-tracking assessment, among 132 uninjured adolescents (mean age: 15.3, 56.2% female), 110 acute cases (mean days since injury: 12.5, mean age: 15.4, 46.4% female), and 95 persistent cases (mean days since injury: 53.6, mean age: 15.4, 70.2% female) using Kruskal-Wallis tests with Bonferroni corrections to account for multiple comparisons.

RESULTS

Nine eye-tracking metrics were significantly associated with injury status. One measure of binocular alignment (acute v. control: p = 0.003, persistent v. control: p = 0.001) and one measure of saccadic movement (acute v. persistent: p = 0.03, acute v. control: p = 0.03, persistent v. control: p < 0.001) were worse in cases. Cases had larger left and right mean and median pupil size than uninjured adolescents (acute v. control, p < 0.001; persistent v. control, p < 0.001). Cases had greater differences in mean (acute v. control: p < 0.001, persistent v. control: p < 0.001), median (acute v. control, p < 0.001, persistent v. control, p = 0.003), and variance of (acute v. control: p < 0.001, persistent v. control: p < 0.001) left and right pupil size. Eight of these metrics distinguished female cases from uninjured adolescents, but similar differences were not observed in male participants.

CONCLUSIONS

Objective eye tracking technology can identify vision and pupillary disturbances after concussion. These metrics could be integrated into clinical practice to monitor recovery in a heterogeneous adolescent concussion population and may identify sex-specific differences in autonomic dysfunction.

Variations in Time to Recovery from Pediatric Concussion Based on Differing Outcomes of Interest

OBJECTIVE

To quantify variability in pediatric concussion recovery across multiple outcomes of interest.

BACKGROUND

Pediatric concussion studies are hindered by a common significant limitation: lack of agreement on a standard definition of "recovery." A variety of clinical outcomes of interest utilized across studies, including symptom self-report, neurocognitive testing results, self-reported return to activity, and physician clearance for activity, leads to challenges for both research, as well as clinical concussion management.

DESIGN/METHODS

We enrolled concussed youth, ages 11-18 years, from a specialty sports medicine clinic = 28 days of injury. Patients were followed as part of clinical care for concussion for up to 13 weeks. At each visit, participants completed questionnaires and a battery of clinical measures. From these data, we constructed 10 potential definitions of recovery: 3 based on self-reported symptoms (change from pre-injury, no symptoms, below pre-determined thresholds), 2 based on visio-vestibular examination (VVE) deficits (none, = 1), 2 based on physician clearance (for return to school/sport), and 3 based on self-assessment ("back to normal", return to school/exercise).

RESULTS

One hundred seventy-four concussed youth were enrolled (median age: 15 years, 54.6% female) with a median time from injury to initial visit of 12 days (IQR: 7, 20). Median number of visits was 2 (range: 1, 5). We observed a wide variation in the proportion of participants recovered across the 10 definitions. Depending on definition, between 4% and 45% were considered recovered within 4 weeks, and between 10% and 80% were considered recovered at the end of follow-up. The VVE-based definition (=1 deficit) consistently had the highest proportion recovered at all time points, while self-reported return to exercise had the lowest proportion.

CONCLUSIONS

Recovery from concussion is not a single unitary point in time. These results will provide valuable guidance to clinicians in managing concussion and researchers in designing future observational and interventional trials of pediatric concussion.

Concussion Assessment Across Several Clinical Batteries: Identifying the Components That Best Discriminate Injured Adolescents From Controls

OBJECTIVE

To identify which sub-components of 4 clinical assessments optimize concussion diagnosis.

BACKGROUND

Multiple assessments are part of the clinical toolbox for diagnosing concussions in youth, including the Post-Concussion Symptom Inventory (PCSI), the visio-vestibular exam (VVE), the King-Devick (KD) assessment, and the Sport Concussion Assessment Tool (SCAT-5). Most of these assessments have sub-components that likely overlap in aspects of brain function they assess. Discerning the combination of sub-components that best discriminate concussed adolescents (cases) from uninjured controls would streamline concussion assessment.

DESIGN/METHODS

Participants, 12-18 years, were prospectively enrolled from August 1, 2017 to April 29, 2020 Controls (n = 189, 53% female) were recruited from a suburban high school with PCSI, VVE, KD and SCAT-5 assessments associated with their sport seasons. Cases (n = 213, 52% female) were recruited from a specialty care concussion program, with the same assessments performed ≤28 days from injury. We implemented a forward-selection sparse principal component (PC) regression procedure to group sub-components into interpretable PCs and identify the PCs best able to discriminate cases from controls while accounting for age, sex, and concussion history.

RESULTS

The AUC of the baseline model with age, sex, and concussion history was 62%. The PC that combined all 5 sub-components of PCSI and SCAT-5 symptom count and symptom severity provided the largest AUC increase (+10.6%) relative to baseline. Other PC factors representing (1) KD completion time, (2) Errors in BESS tandem and double-leg stances, and (C) horizontal/vertical saccades and vestibular-ocular reflex also improved model AUC relative to baseline by 5.6%, 4.7%, and 4.5%, respectively. In contrast, the SCAT5 immediate recall test and right/left monocular accommodation did little to uniquely contribute to discrimination (<1% gain in AUC). Overall, the best model included 5 PCs (AUC = 77%).

CONCLUSIONS

These data show overlapping features of clinical batteries, with symptoms providing the strongest discrimination, but unique features obtained from neurocognitive, vision, and vestibular testing.

Persistent Nutritional Deficiency in Pancreatic-Insufficient Children and Adolescents with Cystic Fibrosis Despite Therapeutic Intervention

Background

Cystic fibrosis (CF) is caused by mutations in the gene encoding the CF Transmembrane Conductance Regulator (CFTR) protein, resulting in compromised pulmonary function, malabsorption, and pancreatic insufficiency. The sequelae of CF are heterogeneous, and contributing factors are multifactorial. Nutritional deficiencies, particularly in essential fatty acids (EFA) and vitamins, are known to alter the trajectory of CF unfavorably. The current treatment modalities focus on proactive management of the pulmonary, gastrointestinal, and pancreatic functions; however, information on the monitoring and treatment of nutritional deficiencies in CF patients is scant. The objective of our study was to evaluate the effects of pancreatic function and CFTR modulator therapy on pertinent nutritional deficiencies in children and adolescents diagnosed with CF.

Methods

The study was approved by our institutional IRB and included 77 non-fasted CF participants, 10.4 + 5.2 years of age (range: 4 months-18 years), and an equal ratio of both sexes. Participants were stratified as pancreatic sufficient (PS, n=6), and pancreatic insufficient with (PI, n=48) or without CFTR modulator treatment (PI-M, n=23). Twenty-two fatty acids were measured in plasma by GC-MS, including omega-6 linoleic acid (LA), and omega-3 α-linoleic acid (ALA). Medical records and 24-hour dietary recalls were reviewed to correlate biochemical and clinical findings. Vitamins A and E and zinc levels of the participants were also obtained. Data analyses were performed by one-way ANOVA and Tukey’s multiple comparisons using Prism software (LaJolla, CA).

Results

There were no significant differences in BMI and caloric intake among the groups. The concentrations of EFA, LA, and ALA were significantly higher in the PS group (3904±229 nmol/mL and 149±24 nmol/mL) compared to the PI (2387±89 nmol/mL and 53±4 nmol/mL, p&lt;0.01) and PI-M (2335±159 nmol/mL and 58±7 nmol/mL, p&lt;0.01) groups, respectively. Similarly, the biologically active omega-6 arachidonic acid and omega-3 docosahexaenoic acid were lower in the PI and PI-M groups compared to the PS group (p&lt;0.05). Interestingly, EFA deficiency biomarkers, omega-9 mead acid, and the Triene:Tetraene ratio, were significantly higher in the PI group (17±2 nmol/mL and 0.033±0.003) vs PS group (13±3 nmol/mL and 0.019±0.002, p&lt;0.05), respectively. Higher concentrations of vitamins A and E were observed in the PS group vs PI-M groups (p&lt;0.05), and zinc concentrations were not different among the groups. There were no associations between the concentrations of EFA and BMI, age, total caloric intake, and % calories from fat in PS, PI, and PI-M patients.

Conclusion

While advances in CF therapeutics are remarkable, our data show the persistence of nutritional deficiencies in pancreatic insufficient CF patients regardless of CFTR modulator therapy and support the clinical utility of EFA and vitamins as potential adjuvant biomarkers to assess the severity and assist in the clinical monitoring of CF.