The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland

PURPOSE

The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilization evolved throughout the pandemic. Our objectives were to investigate the impact of the pandemic in three language regions of Switzerland by analyzing trends over time, describe regional differences, and address implications for future healthcare.

METHODS

We conducted a retrospective, longitudinal cohort study at three Swiss tertiary pediatric EDs (March 1st, 2018-February 28th, 2022), analyzing the numbers of ED visits (including patients` age, triage categories, and urgent vs. non-urgent cases). The impact of COVID-19 related non-pharmaceutical interventions (NPIs) on pediatric ED utilization was assessed by interrupted time series (ITS) modelling.

RESULTS

Based on 304'438 ED visits, we found a drop of nearly 50% at the onset of NPIs, followed by a gradual recovery. This primarily affected children 0-4 years, and both non-urgent and urgent cases. However, the decline in urgent visits appeared to be more pronounced in two centers compared to a third, where also hospitalization rates did not decrease significantly during the pandemic. A subgroup analysis showed a significant decrease in respiratory and gastrointestinal diseases, and an increase in the proportion of trauma patients during the pandemic.

CONCLUSIONS

The COVID-19 pandemic had substantial effects on number and reasons for pediatric ED visits, particularly among children 0-4 years. Despite equal regulatory conditions, the utilization dynamics varied markedly between the three regions, highlighting the multifactorial modification of pediatric ED utilization during the pandemic. Furthermore, future policy decisions should take regional differences into account.

Cluster analysis demonstrates co-existing sites of fragility fracture and associated comorbidities

We undertook cluster analysis in 11,003 patients who had sustained ≥ 1 fragility fracture, to find associations between fracture sites and comorbidities. We identified three distinct groups of fracture sites and four clusters of fractures and comorbidities. Knowledge of factors associated with fracture sites will aid prophylaxis in at-risk patients.

INTRODUCTION

Fragility fracture (FF) prevalence is increasing. Subsequent fractures lead to greater morbidity and mortality. Few data are available on the association between FF sites and comorbidities.

OBJECTIVES

1. Establish the most common sites of FF and clusters within patients. 2. Identify patterns of co-existing FF and associated comorbidities.

METHODS

We retrospectively reviewed clinical records of patients undergoing bone mineral density estimation at a district hospital in North-West England, 2004-2016, identifying those who had sustained ≥ 1 FF. Demographics, FF site(s), comorbidities, and medications were recorded. Cluster analysis was performed on fracture sites alone, and sites and comorbidities, using Jaccard similarity coefficient. Results were plotted on a dendrogram and divided into clusters.

RESULTS

Of 28,868 patients, 11,003 had sustained ≥ 1 FF, 84.6% female, with overall mean age 67.5 years and median T-score - 1.12 SD. FF of the forearm was more frequent (n = 5045), most commonly co-existing with tibia/fibula fractures. Three FF site clusters were identified: ankle and elbow; forearm, tibia/fibula, ribs and spine; and pelvis, femur and humerus. When including comorbidities, four clusters were identified: forearm, tibia/fibula, spine, associated with family history of FF, smoking, corticosteroids and bisphosphonates; pelvis associated with hyperparathyroidism, PMR, coeliac disease and HRT; femur and humerus associated with IBD and RA; and ribs associated with alcohol and hyperthyroidism.

CONCLUSION

Cluster analysis demonstrated three fracture site clusters, and four subgroups of FF sites and comorbidities. Cluster analysis is a novel method to evaluate comorbidities associated with FF sites. Knowledge of factors associated with FF sites will aid prophylaxis in at-risk patients.

POS1179 SYSTEMATIC LITERATURE REVIEW ON THE SCREENING AND PROPHYLAXIS OF CHRONIC AND OPPORTUNISTIC INFECTIONS

Background

Opportunistic and chronic infections can arise in the context of treatment used for Autoimmune Rheumatic Diseases (ARDs). Although it is recognized that screening procedures and prophylactic measures must be followed, clinical practice is largely heterogeneous, with relevant recommendations not currently developed or disparately located across the literature.

Objectives

To conduct a systematic literature review (SLR) focusing on the screening and prophylaxis of opportunistic and chronic infections in ARDs. This is preparatory work done by members of the respective EULAR task force (TF).

Methods

Following the EULAR standardised operating procedures, we conducted an SLR with the following 5 search domains; 1) Infection: infectious agents identifed by a scoping review and expert opinion (TF members), 2) Rheumatic Diseases: all ARDs, 3) Immunosuppression: all immunosuppressives/immunomodulators used in rheumatology, 4) Screening: general and specific (e.g mantoux test) terms, 5) Prophylaxis: general and specific (e.g trimethoprim) terms. Articles were retrieved having the terms from domains 1 AND 2 AND 3, plus terms from domains 4 OR 5. Databases searched: Pubmed, Embase, Cochrane. Exclusion criteria: post-operative infections, pediatric ARDs, not ARDs (e.g septic arthritis), not concerning screening or prophylaxis, Covid-19 studies, articles concerning vaccinations and non-Εnglish literature. Quality of studies included was assessed as follows: Newcastle Ottawa scale for non-randomized controlled trials (RCTs), RoB-Cochrane tool for RCTs, AMSTAR2 for SLRs.

Results

5641 studies were initially retrieved (Figure 1). After title and abstract screening and removal of duplicates, 568 full-text articles were assessed for eligibility. Finally, 293 articles were included in the SLR. Most studies were of medium quality. Reasons for exclusion are shown in Figure 1. Results categorized as per type of microbe, are as follows: For Tuberculosis; evidence suggests that tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic DMARDs (csDMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. Conversion of TST/IGRA occurs in about 10-15% of patients treated with biologic DMARDs (bDMARDs). Various prophylactic schemes have been used for latent TB, including isoniazide for 9 months, rifampicin for 4 months, isoniazide/rifampicin for 3-4 months. For hepatitis B (HBV): there is evidence that risk of reactivation is increased in patients positive for hepatitis B surface antigen. These patients should be referred for HBV treatment. Patients who are positive for anti-HBcore antibodies, are at low risk for reactivation when treated with glucocorticoids, cDMARDs and bDMARDs but should be monitored periodically with liver function tests and HBV-viral load. Patients treated with rituximab display higher risk for HBV reactivation especially when anti-HBs titers are low. Risk for reactivation in hepatitis C RNA positive patients, treated with bDMARDs is low. However, all patients should be referred for antiviral treatment and monitored periodically. For pneumocystis jirovecii: prophylaxis with trimethoprim/sulfamethoxazole (alternatively with atovaquone or pentamidine) should be considered in patients treated with prednisolone: 15-30mg/day for more than 4 weeks. Few data exist for screening and prophylaxis from viruses like EBV, CMV and Varicella Zoster Virus. Expert opinion supports the screening of rare bugs like histoplasma and trypanosoma in patients considered to be at high risk (e.g living in endemic areas).

Figure 1.

SLR flowchart

Conclusion

The risk of chronic and opportunistic infections should be considered in all patients prior to treatment with immunosuppressives/immunomodulators. Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics. Collaboration between different disciplines is important.

Acknowledgements

We would like to thank all members of the EULAR Task Force for the screening and prophylaxis of chronic and opportunistic infections in Autoimmune Rheumatic Diseases.

Disclosure of Interests

None declared

POS1461 GIANT CELL ARTERITIS-RELATED STROKE IN A MAN WITH ELDERLY-ONSET RHEUMATOID ARTHRITIS

Background

Giant cell arteritis-related stroke is rare, with high early mortality and major morbidity in survivors.

Objectives

To increase the awareness of coexistence of giant cell arteritis-related stroke and rheumatoid arthritis.

Methods

A case report and discussion.

Results

A 73 year-old man with seronegative elderly-onset rheumatoid arthritis (EORA) presented to the emergency department (ED) with a one week history of frontal headache, vomiting and dizziness. He had multiple cardiovascular comorbidities and took multiple medications, including methotrexate and sulfasalazine. He also had long-standing history of thrombocytopenia without requiring any treatment. Neurological examination performed in the ED was unremarkable. His C-reactive protein (CRP) was 69mg/L and erythrocyte sedimentation rate (ESR) 82mm/hour. Computed tomography (CT) of the brain was normal. The headache settled with analgesia. A diagnosis of probable tension-type headache, with underlying active EORA, was made.

One month later, he presented to an ophthalmologist with recurrence of headache associated with visual disturbance and was diagnosed with giant cell arteritis (GCA). Both CRP (77mg/L) and ESR (85mm/hour) remained raised. Neither temporal artery biopsy nor temporal artery ultrasound were possible due to the coronavirus disease 2019 (COVID-19) pandemic. The headache and visual symptoms resolved completely a week after prednisolone 60mg daily was prescribed. In parallel, the CRP dropped to 2mg/L and ESR 16mm/hour. The patient’s glucocorticoid dose was then tapered. While on prednisolone 20mg daily, about 3 weeks later, he developed slurred speech and generalized weakness. Examination showed cerebellar signs and MRI brain showed acute cerebellar infarct. He was treated pragmatically as an atherosclerotic stroke with clopidogrel, and the steroid was rapidly tapered in view of absence of headache and normalization of inflammatory markers.

Four weeks later, he was noted to have persistent confusion and unsteadiness of gait. CRP was elevated at 92mg/L. An urgent positron emission tomography-CT (PET-CT) scan showed inflammation in the vertebral arteries [Figure 1] and cerebellar stroke. Prednisolone 40mg daily was restarted which led to a rapid improvement in his symptoms and normalization of inflammatory markers. The glucocorticoids were tapered in a slower manner this time.

Figure 1.

Fused axial image of a PET-CT scan demonstrating increased uptake in the region of the left vertebral artery within the vertebral foramen.

A diagnosis of GCA-related cerebellar stroke with vertebral vasculitis was made and, with glucocorticoids, the patient made a good clinical recovery. His inflammatory joints pain also improved in parallel.

Conclusion

Stroke or transient ischemic stroke are rare complications, reported in 2.8-16% of patients with active GCA. Most studies report strokes as occurring between the onset of GCA symptoms and 4 weeks after commencement of glucocorticoids1-3.

Vertebrobasilar territory is involved in 60–88% of cases of GCA-related stroke1-3. In contrast, the vertebrobasilar territory is affected only in 15-20% of atherosclerotic strokes1,2. One study reported fatal outcomes in 11 out of 40 patients (28%) with GCA-related stroke, 7 within 2-13 days of stroke2.

To conclude, this case demonstrates that high-dose glucocorticoids with slower tapering were able to control GCA-related stroke due to vertebral vasculitis in patient with EORA on background methotrexate and sulfasalazine.

References

[1]Gonzalez-Gay MA, Vazquez-Rodriguez TR, Gomez-Acebo I, et al. Strokes at time of disease diagnosis in a series of 287 patients with biopsy-proven giant cell arteritis. Medicine. 2009;88(4):227-35.

[2]de Boysson H, Liozon E, Larivière D, et al. Giant cell arteritis–related stroke: a retrospective multicenter case-control study. 2017;44(3):297-303.

[3]Pariente A, Guédon A, Alamowitch S, et al. Ischemic stroke in giant-cell arteritis: French retrospective study. 2019;99:48.

Acknowledgements

We would like to thank Dr Lenetta Boyce for providing the PET-CT images.

Disclosure of Interests

None declared

Comparing a mindfulness- and CBT-based guided self-help Internet- and mobile-based intervention against a waiting list control condition as treatment for adults with frequent cannabis use: a randomized controlled trial of CANreduce 3.0

BACKGROUND

Though Internet- and mobile-based interventions (IMIs) and mindfulness-based interventions (generally delivered in-situ) appear effective for people with substance use disorders, IMIs incorporating mindfulness are largely missing, including those targeting frequent cannabis use.

METHODS

This paper details the protocol for a three-arm randomized controlled trial comparing a mindfulness-based self-help IMI (arm 1) and cognitive-behavioral therapy (CBT)-based self-help IMI (arm 2) versus being on a waiting list (arm 3) in their effectiveness reducing cannabis use in frequent cannabis users. Predictors of retention, adherence and treatment outcomes will be identified and similarities between the two active intervention arms explored. Both active interventions last six weeks and consist of eight modules designed to reduce cannabis use and common mental health symptoms. With a targeted sample size of n = 210 per treatment arm, data will be collected at baseline immediately before program use is initiated; at six weeks, immediately after program completion; and at three and six months post baseline assessment to assess the retention of any gains achieved during treatment. The primary outcome will be number of days of cannabis use over the preceding 30 days. Secondary outcomes will include further measures of cannabis use and use of other substances, changes in mental health symptoms and mindfulness, client satisfaction, intervention retention and adherence, and adverse effects. Data analysis will follow ITT principles and primarily employ (generalized) linear mixed models.

DISCUSSION

This RCT will provide important insights into the effectiveness of an IMI integrating mindfulness to reduce cannabis use in frequent cannabis users.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number Registry: ISRCTN14971662 ; date of registration: 09/09/2021.

Brain metastases: An update on the multi-disciplinary approach of clinical management

IMPORTANCE

Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1.

OBSERVATIONS

The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life.

CONCLUSION

With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).

Stakeholders' views on online interventions to prevent common mental health disorders in adults implemented into existing healthcare systems in Europe

BACKGROUND

Online preventive interventions can help to reduce the incidence of mental disorders. Whereas knowledge on stakeholders' attitudes and factors relevant for successfully integrating online treatment into existing healthcare systems is available, knowledge is scarce for online prevention.

METHODS

Stakeholders from Germany, Switzerland, Austria and Spain were surveyed. Potential facilitators/delivery staff (e.g. psychologists, psychotherapists) completed an online questionnaire (n = 183), policy makers (i.e. from the governing sector or health insurance providers) participated in semi-structured interviews (n = 16) and target groups/potential users of mental illness prevention (n = 49) participated in ten focus groups. Thematic analysis was used to identify their experiences with and attitudes and needs regarding online programmes to prevent mental disorders. Additionally, it was examined which groups they consider underserved and which factors they consider as fostering and hindering for reach, adoption, implementation and maintenance (cf. RE-AIM model) when integrating online prevention into existing healthcare systems.

RESULTS

Main advantages of online mental illness prevention are perceived in low structural and psychological barriers. Lack of personal contact, security, privacy and trust concerns were discussed as disadvantages. Relevant needs are high usability and target group appropriateness, evidence for effectiveness and the use of motivational tools.

CONCLUSIONS

Positive attitudes among stakeholders are the key for successful integration of online mental illness prevention into existing healthcare systems. Potential facilitators/delivery staff must receive training and support to implement these programmes; the programmes must be attractive and continuously evaluated, updated and promoted to ensure ongoing reach; and existing infrastructure and contextual factors must be considered.

Online prevention programmes for university students: stakeholder perspectives from six European countries

Background

Students beginning university are at a heightened risk for developing mental health disorders. Online prevention and early intervention programmes targeting mental health have the potential to reduce this risk, however, previous research has shown uptake to be rather poor. Understanding university stakeholders’ (e.g. governing level and delivery staff [DS] and students) views and attitudes towards such online prevention programmes could help with their development, implementation and dissemination within university settings.

Methods

Semi-structured interviews, focus groups and online surveys were completed with staff at a governing level, university students and DS (i.e. student health or teaching staff) from six European countries. They were asked about their experiences with, and needs and attitudes towards, online prevention programmes, as well as the factors that influence the translation of these programmes into real-world settings. Results were analyzed using thematic analysis.

Results

Participating stakeholders knew little about online prevention programmes for university settings; however, they viewed them as acceptable. The main themes to emerge were the basic conditions and content of the programmes, the awareness and engagement, the resources needed, the usability and the responsibility and ongoing efforts to increase reach.

Conclusions

Overall, although these stakeholders had little knowledge about online prevention programmes, they were open to the idea of introducing them. They could see the potential benefits that these programmes might bring to a university setting as a whole and the individual students and staff members.

AB0649 INFECTION PROFILE OF IMMUNE-MODULATORY DRUGS USED IN AUTOIMMUNE DISEASES: ANALYSIS OF SUMMARY OF PRODUCT CHARACTERISTIC DATA

Background:

The number of immune-modulatory drugs used to treat immune-mediated inflammatory diseases (IMIDs) has exponentially increased in recent decades. While effective in controlling disease, serious infection remains a concern.

Accurate information on immune-modulatory drugs, including infections, is required to guide prescribing decisions. The “summary of product characteristics” (SmPC) by the European Medicines Agency (EMA) provides a useful repository of information on adverse events e.g. infections, from clinical trials and post-marketing pharmacovigilance (1).

To date, no comparison has been undertaken on reported infection frequencies across SmPCs for immune-modulators.

Objectives:

To compare infection frequency, site and type across the most commonly-prescribed immune-modulatory drugs used to treat IMIDs, using information provided by SmPCs.

Methods:

A drug was included if licensed in Europe for treatment of one of the following: rheumatoid arthritis, axial spondyloarthritis, connective tissue disease, autoimmune vasculitis, autoinflammatory syndromes, inflammatory bowel disease (Crohn’s and ulcerative colitis), psoriasis, multiple sclerosis and other rarer conditions.

The Electronic Medicines Compendium (EMC) was searched for commonly prescribed immune-modulatory drugs used for the above indications. SmPC documents were manually searched for information on infection frequency, extracted from sections 4.4 and 4.8. Infection frequency was recorded as per convention in the SmPC: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000) (1), for each drug. Information was further extracted on infection site (e.g. respiratory, skin etc), type (e.g. bacterial, viral etc) and individual pathogenic organisms.

25% of included SmPCs were screened and extracted by a second reviewer. Disagreements were resolved with input from a third reviewer.

Results:

In total, 39 drugs were included, used across 20 indications: nine conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), six targeted synthetic DMARDs (tsDMARDs; four Janus kinase [JAK] inhibitors, two sphingosine 1-phosphate receptor modulators) and 24 biologic DMARDs (17 cytokine-targeted; seven cell-targeted).

Twelve sites of infection were recorded. Minimal or no site information was available for most csDMARDs and siponimod, certolizumab pegol and rituximab. The most common sites of infection are listed by drug group in Figure 1. Upper respiratory tract was the most common site, especially with bDMARDs. Lower respiratory, ear/nose/throat (including sinusitis) and urinary tract infections were moderately common, with clustering within drug groups. No drugs reported risk of cardiac infections; the eye, musculoskeletal, neurological, oral and reproductive sites were the least commonly-reported sites of infection.

Infection data for 27 distinct pathogens were recorded, the majority viruses, especially with bDMARD use. Herpes simplex and zoster were the most frequently listed (mainly with bDMARDs and tsDMARDs), followed by influenza. Common non-viral causes of infection were candida and tinea species.

Variable or absent reporting was noted for opportunistic infections (e.g. tuberculosis and fungi) and certain high-prevalence viruses e.g. Epstein-Barr.

Conclusion:

The SmPC literature reports differences in infection risk, by site and pathogen, between immune-modulatory drugs. The findings can be used to visualise differences and aid treatment decisions. However, some of the patterns we have shown lack face-validity to clinicians familiar with real-world safety data. The data fail to capture risk of rare infections, are likely skewed by trial selection criteria, varying number of trials per drug and quirks of individual study-reporting methodologies.

The findings highlight the need for robust post-marketing pharmacovigilance studies.

References:

[1]A Guideline on Summary of Product Characteristics Module 1.3. 2008.

Disclosure of Interests:

None declared.

Stigmatizing attitudes of Swiss youth towards peers with mental disorders

Background

Previous research on public stigma towards people with mental disorders has mostly targeted adult samples and focused on depression, schizophrenia or mental disorders in general. Hence, the present study aimed to investigate predictors of stigmatizing attitudes towards different mental disorders (including less researched ones) in a representative sample of adolescents and young adults.

Methods

Data from the Swiss Youth Mental Health Literacy and Stigma Survey were used (analytical sample: n = 4,932). Each participant was randomly presented with one of five vignettes (depression; alcohol abuse; depression and alcohol abuse combined; schizophrenia; social anxiety). The structure of stigmatizing attitudes was assessed using confirmatory factor analysis. Regression models, implemented within a structural equation framework, were used to study predictors for the identified latent variables.

Results

A three-factor model for stigmatizing attitudes–consisting of ‘dangerous/unpredictable’, ‘weak-no-sick’, and ‘social distance’ factors–best fitted the data. Female gender was associated with less stigmatizing attitudes. Associations in opposite directions with different latent factors were found for educational and migration background. Exposure to mental disorders (being personally affected, personally having received professional help or knowing someone close who has received treatment for a mental disorder) was either not or was negatively associated with stigmatizing attitudes. In contrast, current mental health symptoms (heightened levels of psychological distress, problematic alcohol use) were generally not or were positively associated with stigmatizing attitudes. Even though the included predictors had some predictive value, the variance explained by the models was rather small (the adjusted R² varied between 0.03 and 0.26).

Conclusions

The current study indicates that contact with someone who has received treatment for a mental disorder might be an important component of programs aiming to decrease stigmatizing attitudes towards people with mental disorders, since this exposure variable predicted lower levels of stigmatizing attitudes. Furthermore, the findings suggest that target-group interventions for specific subgroups need to be considered, as the process leading to stigmatizing attitudes towards people with mental disorders appears to differ between specific sociodemographic subgroups.

OP0294 DIFFERENTIAL INFLUENCE OF CO-MORBIDITIES ON SITE OF FRAGILITY FRACTURES

Background:

Fragility fractures (FF) can occur at various sites of the skeleton, and are associated with multiple risk factors [1]. The prevalence of FF markedly increases with age. As the longevity of the population increases, so will the incidence of FF, and that of associated co-morbidities and risk factors. There are few data on co-morbidities associated with fractures at each site.

Objectives:

Identify associations of co-morbidities with sites of FF, by applying cluster analysis.

Methods:

We reviewed 28868 patients presenting for BMD estimation at a district general hospital in North West England, 2004-2016. We identified patients who had sustained one or more FF at time of presentation. Site(s) of FF were recorded for each patient, including femur, forearm, humerus, pelvis, ribs, spine, tibia or fibula. The following co-morbidities or treatments were recorded: excess alcohol consumption (previous or current); bisphosphonates; coeliac disease; family history of FF; hormone replacement therapy; hyperparathyroidism; hyperthyroidism; inflammatory bowel disease; polymyalgia rheumatica; rheumatoid arthritis; smoking (previous or current); corticosteroids (previous or current). Cluster analysis was performed on fracture sites and co-morbidities, using Jaccard similarity coefficient, and plotted on a dendrogram. Results were divided into an optimal number of clusters, derived using the elbow and silhouette methods.

Results:

11003 of 28868 patients had sustained one or more FF at time of BMD estimation. Overall, 84.6% patients were female, mean age 67.5years, and median T-score -1.12 SD. Cluster analysis was performed for FF sites and co-morbidities, with Jaccard similarity coefficients calculated. 4 clusters were identified (Figure 1): FF of forearm (n=5054), tibia/fibula (n=2617), spine (n=2352), associated with family history of FF, smoking, corticosteroids, and bisphosphonate treatment; FF of pelvis (n=300) associated with hyperparathyroidism, PMR, coeliac disease, and HRT; FF of femur (n=1181) and humerus (n=1131) associated with IBD and RA; FF of ribs (n=1022) associated with alcohol and hyperthyroidism.

Conclusion:

Cluster analysis demonstrated 4 distinct subgroups of FF sites and associated co-morbidities. To our knowledge, this is the first study applying cluster analysis to evaluate co-morbidities associated with FF sites. Risk factors may influence trabecular more than cortical bone, accounting for the difference in clusters. Knowledge of risk factors associated with FF site subgroups will aid prophylaxis and management in at-risk patients.

References:

[1]Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet (London, England). 2002 Jun 1;359(9321):1929–36

Disclosure of Interests:

Mrinalini Dey: None declared, Marwan Bukhari Speakers bureau: Bristol-Myers Squib, UCB celltech, Roche/Chugai, Pfizer, Abbvie, Merck, Mennarini, Sanofi-aventis, Eli-Lilly, Janssen, Amgen and Novartis.

OP0324 CLUSTERING OF FRAGILITY FRACTURES BY SITE IN PATIENTS REFERRED FOR BONE MINERAL DENSITY ESTIMATION: AN OBSERVATIONAL STUDY

Background:

Fragility fractures (FF) are those resulting from mechanical forces equivalent to a fall from standing height or less [1]. They most commonly occur in the spine (vertebrae), forearm, and femur, but also occur at other sites. Prevalence markedly increases with age, due to age-related and menopause-related bone loss. FF cause substantial pain and disability, and are associated with decreased life expectancy. While many studies have investigated risk factors associated with FF, there are few data on the association between FF sites in at-risk patients.

Objectives:

1. Establish the most common sites of FF in patients presenting for bone mineral density (BMD) estimation.

2. Identify patterns of co-existing FF in the above cohort by applying cluster analysis.

Methods:

We retrospectively reviewed the clinical records of 28868 patients presenting for BMD estimation at a district general hospital in North West England, 2004-2016, identifying those who had sustained one or more FF. Site(s) of FF were recorded for each patient, categorised as: ankle, elbow, femur, forearm, humerus, pelvis, ribs, spine, tibia or fibula (recorded as “tibfib”). Cluster analysis was performed on fracture sites, using Jaccard similarity coefficient. Results were plotted on a dendrogram and divided into clusters, as per results derived from elbow and silhouette cluster methods.

Results:

Out of 28868 patients presenting for BMD estimation, 11003 were identified as having sustained one or more FF. 84.6% patients were female, with overall mean age 67.5years and median T-score -1.12 SD. The most common site of FF was the forearm (n=5045), most commonly co-existing with fractures of the tibia or fibula. Frequencies of the most common and co-existing FF sites are shown in Figure 1 (top). Cluster analysis identified 3 clusters: ankle and elbow; forearm, tibia/fibula, ribs, and spine; pelvis, femur, and humerus. The second half of Figure 1 displays the dendrogram of cluster analysis results, with Jaccard similarity measure.

Conclusion:

We applied cluster analysis to a large cohort of patients presenting for BMD estimation. Our results are in keeping with previous studies demonstrating the FF to most commonly occur in the forearm, and in those with osteopenia (T-score -2.5 < -1 SD) [2]. To our knowledge, this is the first study to apply cluster analysis to sites of FF. Results may be due to differences in cortical and trabecular bone structure, and have potential to aid prevention, monitoring, and management in at-risk patients.

References:

[1]National Institute for Health and Care Excellence (NICE). Osteoporosis: assessing the risk of fragility fracture - Clinical Guideline (CG146). 2012;(August):1–14.

[2]Siris ES et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med. 2004 May 24;164(10):1108–12.

Disclosure of Interests:

Mrinalini Dey: None declared, Marwan Bukhari Speakers bureau: Bristol-Myers Squib, UCB celltech, Roche/Chugai, Pfizer, Abbvie, Merck, Mennarini, Sanofi-aventis, Eli-Lilly, Janssen, Amgen and Novartis.

AB0940 BIOMARKERS IN THE DIAGNOSIS OF ACUTE HOT JOINTS: AN EVALUATION OF RESEARCH INTEREST 1960-2018

Background:

The acute hot joint presentation is a common clinical emergency, often the result of crystal arthritis or trauma. However, all diagnoses can mimic septic arthritis, which should be excluded promptly due to the potential for rapid joint destruction and significant morbidity. The gold-standard test for septic arthritis is synovial fluid culture, which can take several days to perform. Meanwhile, patients are often admitted and given antimicrobials. Other specialties have made use of rapid biomarkers to exclude infection, for example, exclusion of empyema using pleural fluid pH and glucose [1]. Such biomarkers could reduce the need for lengthy hospital admissions and inappropriate antibiotic use in the acute hot joint presentation.

Objectives:

1.Evaluate research interest over time, on the use of diagnostic biomarkers in the acute hot joint presentation.

2.Compare research interest in the use of diagnostic biomarkers in acute hot native versus acute hot prosthetic joints.

Methods:

We performed a review of the number of publications reporting the use and diagnostic accuracy of biomarkers to exclude infection in the acute hot joint presentations. The database,Scopus, was searched for English-language studies (1946-2018) using search terms relating to septic arthritis, crystal arthritis, and diagnostic markers derived from synovial fluid/aspirate. The number of papers published per year on prosthetic joints only was also calculated. Therefore, the following were recorded for each year 1946-2018: total number of studies; prosthetic joints only; native joints only. Values were plotted, with polynomial trend-lines and R2calculated.

Results:

Our search yielded 2279 relevant studies in total (561 on prosthetic joints), published 1946-2018. Only 1 study was identified for the year 1946; the next recorded publication was in 1960. Therefore, this single study was excluded as an outlier. Results are presented in Figure 1. The number of studies on diagnostic biomarkers for acute hot joints continued to increase after 1960. From 2016, the number of studies conducted in prosthetic joints outnumbered those done in native joints. Polynomial trend-lines applied to the results showed studies on native acute hot joints are predicted to decline, while those in prosthetic joints will continue to increase.

Conclusion:

Reasons for an increasing number of studies on prosthetic compared to native acute hot joints include a narrower differential diagnosis in prosthetic joints, i.e. septic vs aseptic. In contrast, native acute hot joints may be the result of various causes including crystal arthritis, inflammatory arthritis, and trauma. Having a narrower differential diagnosis may facilitate diagnostic research in prosthetic joint presentations. Furthermore, incidence of prosthetic joint infection is also greater than that of native joint infection [2]. Nonetheless, the incidence of native joint infection is increasing [3]. This, and the lack of methods by which to rapidly distinguish native joint septic arthritis from non-infective causes, indicates that more research is required in this area.

References:

[1]Heffner JE et al. Pleural fluid chemical analysis in parapneumonic effusions. A meta-analysis. Am J Respir Crit Care Med. 1995 Jun;151(6):1700–8.

[2]Roerdink RL et al. The difference between native septic arthritis and prosthetic joint infections: A review of literature. J Orthop Surg (Hong Kong).

[3]Rutherford AI et al. A population study of the reported incidence of native joint septic arthritis in the United Kingdom between 1998 and 2013. Rheumatol (United Kingdom). 2016;55(12):2176–80.

Disclosure of Interests:

None declared

Psychiatric disorders, suicidality, and personality among young men by sexual orientation

Personality and its potential role in mediating risk of psychiatric disorders and suicidality are assessed by sexual orientation, using data collected among young Swiss men (n = 5875) recruited while presenting for mandatory military conscription. Mental health outcomes were analyzed by sexual attraction using logistic regression, controlling for five-factor model personality traits and socio-demographics. Homo/bisexual men demonstrated the highest scores for neuroticism-anxiety but the lowest for sociability and sensation seeking, with no differences for aggression-hostility. Among homo/bisexual men, 10.2% fulfilled diagnostic criteria for major depression in the past 2 weeks, 10.8% for ADHD in the past 12 months, 13.8% for lifetime anti-social personality disorder (ASPD), and 6.0% attempted suicide in the past 12 months. Upon adjusting (AOR) for personality traits, their odds ratios (OR) for major depression (OR = 4.78, 95% CI 2.81–8.14; AOR = 1.46, 95% CI 0.80–2.65) and ADHD (OR = 2.17, 95% CI = 1.31–3.58; AOR = 1.00, 95% CI 0.58–1.75) lost statistical significance, and the odds ratio for suicide attempt was halved (OR = 5.10, 95% CI 2.57–10.1; AOR = 2.42, 95% CI 1.16–5.02). There are noteworthy differences in personality traits by sexual orientation, and much of the increased mental morbidity appears to be accounted for by such underlying differences, with important implications for etiology and treatment.

Quality of life of parents of mentally-ill children: a systematic review and meta-analysis

AIMS

To examine the quality of life (QOL) of parents of children with a specific mental disorder (any age).

METHODS

Relevant articles were searched using different databases. Articles were included that compared the QOL of parents with mentally-ill children to parents of healthy controls or norm values or provided the required data for this comparison. A meta-analysis was conducted to obtain an overall mean effect size estimate. Additional analyses were performed to assess publication bias and moderation.

RESULTS

Twenty-six out of 10 548 articles met the pre-defined inclusion criteria. Most of these studies focused on attention-deficit/hyperactivity disorder or autism spectrum disorder, used clinical samples that mainly included males and young children and studied the QOL of mothers. The meta-analysis revealed that parents of mentally-ill children are experiencing a clinically relevant reduction in their QOL relative to parents of healthy children and norm values (g = -0.66).

CONCLUSIONS

The compromised QOL of parents of mentally-ill children needs to be considered and addressed by health professionals who are in contact with them. The paper provides insights into existing research gaps and suggests improvements for subsequent work.

Problematic smartphone use in young Swiss men: Its association with problematic substance use and risk factors derived from the pathway model

BACKGROUND AND AIMS

This study aimed to examine associations between risk factors suggested in the pathway model proposed by Billieux et al., demographic and substance use variables, and problematic smartphone use (PSU).

METHODS

The analytical sample consisted of 5,096 Swiss men (mean age = 25.5 years, SD = 1.26). Multiple linear regression analyses were conducted with PSU as dependent and the following as independent variables: (a) Billieux's pathway model variables (depression, social anxiety, ADHD, aggression-hostility, and sensation seeking); (b) substance use variables [alcohol: at-risk risky single-occasion drinking (RSOD); at-risk volume drinking; tobacco use: daily smoking; illicit drug use: more than weekly cannabis use; having used at least one other illicit drug besides cannabis over the preceding 12 months]; and (c) sociodemographic variables (age, language region, and education).

RESULTS

All pathway-model variables except sensation seeking were significant predictors of PSU, especially symptoms of social anxiety (β = 0.196) and ADHD (β = 0.184). At-risk RSOD was positively (β = 0.071) associated with PSU, whereas both frequent cannabis use (β = -0.060) and daily cigarette smoking (β = -0.035) were negatively associated with PSU. Higher-achieved educational levels and being from the German-speaking part of Switzerland predicted PSU.

DISCUSSION AND CONCLUSIONS

The findings of this study can be used to develop tailored interventional programs that address the co-occurrence of certain risky behaviors (e.g., at-risk RSOD and PSU) and target individuals who might be particularly prone to PSU. Such interventions would need to ensure that addressing one problem (e.g., decreasing PSU) does not lead to some other compensatory behavior (e.g., frequent cigarette smoking).

Efficacy and cost-effectiveness of guided and unguided internet- and mobile-based indicated transdiagnostic prevention of depression and anxiety (ICare Prevent): A three-armed randomized controlled trial in four European countries

BACKGROUND

Depression and anxiety are highly prevalent and often co-occur. Several studies indicate the potential of disorder-specific psychological interventions for the prevention of each of these disorders. To treat comorbidity, transdiagnostic treatment concepts seem to be a promising approach, however, evidence for transdiagnostic concepts of prevention remains inconclusive. Internet- and mobile-based interventions (IMIs) may be an effective means to deliver psychological interventions on a large scale for the prevention of common mental disorders (CMDs) such as depression and anxiety. IMIs have been shown to be effective in treating CMDs, e.g. in reducing symptoms of depression and anxiety. However, there is a lack of studies examining the efficacy of interventions reducing the incidence of CMDs. Moreover, the comparative cost-effectiveness of guided versus unguided IMIs for the prevention of depression and anxiety has not been studied yet. Hence, this study aims at investigating the (cost-) effectiveness of guided and unguided internet- and mobile-based transdiagnostic individually tailored indicated prevention of depression and anxiety.

METHODS

A multi-country three-armed randomized controlled trial will be conducted to compare a guided and unguided intervention to treatment as usual (TAU). Both active conditions are based on the same intervention, ICare Prevent, and differ only with regard to guidance format. Altogether, 954 individuals with subclinical symptoms of depression (CES-D ≥ 16) and anxiety (GAD-7 ≥ 5) who do not have a full-blown disorder will be recruited in Germany, Switzerland, Spain and the Netherlands, and randomized to one of three conditions (guided intervention, unguided intervention, or TAU). The TAU arm will receive access to the training after a 12-month waiting period. The primary outcome will be time to CMD onset (any depression/anxiety disorder) within a follow-up period of 12 months after baseline. Secondary outcomes will include disorder-specific symptom severity (depression/anxiety) assessed by diagnostic raters blinded to intervention condition at post-intervention, self-reports, acceptability, health related quality of life, and psychosocial variables associated with developing a CMD. Assessments will take place at baseline, mid-intervention (5 weeks into the intervention), post-intervention (8 weeks after randomization) and follow-up (6 and 12 months after randomization). Data will be analyzed on an intention-to-treat basis and per protocol. Cost-effectiveness will be evaluated from a public health and a societal perspective, including both direct and indirect costs.

DISCUSSION

The present study will further enhance the evidence-base for transdiagnostic preventive interventions and provide valuable information about optimal trade-off between treatment outcome and costs.

TRIAL REGISTRATION

German Clinical Trial Registration (DRKS - http://www.drks.de/drks_web/): DRKS00011099.

One size does not fit all-evolution of opioid agonist treatments in a naturalistic setting over 23 years

BACKGROUND AND AIMS

Opioid agonist treatment (OAT) is currently the most effective treatment for people with opioid dependence. In most countries, however, access to the whole range of effective medications is restricted. This study aims to model the distribution of different OAT medications within a naturalistic and relatively unrestricted treatment setting (Zurich, Switzerland) over time, and to identify patient characteristics associated with each medication.

METHODS

We used generalized estimating equation analysis with data from the OAT register of Zurich and the Swiss register for heroin-assisted treatment (HAT) to model and forecast the annual proportion of opioids applying exponential distributions until 2018 and patient characteristics between 1992 and 2015.

RESULTS

Data from 11 895 patients were included in the analysis. Methadone remains the mainstay of OAT, being prescribed to two-thirds of patients. Following its approval, the proportion of HAT increased rapidly and is now constant at 12.16% [95% confidence interval (CI) = 11.15-13.17]. The initial increase of proportions of buprenorphine or slow-release oral morphine (SROM) following their approval for OAT was slower. While in 2014 both medications had a proportion of 10.2% and 10.3%, respectively, our model predicts a further increase of SROM to 19.9% in 2018, with a ceiling level of 25.19% (21.40-28.98%) thereafter. SROM patients display characteristics similar to those treated with methadone; buprenorphine patients show the highest social integration; and HAT patients are the most homogeneous group, with highest mean age, most widespread injecting experience and lowest social integration.

CONCLUSIONS

Based on data from Zurich, Switzerland from 1992 to 2015, there is no evidence for an excessive demand for a single medication in a naturalistic and liberal opioid agonist treatment setting. Rather, the specific patient characteristics associated with each medication underline the need for diversified treatment options for opioid dependence.

Predictors of fracture risk in patients with systemic lupus erythematosus

Objectives Bone loss in systemic lupus erythematosus is multifactorial. Recent studies demonstrate corticosteroids, previous fractures and increasing age decrease bone mineral density. The effect of body mass index and fat mass are less well characterized. We sought to determine fracture risk factors in patients undergoing dual-energy X-ray absorptiometry scanning at a district hospital in 2004-2015. Methods Standard dual-energy X-ray absorptiometry parameters were recorded, plus rheumatoid arthritis diagnosis, smoking status, alcohol consumption, family history of fractures, history of secondary operation and corticosteroid use. Data were analyzed using Fisher's exact test for categorical data and logistic regression for continuous data. Results One hundred and fifty patients (141 women, nine men) with SLE were included; 52 (34.6%) had sustained at least one fracture. Fracture risk increased with increased age, body mass index, fat mass and average tissue thickness, and decreased lean mass (adjusted for steroid use), as well as with smoking and rheumatoid arthritis. Increased femoral and vertebral bone mineral density conversely decreased fracture risk. Conclusion Our study suggests increased age, body mass index, fat mass, smoking and/or rheumatoid arthritis increase fracture risk in SLE patients. To our knowledge, this is the first demonstration of a correlation between increased fat mass, adjusted for steroid use and fracture risk, in adults, potentially indicating a differential effect of fat on bone metabolism and lessening of lean body mass.

Postrenal transplant metastatic colonic neoplasm: Posttransplant lymphoproliferative disorder or adenocarcinoma?

Transplant recipients are vulnerable to a horde of infections and neoplastic conditions due to immunosuppression. Posttransplant lymphoproliferative disorder (PTLD) is a condition unique to the transplant recipient occurring due to monoclonal lymphocytic proliferation. It may affect any organ system with reportedly highest incidence in the gastrointestinal tract. The incidence of adenocarcinoma of the colon, however, has not been shown to be uniformly higher in transplant recipients. We report here an unusual case of adenocarcinoma of the ascending colon presenting with liver, lymph node and skin metastasis in a transplant recipient, which simulated PTLD both clinically and radiologically. For any gastrointestinal lesion in transplant recipient, the possibility of carcinoma must be considered. However, a high index of suspicion for PTLD facilitates early diagnosis since the treatment of the two conditions is starkly different.

Efficacy of a web- and text messaging-based intervention to reduce problem drinking in adolescents: Results of a cluster-randomized controlled trial

OBJECTIVE

To test the efficacy of a combined web- and text messaging-based intervention to reduce problem drinking in young people compared to assessment only.

METHOD

Two-arm, parallel-group, cluster-randomized controlled trial with assessments at baseline and 6-month follow up. The automated intervention included online feedback, based on the social norms approach, and individually tailored text messages addressing social norms, outcome expectations, motivation, self-efficacy, and planning processes, provided over 3 months. The main outcome criterion was the prevalence of risky single-occasion drinking (RSOD, defined as drinking at least 5 standard drinks on a single occasion in men and 4 in women) in the past 30 days. Irrespective of alcohol consumption, 1,355 students from 80 Swiss vocational and upper secondary school classes, all of whom owned a mobile phone, were invited to participate in the study. Of these, 1,041 (76.8%) students participated in the study.

RESULTS

Based on intention-to-treat analyses, RSOD prevalence decreased by 5.9% in the intervention group and increased by 2.6% in the control group, relative to that of baseline assessment (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.44-0.87). No significant group differences were observed for the following secondary outcomes: RSOD frequency, quantity of alcohol consumed, estimated peak blood alcohol concentration, and overestimation of peer drinking norms.

CONCLUSIONS

The intervention program reduced RSOD, which is a major indicator of problem drinking in young people, effectively. (PsycINFO Database Record

Efficacy of an internet-based self-help intervention to reduce co-occurring alcohol misuse and depression symptoms in adults: study protocol of a three-arm randomised controlled trial

INTRODUCTION

In the general population, alcohol use disorder and depression more often occur together than any other combination of a mental illness with a substance use disorder. It is important to have a cost-effective intervention that is able to reach at-risk individuals in the early stages of developing alcohol use disorders and depression disorders.

METHODS AND ANALYSIS

This paper presents the protocol for a 3-arm multicentre randomised controlled trial (RCT) to test the efficacy and cost-effectiveness of the combined internet-based self-help intervention Take Care of You (TCOY) to reduce alcohol misuse and depression symptoms in comparison with a waiting list control group and a comparable intervention focusing on problematic alcohol use only. The active interventions consist of modules designed to reduce alcohol use, based on the principles of motivational interviewing and methods of cognitive behavioural therapy, together with additional modules in the combined study arm to reduce symptoms of depression. Data will be collected at baseline, as well as at 3 and 6 months postrandomisation. The primary outcome is the quantity of alcohol used in the past 7 days. A number of secondary outcome measures will be studied. These include the Centre of Epidemiologic Studies of Depression Scale (CES-D) and a combined measure with the criteria of values below the cut-off for severe alcohol use disorder and for CES-D. Data analysis will follow the intention-to-treat principle using (generalised) linear mixed models. In order to investigate the interventions' cost-utility and cost-effectiveness, a full economic evaluation will be performed.

ETHICS AND DISSEMINATION

This RCT will be executed in compliance with the Helsinki Declaration and has been approved by 2 local Ethics Committees. Results will be reported at conferences and in peer-reviewed publications. Participant-friendly summaries of trial findings will be published on the TCOY websites.

TRIAL REGISTRATION NUMBER

ISRCTN10323951.

Young people's difficulty in talking to others about mental health problems: An analysis of time trends in Switzerland

The article aimed to analyse time trends regarding young people's willingness to talk about mental health problems. Data on 16,774 participants (16-20-year olds) of the 'Swiss Multicentre Adolescent Survey on Health' (SMASH) were analysed. The survey was conducted in 1992/93 and in 2002. Logistic regression analyses were conducted to identify predictors associated with the self-reported willingness of youth to talk about mental health problems with adults (other than parents), friends or no one. Socio-demographic characteristics were used as covariates. These analyses were first carried out for the total sample and, in a second step, stratified by suicidality of the participants. The percentage of participants who would talk about mental health problems with adults or friends increased between 1992/93 and 2002, while the percentage of those who would not talk about such problems decreased. This pattern was confirmed in the stratified analyses (i.e., for suicidal and non-suicidal individuals). Hence, Swiss youth seem to have less difficulty in talking with others about mental health problems than previous cohorts. This trend towards increased disclosure may have implications for claims that the prevalence of mental health problems has increased in recent decades.

The Swiss Cohort Study on Substance Use Risk Factors – Findings of two Waves

Abstract. Aim: To summarize published findings in peer-reviewed journals of the first two waves of the Swiss Cohort Study on Substance Use Risk Factors (C-SURF), a longitudinal study assessing risk and protective factors of 5,987 young men during the phase of emerging adulthood (20 years at baseline, followed-up 15 months later). Methods: Included were 33 studies published until November 2014 focusing on substance use. Results: Substance use in early adulthood is a prevalent and stable behavior. The 12-month prevalence of nonmedical use of prescription drugs (10.6 %) lies between that of cannabis (36.4 %) and other illicit drugs such as ecstasy (3.7 %) and cocaine (3.2 %). Although peer pressure in the form of misconduct is associated with increased substance use, other aspects such as peer involvement in social activities may have beneficial effects. Regular sport activities are associated with reduced substance use, with the exception of alcohol use. Young men are susceptible to structural conditions such as the price of alcohol beverages or the density of on-premise alcohol outlets. Particularly alcohol use in public settings such as bars, discos or in parks (compared with private settings such as the home) is associated with alcohol-related harm, including injuries or violence. Being a single parent versus nuclear family has no effect on alcohol use, but active parenting does. Besides parenting, religiousness is an important protective factor for both legal and illegal substance use. Merely informing young men about the risks of substance use may not be an effective preventive measure. At-risk users of licit and illicit substances are more health literate, e. g., for example, they seek out more information on the internet than non-at-risk-users or abstainers. Discussion: There are a number of risk and protective substance use factors, but their associations with substance use do not necessarily agree with those found outside Europe. In the United States, for example, heavy alcohol use in this age group commonly takes place in private settings, whereas in Switzerland it more often takes place in public settings. Other behaviors, such as the nonmedical use of prescription drugs, appear to be similar to those found overseas, which may show the need for targeted preventive actions. C-SURF findings point to the necessity of establishing European studies to identify factors for designing specific preventive actions.

Cross-sectional time trends in psychological and somatic health complaints among adolescents: a structural equation modelling analysis of 'Health Behaviour in School-aged Children' data from Switzerland

PURPOSE

This study examined cross-sectional time trends in health complaints among adolescents living in Switzerland, including differences between population subgroups and sources of differential response to items.

METHODS

Swiss data were analysed from the Health Behaviour in School-aged Children (HBSC; including 11-15 years old) from 1994 (n = 7008), 1998 (n = 8296), 2002 (n = 9066) and 2006 (n = 9255). Structural equation modelling was used to assess (1) the structure of the HBSC Symptom Checklist (HBSC-SCL; questionnaire, which asks about the frequency of eight health complaints) and (2) associations between the HBSC-SCL with year of data collection and demographic characteristics of the participants.

RESULTS

Two correlated factors fitted the data better than a single factor. The psychological factor included the items 'feeling low,' 'irritability and bad temper,' 'nervousness' and 'difficulties in getting to sleep,' and the somatic factor the items 'headache', 'backache', 'stomach ache' and 'dizziness'. Relative to 1994, lower levels of psychological health complaints were experienced in 1998, 2002 and 2006. However, the changes were only minor. In contrast, somatic health complaints increased monotonically over the years of the survey. Experiencing psychological and somatic health complaints was more pronounced with age among females relative to males and was associated with living in particular language regions of Switzerland.

CONCLUSIONS

Different cross-sectional time trends were identified for the psychological and somatic latent variables, indicating that both factors should be investigated when studying period effects.

DSM-IV and DSM-5 alcohol use disorder among young Swiss men

BACKGROUND AND AIMS

Previous studies suggest that the new DSM-5 criteria for alcohol use disorder (AUD) will increase the apparent prevalence of AUD. This study estimates the 12-month prevalence of AUD using both DSM-IV and DSM-5 criteria and compares the characteristics of men in a high risk sample who meet both, only one and neither sets of diagnostic criteria.

DESIGN, SETTING AND PARTICIPANTS

5943 Swiss men aged 18-25 years who participated in the Cohort Study on Substance Use Risk Factors (C-SURF), a population-based cohort study recruited from three of the six military recruitment centres in Switzerland (response rate = 79.2%).

MEASUREMENTS

DSM-IV and DSM-5 criteria, alcohol use patterns, and other substance use were assessed.

FINDINGS

Approximately 31.7% (30.5-32.8) of individuals met DSM-5 AUD criteria [21.2% mild (20.1-22.2); 10.5% moderate/severe (9.7-11.3)], which was less than the total rate when DSM-IV criteria for alcohol abuse (AA) and alcohol dependence (AD) were combined [36.8% overall (35.5-37.9); 26.6% AA (25.4-27.7); 10.2% AD (9.4-10.9)]. Of 2479 respondents meeting criteria for either diagnoses, 1585 (63.9%) met criteria for both. For those meeting DSM-IV criteria only (n = 598, 24.1%), hazardous use was most prevalent, whereas the criteria larger/longer use than intended and tolerance to alcohol were most prevalent for respondents meeting DSM-5 criteria only (n = 296, 11.9%). Two in five DSM-IV alcohol abuse cases and one-third of DSM-5 mild AUD individuals fulfilled the diagnostic criteria due to the hazardous use criterion. The addition of the craving and excluding of legal criterion, respectively, did not affect estimated AUD prevalence.

CONCLUSIONS

In a high-risk sample of young Swiss males, prevalence of alcohol use disorder as diagnosed by DSM-5 was slightly lower than prevalence of DSM-IV diagnosis of dependence plus abuse; 63.9% of those who met either criterion met criteria for both.

Does Drinking Location Matter? Profiles of Risky Single-Occasion Drinking by Location and Alcohol-Related Harm among Young Men

In adolescents and young adults, acute consequences like injuries account for a substantial proportion of alcohol-related harm, especially in risky single-occasion (RSO) drinkers. The primary aim of the study was to characterize different drinking profiles in RSO drinkers according to drinking locations and their relationship to negative, alcohol-related consequences. The sample consisted of 2746 young men from the Cohort Study on Substance Use Risk Factors who had reported drinking six or more drinks on a single-occasion at least monthly over the preceding 12 months. Principal component analysis on the frequency and amount of drinking at 11 different locations was conducted, and 2 distinguishable components emerged: a non-party-dimension (loading high on theater/cinema, sport clubs, other clubs/societies, restaurants, and sport events) and a party-dimension (loading high on someone else’s home, pubs/bars, discos/nightclubs, outdoor public places, special events, and home). Differential impacts of drinking location profiles were observed on severe negative alcohol-related consequences (SAC). Relative to those classified as low or intermediate in both dimensions, no significant difference experiencing SAC was found among those who were classified as high in the non-party-dimension only. However, those who were classified as high in the party-dimension alone or in both dimensions were more likely to experience SAC. These differential effects remained after adjusting for alcohol consumption (volume and risky single-occasion drinking), personality traits, and peer-influence [adjusted OR = 0.83 (0.68–1.02), 1.57 (1.27–1.96), and 1.72 (1.23–2.41), respectively], indicating independent effects of drinking location on SAC. The inclusion of sociodemographic factors did not alter this association. The fact that this cluster of party-dimension locations seems to predispose young men to experiencing SAC has important implications for alcohol control policies.

Conversion of differentiated cancer cells into cancer stem-like cells in a glioblastoma model after primary chemotherapy

Glioblastoma multiforme patients have a poor prognosis due to therapeutic resistance and tumor relapse. It has been suggested that gliomas are driven by a rare subset of tumor cells known as glioma stem cells (GSCs). This hypothesis states that only a few GSCs are able to divide, differentiate, and initiate a new tumor. It has also been shown that this subpopulation is more resistant to conventional therapies than its differentiated counterpart. In order to understand glioma recurrence post therapy, we investigated the behavior of GSCs after primary chemotherapy. We first show that exposure of patient-derived as well as established glioma cell lines to therapeutic doses of temozolomide (TMZ), the most commonly used antiglioma chemotherapy, consistently increases the GSC pool over time both in vitro and in vivo. Secondly, lineage-tracing analysis of the expanded GSC pool suggests that such amplification is a result of a phenotypic shift in the non-GSC population to a GSC-like state in the presence of TMZ. The newly converted GSC population expresses markers associated with pluripotency and stemness, such as CD133, SOX2, Oct4, and Nestin. Furthermore, we show that intracranial implantation of the newly converted GSCs in nude mice results in a more efficient grafting and invasive phenotype. Taken together, these findings provide the first evidence that glioma cells exposed to chemotherapeutic agents are able to interconvert between non-GSCs and GSCs, thereby replenishing the original tumor population, leading to a more infiltrative phenotype and enhanced chemoresistance. This may represent a potential mechanism for therapeutic relapse.

Prevalence of and associated factors for adult attention deficit hyperactivity disorder in young Swiss men

OBJECTIVE

The present study aimed to measure the prevalence of adult attention deficit hyperactivity disorder (ADHD) in a large, representative sample of young Swiss men and to assess factors associated with this disorder.

METHODS

Our sample consisted of 5656 Swiss men (mean age 20 years) who participated in the Cohort Study on Substance Use Risk Factors (C-SURF). ADHD was assessed with the World Health Organization (WHO) adult ADHD Self Report Screener (ASRS). Logistic regression analyses were conducted to assess the association between ADHD and several socio-demographic, clinical and familial factors.

RESULTS

The prevalence of ADHD was 4.0%, being higher in older and French-speaking conscripts. A higher prevalence also was identified among men whose mothers had completed primary or high school/university and those with a family history of alcohol or psychiatric problems. Additionally, adults with ADHD demonstrated impairment in their professional life, as well as considerable mental health impairment.

CONCLUSION

Our results demonstrate that ADHD is common among young Swiss men. The impairments in function and mental health we observed highlight the need for further support and interventions to reduce burden in affected individuals. Interventions that incorporate the whole family also seem crucial.

Body mass index and health-related quality of life among young Swiss men

BACKGROUND

Studies about the association between body mass index (BMI) and health-related quality of life (HRQOL) are often limited, because they 1) did not include a broad range of health-risk behaviors as covariates; 2) relied on clinical samples, which might lead to biased results; and 3) did not incorporate underweight individuals. Hence, this study aims to examine associations between BMI (from being underweight through obesity) and HRQOL in a population-based sample, while considering multiple health-risk behaviors (low physical activity, risky alcohol consumption, daily cigarette smoking, frequent cannabis use) as well as socio-demographic characteristics.

METHODS

A total of 5 387 young Swiss men (mean age = 19.99; standard deviation = 1.24) of a cross-sectional population-based study were included. BMI was calculated (kg/m²) based on self-reported height and weight and divided into 'underweight' (<18.5), 'normal weight' (18.5-24.9), 'overweight' (25.0-29.9) and 'obese' (≥30.0). Mental and physical HRQOL was assessed via the SF-12v2. Self-reported information on physical activity, substance use (alcohol, cigarettes, and cannabis) and socio-demographic characteristics also was collected. Logistic regression analyses were conducted to study the associations between BMI categories and below average mental or physical HRQOL. Substance use variables and socio-demographic variables were used as covariates.

RESULTS

Altogether, 76.3% were normal weight, whereas 3.3% were underweight, 16.5% overweight and 3.9% obese. Being overweight or obese was associated with reduced physical HRQOL (adjusted OR [95% CI] = 1.58 [1.18-2.13] and 2.45 [1.57-3.83], respectively), whereas being underweight predicted reduced mental HRQOL (adjusted OR [95% CI] = 1.49 [1.08-2.05]). Surprisingly, obesity decreased the likelihood of experiencing below average mental HRQOL (adjusted OR [95% CI] = 0.66 [0.46-0.94]). Besides BMI, expressed as a categorical variable, all health-risk behaviors and socio-demographic variables were associated with reduced physical and/or mental HRQOL.

CONCLUSIONS

Deviations from normal weight are, even after controlling for important health-risk behaviors and socio-demographic characteristics, associated with compromised physical or mental HRQOL among young men. Hence, preventive programs should aim to preserve or re-establish normal weight. The self-appraised positive mental well-being of obese men noted here, which possibly reflects a response shift, might complicate such efforts.

Health-risk behaviors and quality of life among young men

PURPOSE

To examine the associations between substance use and other health-risk behaviors and quality of life (QOL) among young men.

METHODS

The analytical sample consisted of 5,306 young Swiss men who participated in the Cohort Study on Substance Use Risk Factors. Associations between seven distinct self-reported health-risk behaviors (risky single-occasion drinking; volume drinking; cigarette smoking; cannabis use; use of any other illicit drugs; sexual intercourse without a condom; low physical activity) were assessed via chi-square analysis. Logistic regression analyses were conducted to study the associations between each particular health-risk behavior and either physical or mental QOL (assessed with the SF-12v2) while adjusting for socio-demographic variables and the presence of all other health-risk behaviors.

RESULTS

Most health-risk behaviors co-occurred. However, low physical activity was not or negatively related to other health-risk behaviors. Almost all health-risk behaviors were associated with a greater likelihood of compromised QOL. However, sexual intercourse without a condom (not associated with both physical and mental QOL) and frequent risky single-occasion drinking (not related to mental QOL after adjusting for the presence of other health-risk behaviors; positively associated with physical QOL) differed from this pattern.

CONCLUSIONS

Health-risk behaviors are mostly associated with compromised QOL. However, sexual intercourse without a condom and frequent risky single-occasion drinking differ from this pattern and are therefore possibly particularly difficult to change relative to other health-risk behaviors.

Beverage preferences and associated drinking patterns, consequences and other substance use behaviours

BACKGROUND

Studies about beverage preferences in a country in which wine drinking is relatively widespread (like Switzerland) are scarce. Therefore, the main aims of the present study were to examine the associations between beverage preferences and drinking patterns, alcohol-related consequences and the use of other substances among Swiss young men.

METHODS

The analytical sample consisted of 5399 Swiss men who participated in the Cohort Study on Substance Use Risk Factors (C-SURF) and had been drinking alcohol over the preceding 12 months. Logistic regression analyses were conducted to study the associations between preference for a particular beverage and (i) drinking patterns, (ii) negative alcohol-related consequences and (iii) the (at-risk) use of cigarettes, cannabis and other illicit drugs.

RESULTS

Preference for beer was associated with risky drinking patterns and, comparable with a preference for strong alcohol, with the use of illicit substances (cannabis and other illicit drugs). In contrast, a preference for wine was associated with low-risk alcohol consumption and a reduced likelihood of experiencing at least four negative alcohol-related consequences or of daily cigarette smoking. Furthermore, the likelihood of negative outcomes (alcohol-related consequences; use of other substances) increased among people with risky drinking behaviours, independent of beverage preference.

CONCLUSIONS

In our survey, beer preference was associated with risky drinking patterns and illicit drug use. Alcohol polices to prevent large quantities of alcohol consumption, especially of cheaper spirits like beer, should be considered to reduce total alcohol consumption and the negative consequences associated with these beverage types.

Health literacy and substance use in young Swiss men

OBJECTIVES

The purpose of the present study was to describe health literacy and its association with substance use among young men.

METHODS

The present study was part of the Cohort Study on Substance Use Risk Factors that included 11,930 Swiss males participating in initial screening from August 2010 to July 2011. Self-completed questionnaires covered use of three substances and three components of health literacy.

RESULTS

Roughly 22 % reported having searched the Internet for health information and 16 % for information on substances over the past 12 months. At-risk and not at-risk users of alcohol (adjusted odds ratio (AOR) = 2.50 and 1.46), tobacco (AOR = 2.51 and 1.79) and cannabis (AOR = 4.86 and 3.53) searched for information about substances significantly more often via the Internet than abstainers. Furthermore, at-risk users reported better knowledge of risks associated with substance use and a marginally better ability to understand health information than abstainers.

CONCLUSIONS

Substance users appear to be more informed and knowledgeable about the risks of substance use than non-users. Consequently, interventions that focus only on information provision may be of limited benefit for preventing substance use.

Assessing parent-child agreement in health-related quality of life among three health status groups

PURPOSE

To examine parent-child agreement regarding a child's health-related quality of life (HRQOL) among three health status groups.

METHODS

Parent-child agreement was evaluated for three health status groups of a population-based sample: (1) children with mental health problems (N = 461), (2) children with physical health problems (N = 281), and (3) healthy controls (N = 699). The KIDSCREEN-27 was used to assess HRQOL. The children were 9-14 years of age.

RESULTS

Intraclass correlation coefficients were mostly good across all HRQOL scores and health status groups. This relatively high level of agreement was also reflected by the following findings: first, the AGREE group was the largest in three out of five HRQOL subscales in all health status groups; second, when disagreement occurred, it was often minor in magnitude. Despite this relatively high level of agreement, the means of self-ratings were significantly higher for all HRQOL scores and health status groups than the means of proxy ratings. These higher self-ratings were especially pronounced among children with mental health problems in certain HRQOL domains.

CONCLUSIONS

Even though the level of parent-child agreement regarding a child's HRQOL is relatively high, it should be considered that children (especially those with mental health problems) often report better HRQOL than their parents. It is, therefore, highly recommended that both proxy- and self-ratings are used to evaluate a child's HRQOL comprehensively.

Health-related quality of life among children with mental disorders: a systematic review

PURPOSE

To systematically review studies about the quality of life (QOL) of children with various mental disorders relative to healthy controls and to describe limitations in these studies.

METHODS

Relevant articles were searched using different databases, by checking reference lists and contacting experts. We included articles that either compared children with mental disorders to healthy controls/norm values or made such a comparison possible.

RESULTS

Sixteen out of 4,560 articles met the pre-defined inclusion criteria. These studies revealed that the QOL of children with various mental disorders is compromised across multiple domains. The largest effect sizes were found for psychosocial and family-related domains and for the total QOL score, whereas physical domains generally were less affected. The most important limitations in the existing literature include the lack of study samples drawn from the general population, the failure to use self-ratings, not considering item overlap between measuring QOL and assessing for the presence of a particular mental disorder, and not determining whether the children were receiving medication for their mental disorder.

CONCLUSIONS

Children with mental disorders experience a considerable reduction in QOL across various domains. Research studies that avoid previous limitations are crucial to fill existing knowledge gaps.

Health-related quality of life among children with mental health problems: a population-based approach

Background

Children with mental health problems have been neglected in health-related quality of life (HRQOL) studies. Therefore, the aims of the current study were 1) to assess the influence of the presence of mental or physical health problems on HRQOL; and 2) to analyze the effects of item overlap between mental health problems and HRQOL-measurements.

Methods

Proxy- and self-rated HRQOL (KIDSCREEN-27) of children 9–14 years old was assessed across children with mental health problems (n = 535), children with physical health problems (n = 327), and healthy controls (n = 744). Multiple linear regression analyses were conducted with health status, severity of symptoms, status of medication use, gender and nationality as independent, and HRQOL scores as dependent variables. The effects of item overlap were analyzed by repeating regression analyses while excluding those HRQOL items that contextually overlapped the most frequently-occurring mental health problem (attention deficits).

Results

Severity of symptoms was the strongest predictor of reduced HRQOL. However, all other predictors (except for the status of medication use) also contributed to the prediction of some HRQOL scores. Controlling for item overlap did not meaningfully alter the results.

Conclusions

When children with different health constraints are compared, the severity of their particular health problems should be considered. Furthermore, item overlap seems not to be a major problem when the HRQOL of children with mental health problems is studied. Hence, HRQOL assessments are useful to gather information that goes beyond the clinical symptoms of a health problem. This information can, for instance, be used to improve clinical practice.

A comparison of health-related quality of life between children with versus without special health care needs, and children requiring versus not requiring psychiatric services

PURPOSE

The purpose of the present study was to compare health-related quality of life (HRQoL) between children with special health care needs (CSHCN) and those without. In particular, CSHCN who require psychiatric services and those who do not were compared.

METHODS

A representative community sample of 3,325 children (10-14 years old) was recruited from the Canton of Zurich. Via either computer-assisted telephone interviews or a written questionnaire, special health care needs were assessed using the five-item parent-reported CSHCN Screener. Subsequent to screening, a written questionnaire was sent to a sub-sample of 974 children to acquire more detailed information, both from the children and their parents, about their health and health care utilization, and to assess HRQoL (KIDSCREEN-27) and emotional and behavioral problems (SDQ). A total of 626 children responded to the questionnaire. Multiple linear regression models were used to examine the association between HRQoL and subject group, controlling for other covariates.

RESULTS

Among 2,586 children whose parents participated in the screening stage, roughly 18% were identified as CSHCN, with 6.2% requiring psychiatric services. The subsequent survey revealed that those CSHCN who required psychiatric services had the lowest HRQoL scores and highest SDQ scores. CSHCN who utilized psychiatric services were particularly prone to low HRQoL, especially among lower income families.

CONCLUSIONS

The influence of noticeable emotional and behavioral problems on HRQoL should be afforded more attention, both in clinical practice and empirical studies involving children with special health care needs.

Accommodation: its relation to refractive errors, amblyopia and biometric parameters

AIM

To study accommodation in relation to different refractive errors, amblyopia and to measure the anatomical changes in the accommodating eye

MATERIALS AND METHODS

We studied the amplitude of accommodation (AA) in 150 patients in the age group 11 ± 30 years which included emmetropes, myopes, hypermetropes and hypermetropic amblyopes using the Royal Air Force (RAF) rule. The anterior chamber depth (ACD), axial length (AxL) and lens thickness (LT) changes during accommodation were measured using an A-scan. Myopes and hypermetropes were further divided based on the amount of refractive error : less than 2D, 2 -4D and greater than 4D.

RESULTS

Corrected low myopes had the highest accommodation amplitude (p less than 0.05) followed by emmetropes. Corrected hypermetropes were found to have the lowest amplitude of accommodation (p less than 0.05). The amblyopic eye had a significantly low AA compared to the non-amblyopic eye (p less than 0.05). ACD decreased (p less than 0.05) and LT increased (p less than 0.05) during accommodation. The AxL increase was maximum in myopes (p less than 0.05) followed by hypermetropes but the change was not significant in hypermetropes (p greater than 0.05).

CONCLUSION

The amblyopic eye has low amplitudes of accommodation proving the benefit of near adds in amblyopic patients. Prolonged near work might induce myopia in susceptible eyes by increasing the axial length.

Presbyopia and its anatomical and physiological variants

AIM

To study the various ocular anatomical and physiological parameters in presbyopia.

MATERIALS AND METHODS

We studied the various ocular anatomical and physiological parameters like corneal curvature (keratometry readings: K1 and K2), central corneal thickness (CCT), anterior chamber depth (ACD), lens thickness (LT) and axial length (AL) in 100 presbyopic patients between 35 - 55 years of age. The patients were divided into two age groups: I (35 ± 44 years) and II (45-55 yrs). ACD, AL and LT were measured using an Ascan. CCT was measured with ultrasonic pachymetry.

RESULTS

The CCT decreased (BE), LT increased and ACD decreased (RE) significantly with increasing age (p less than 0.05). There was no significant difference in males and females. Nearly 3/4th of the total increase in lens thickness was responsible for the decrease in the anterior chamber depth and the rest, 1/4th , goes posteriorly. Corneal curvature and AL showed no significant change with age.

CONCLUSIONS

The mean of CCT decreased significantly with advancing age. As age increased, the mean value of lens thickness increased and anterior chamber depth decreased. Nearly 3/4th of total increase in LT was anteriorly, decreasing the ACD. Corneal curvature and AL has no relation with age.