High Levels Of Comorbidity Research Articles

Management of geriatric cancer patients during the COVID-19 pandemic

Physiological vulnerabilities greatly impact the outcome of coronavirus disease 2019 (COVID-19) infection. The COVID-19 infection results in far more serious illness in patients with compromised physiological reserve (older patients, infants, and pregnant women) and in those with preexisting or poorly controlled comorbidities. The COVID-19 infection can be life-threatening in older patients with cancer, but there are no standard guidelines or individual hospital data regarding methods or policies implemented to guide clinicians. Evolving clinical experience suggests that cancer patients with COVID-19 have more serious complications, such as intensive care admission from severe pneumonia or sepsis and a greater case fatality rate. Cancer history portends the highest risk of serious events. Considering the evidence for a clear association for older age and higher levels of comorbidity with more severe COVID-19 symptoms and adverse outcomes, the concept of risk mitigation is highly relevant to older patients with cancer. Chronological age alone cannot be relied on to ascertain the true biological status of an individual, and a comprehensive geriatric assessment (CGA) provides a multidisciplinary diagnostic process that encompasses several objectively evaluable domains to reliably and objectively assess medical, psychosocial, and functional limitations. With formal assessment tools, previsit questionnaires and appropriate training can reduce this burden on the clinician performing the initial CGA. This would enhance overall capabilities in reliable use of recommendations regarding treatment for comorbidities, geriatric syndromes, supportive care, drug interactions, and toxicities. Routine use of CGA would mitigate most of the risks related to biological vulnerability. Measures to reduce hospital visits such as shorter radiotherapy fractionation and conversion of intravenous to oral systemic regimens can be considered. Proactive discussions regarding end-of-life and hospice care at isolation facilities should be discussed in the management of older patients with cancer and COVID-19 infection. Oncologists should make an extra effort to educate and provide additional guidance to help patients and caretakers making hard decisions regarding withholding anticancer treatment to mitigate the risk of viral infection.

Predictors of iron-deficiency anemia in primary care older adults: a real-world European multi-country longitudinal study.

Iron deficiency is a major cause of anemia in older people. Increasing the knowledge on the predictors of iron-deficiency anemia (IDA) may facilitate its timely diagnosis. To investigate the predictors of IDA in older people in four European countries. Retrospective longitudinal study. Primary care patients aged 65 or older (N = 24,051) in four European countries. IDA predictors were estimated using multivariate Cox regression based on information gathered from national primary care databases: Italy (years 2002-2013), Belgium, Germany and Spain (years 2007-2012). Adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) were estimated. In Spain and Belgium, men were at greater risk of IDA than women, while they had a lower risk in Italy. Weakness, irritability, alopecia and xerostomia were signs and symptoms significantly associated with IDA. Concurrent diseases, potential causes of anemia, positively associated with IDA were small bowel polyposis, stomach cancer, obesity, gastritis and peptic ulcer, esophagitis, Crohn's disease, celiac disease, lymphangiectasis, gastrectomy or gastric atrophy, gut resection or bypass, and cardiac prosthetic valve. Aspirin users had a 12-35% higher hazard of IDA than non-users. Similarly, corticosteroids and anti-acids were positively associated with IDA. A higher level of comorbidity was associated with an increased hazard of IDA in all countries. Specific signs and symptoms, chronic conditions, a greater comorbidity burden, and specific pharmacological treatments registered in primary care databases represent relevant predictors and correlates of incident IDA in older people in Europe. General practitioners might employ this information to obtain early diagnosis of IDA in community-dwelling older adults.

Technological Hindrances of Behavioral Medicine Patient Access: A Literature Review

Technology is a pervasive tool utilized throughout inpatient and outpatient hospital care. Behavioral medicine has a plethora of technology to integrate and support medical infrastructure and processes. A systematic literature review was performed to classify the technological hinderances that specifically plague behavioral medicine. Researchers examined articles contained within the databases of CORE, Elsevier, PubMed, ResearchGate, and ScienceOpen and pulled all relevant articles. A total of 85 articles were collected after the removal of duplicates. Several themes have been identified in the systematic literature review that negatively affects behavioral medicine treatment at the provider, clinical staff, non-clinical staff, patient, and organizational levels. These themes are a lack of behavioral medicine patient resources, a surfeit of stigmas surrounding treatment, higher levels of comorbidities in these patients as compared to non-behavioral medicine specialties, and a reliance on outdated educational protocols for training staff. The themes significantly affect patients within the behavioral medicine specialty more than other subsectors of medicine due to the unique ailments that behavioral medicine encompasses. The future climate of behavioral medicine treatment could be affected by the aforementioned hinderances. However, evidence in the literature review displays positive findings when employee education and technological integration are combined. Further research should be directed towards the implementation of SBE into clinical and non-clinical behavioral medicine employee training.

Posttraumatic growth in psychosis: Challenges to the assumptive world.

Research has shown high rates of exposure to trauma among people with serious mental illness (SMI). In addition, studies suggest that psychosis and mental illness-related experiences can be extremely traumatic and may lead to significant symptomatology. Indeed, overwhelming traumatic experiences may shatter people's core beliefs about themselves, the world, and others. However, coping with adversity may also foster a unique outcome; namely posttraumatic growth (PTG). The experience of PTG is contingent on people's ability to reexamine their core beliefs after trauma. Little is known about whether and how such core-belief reexamination is related to PTG among people with SMI and psychosis, specifically people who experience positive, negative, and general psychopathological symptoms (PANSS). For the purpose of this study, 121 participants were recruited from community mental health rehabilitation centers and administered trauma- and psychiatry-oriented questionnaires. In addition to high levels of traumatic exposure, we observed that people with SMI can experience PTG, which is mediated by reexamination of core beliefs, contingent on low levels of illness-related psychopathological symptoms. The ability to challenge one's world assumptions and reestablish a functional set of assumptions is critical to the development of PTG. In light of the high levels of posttraumatic comorbidity found in this population, psychiatric facilities should place greater emphasis on treating the traumatic aspects of SMI and on teaching and practicing effective strategies to reevaluate life after trauma. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Contribution of Personality Traits, Psychological Factors, and Health-Related Quality of Life to Medication Adherence in Patients with Rheumatoid Arthritis.

PurposeThis study sought to investigate the associations between personality traits and medication adherence and to identify predictors of good medication adherence in rheumatoid arthritis (RA) patients.Materials and MethodsA total of 207 RA patients using disease-modifying anti-rheumatic drugs were invited for an interview and questionnaire study. Medication adherence was measured using the Compliance Questionnaire for Rheumatology (CQR). Personality traits were analyzed with the five-factor model of the Korean version of the Big Five Inventory 10. Psychological factors were assessed with the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and British Columbia Cognitive Inventory. Health-related Quality of Life (HRQoL) and functional disability were evaluated with the EuroQoL-5 dimension questionnaire and Health Assessment Questionnaire. Multivariate logistic regression analyses were performed to investigate predictors of good medication adherence.ResultsNonadherence to medication was reported by 66.7%. The number of daily prescribed pills was higher in the medication adherence group than in the nonadherence group. Concomitant oral glucocorticoid doses were associated with medication adherence. A high level of conscientiousness and diabetes mellitus comorbidity were associated with better medication adherence [odds ratio (OR), 2.11; 95% confidence interval (CI), 1.01–4.38 and OR, 3.00; 95% CI, 1.12–8.07, respectively]. There were no significant differences in psychological factors or HRQoL between medication adherence and nonadherence groups.ConclusionThe personality trait of conscientiousness was associated with medication adherence among the five personality traits evaluated. Patients with diabetes mellitus also showed higher medication adherence than those without this comorbidity.

Chemotherapy effectiveness in trial-underrepresented groups with early breast cancer: A retrospective cohort study.

Adjuvant chemotherapy in early stage breast cancer has been shown to reduce mortality in a large meta-analysis of over 100 randomised trials. However, these trials largely excluded patients aged 70 years and over or with higher levels of comorbidity. There is therefore uncertainty about whether the effectiveness of adjuvant chemotherapy generalises to these groups, hindering patient and clinician decision-making. This study utilises administrative healthcare data-real world data (RWD)-and econometric methods for causal analysis to estimate treatment effectiveness in these trial-underrepresented groups. Women with early breast cancer aged 70 years and over and those under 70 years with a high level of comorbidity were identified and their records extracted from Scottish Cancer Registry (2001-2015) data linked to other routine health records. A high level of comorbidity was defined as scoring 1 or more on the Charlson comorbidity index, being in the top decile of inpatient stays, and/or having 5 or more visits to specific outpatient clinics, all within the 5 years preceding breast cancer diagnosis. Propensity score matching (PSM) and instrumental variable (IV) analysis, previously identified as feasible and valid in this setting, were used in conjunction with Cox regression to estimate hazard ratios for death from breast cancer and death from all causes. The analysis adjusts for age, clinical prognostic factors, and socioeconomic deprivation; the IV method may also adjust for unmeasured confounding factors. Cohorts of 9,653 and 7,965 were identified for women aged 70 years and over and those with high comorbidity, respectively. In the ≥70/high comorbidity cohorts, median follow-up was 5.17/6.53 years and there were 1,935/740 deaths from breast cancer. For women aged 70 years and over, the PSM-estimated HR was 0.73 (95% CI 0.64-0.95), while for women with high comorbidity it was 0.67 (95% CI 0.51-0.86). This translates to a mean predicted benefit in terms of overall survival at 10 years of approximately3% (percentage points) and 4%, respectively. A limitation of this analysis is that use of observational data means uncertainty remains both from sampling uncertainty and from potential bias from residual confounding. The results of this study, as RWD, should be interpreted with caution and in the context of existing and emerging randomised data. The relative effectiveness of adjuvant chemotherapy in reducing mortality in patients with early stage breast cancer appears to be generalisable to the selected trial-underrepresented groups.

A profile of mental health and behaviour in Prader-Willi syndrome.

Prader-Willi syndrome (PWS) is a neurogenetic syndrome with an associated behavioural phenotype and a high incidence of behaviours of concern and psychiatric co-morbidity. These associated behaviours and co-morbidities are not well addressed by existing interventions, and they impact significantly on affected individuals and their caregivers. We undertook a national survey of the needs of individuals with PWS and their families in Ireland. In this paper, we report on the parent/caregiver-reported mental health, behavioural and access to services. Over 50% of individuals with PWS in this survey had at least one reported psychiatric diagnosis, the most common diagnosis was anxiety. The most commonly reported behaviours in children were skin picking, repetitive questioning, difficulty transitioning and non-compliance. The same four behaviours were reported by caregivers as being the most commonly occurring in adolescents and adults in addition to food-seeking behaviours. Increased needs for mental health services were also reported by caregivers. Individuals with PWS had an average wait of 22months for an appointment with a psychologist and 4months for an appointment with a psychiatrist. This study highlighted high levels of psychiatric co-morbidities and behavioural concerns in individuals with PWS in Ireland. The findings of this study suggest that there is an urgent need to provide specialist psychiatric and behavioural interventions to manage complex mental health and behavioural needs to better support individuals with PWS and reduce caregiver burden.

Efficacy of toric intraocular lens implantation with high corneal astigmatism within the United Kingdom's National Health Service.

To determine the efficacy of toric intraocular lens (TIOL) implantation in cataract surgery patients with high levels of pre-operative corneal astigmatism and ocular co-morbidities in a state funded, National Health Service (NHS) hospital. Retrospective cohort study involving consecutive cases of TIOL implantation in cataract surgery with over 3.00DC of pre-operative corneal astigmatism. Subjects were implanted with the Tecnis TIOL (Abbot Medical Optics) with capsular tension ring stabilisation using the Callisto system (Carl Zeiss Meditec). Visual acuity and refraction were assessed at 4-6 weeks post-operatively. Vector analysis was used to calculate the intended refractive correction, surgically induced refractive correction (SIRC), correction ratio (CR), error of magnitude (EM) and error vector (EV). Sixty-six eyes of forty-seven subjects aged 73.8 ± 11.9 were included. Eyes with ocular co-morbidities included dry age-related macular degeneration (n = 13), amblyopia (n = 7), high myopia (n = 7), glaucoma (n = 6), previous corneal transplantation (n = 2), nanophthalmos (n = 2) and corneal scarring (n = 1). Pre-operative corneal astigmatism was 4.25 ± 1.69DC (range 3.00-12.00), post-operative refractive astigmatism was 1.31 ± 1.05DC (range 0.00-6.50DC) and post-operative unaided visual acuity was 0.25 ± 0.19 LogMAR. Vector analysis demonstrated an SIRC of 4.08 ± 1.39DC, CR = 1.1 ± 0.3, EM -0.4 ± 1.0 and EV of 1.23 ± 0.72. The results demonstrate the efficacy of TIOL implantation in patients with high corneal astigmatism and provide strong evidence advocating their use in cataract surgery within a state funded hospital eye service. Refractive astigmatism was significantly lower than the pre-operative corneal astigmatism and a low error vector was achieved relative to the magnitude of correction.

Who is seeking help for sleep? a clinical profile of patients in a sleep psychology clinic

The present study outlines a clinical profile of an ecologically valid population consulting for sleep difficulties at the Sleep Psychology Clinic of the Consultation service of the School of Psychology of Universite Laval . Patients self-report to the sleep clinic. Following a phone screening interview, patients present to the clinic for a semi-structured clinical interview for sleep and psychopathology, which is conducted by psychologists and doctorate psychology students. A chart review of adult patients (56% female, Mage = 43.6 years) was conducted (between 2015 and 2018) to record diagnosed sleep, psychiatric, and medical conditions. There was a high level of comorbidity with an average of 2.85 diagnoses (any diagnosis combined) per patient (SD = 1.76), with 27% of the patients having at least four diagnoses. Reviewing specific types of disorders, 58.5% of patients presented with at least one comorbid psychiatric disorder, 27.5% with one medical comorbidity, or 39.5% with another sleep disorder alongside their primary sleep concern. Insomnia was the main sleep disorder (76%). Anxiety (77.8%) and depression (53.8%) were the predominant psychiatric disorders, while fibromyalgia (10.9%), hypertension (10.9%), and head trauma (9.1%) were the main medical conditions. Of patients with five diagnoses and more, 77.8% were taking on average 3.2 different types of medications. The number of diagnoses predicted the use of prescribed hypnotics and the use of any type of medications. This clinical profile emphasizes the reality of multiple morbidities, which may have implications for clinical decisions. Future research is required to evaluate transdiagnostic approaches for the sleep disorder patient with multiple morbidities.

OSTEOARTHRITIS AND DEPRESSION IN A MALE VA POPULATION

Osteoarthritis (OA) is a leading cause of disability among older adults. By 2050, approximately 60 million will suffer from arthritis adding up to a total societal cost of $65 billion. Chronic illnesses resulting in pain, and functional decline have been associated with depression in previous studies. The primary goal of this study is to investigate whether OA severity, as measured by the Western Ontario McMasters Arthritis Composite (WOMAC), impacts reported levels of depression and to what degree clinical and sociodemographic variables play a part. A causal model was developed and tested examining the antecedents of OA disease severity and depression. Information on clinical, demographic, socioeconomic, and psychosocial variables was collected on 596 male Veterans with moderate to severe symptomatic OA of the knee\\hip. A Confirmatory Factor Analysis was conducted to determine the factor structure of the WOMAC. A 2nd order three factor solution (pain, stiffness, and function) fit the data well (TLI of .94, a CFI of .94 and a RMSEA of .058). The results of the Structural Equation Model reveal a final model that fit the data well (TLI of .95, a CFI of .97 and a RMSEA of .047). Depression was predicted by higher WOMAC scores (beta=.37 , p<.01); higher levels of comorbidity (beta= .11, p<.05); younger age (beta= -.29, p<.01); being white (beta=-.11, p<.05); lower levels of income (beta= -.12, p<.05); lower levels of religiosity (beta= 11, p<.05). Clinicians should be aware of the impact of disease severity when treating OA patients with depression.

EMDR Therapy's Efficacy in the Treatment of Pain

Chronic pain is the most common global cause of functional and quality of life limitations. Although there are many effective therapies for the treatment of acute pain, chronic pain is often unsatisfactory. Against this background, there is currently an urgent need to develop innovative therapies that enable more efficient pain relief. Psychosocial factors play an important role in the development and persistence of chronic pain. Especially in patients with high levels of emotional stress, significant anxiety, or relevant psychological comorbidity, classical pain therapy approaches often fail. This is in line with the results of recent pain research, which has shown that dysfunctions in emotion processing have a significant influence on the persistence of pain symptoms. The recognition that pain can become chronic through maladaptive emotional processing forms the pathophysiological basis for the application of eye movement desensitization and reprocessing (EMDR) in the treatment of chronic pain. In this sense, EMDR can be used as an established method for desensitizing and processing of emotional distress from trauma therapy specifically for processing emotional stress in patients with chronic pain. Against this background, it is not surprising that the implementation of EMDR for patients with chronic pain is expanding. However, the increasing clinical use of EMDR in the treatment of chronic pain has also led to a reputation to test the efficacy of EMDR in pain management through randomized clinical trials. In addition to numerous case control studies, there are now also six randomized controlled clinical trials available that demonstrate the efficacy and safety of EMDR in the treatment of different pain conditions. However, in order to overcome several methodological limitations, large multicenter studies are needed to confirm the results.

Nonepileptic seizures in individuals attending neurological services in New Zealand

ObjectivesThis study examined the demographic, social, and clinical (neurological and psychiatric) characteristics of people with psychogenic nonepileptic seizures (PNES) presenting to tertiary neurological services at Auckland District Health Board, New Zealand. MethodsElectronic notes and video-electroencephalography (video-EEG) data gathered from the telemetry unit based on synchronized acquisition (motor activity and brain electrophysiology) over a five-year period (2011 to 2015 inclusive) were retrospectively examined. Two groups were compared: people with PNES only or people with combined PNES and epileptic seizures (ES) (the group with PNES) and a control group with ES only, matched 1:1 by age and gender. ResultsSixty-six people in the group with PNES were matched with an equivalent number of ES controls. As a cohort, there was high psychiatric and medical comorbidity in both groups, but overall, those with PNES experienced higher rates than their ES counterparts. An older age of onset, female gender, and history of abuse were more frequently seen in those with PNES. Compared with controls, people with PNES more commonly had daily seizures (rather than monthly) but presented less frequently to neurology services. A high proportion of people with PNES experienced historical traumas, ongoing stressors, and disability. Almost half of the people with PNES were on antiepileptic drugs (AEDs) and received limited psychiatric or psychological input. In contrast, people with ES were more likely to be on psychotropic medication. ConclusionBoth PNES and ES are associated with high levels of psychiatric and medical comorbidity. Additionally, PNES were found to be associated with iatrogenic harm and disability. Though people with PNES and ES often have a range of associated needs, there is, however, limited access to appropriate services. The needs of these populations should be better met through enhanced integration across psychiatry, neurology, and multidisciplinary services.

Study Protocol: A Multisite Trial of Work-Related Cognitive Behavioral Therapy for Unemployed Persons with Social Anxiety

This paper provides a methodological description of a multi-site, randomized controlled trial (RCT) of a cognitive-behavioral intervention for enhancing employment success among unemployed persons whose employment efforts have been undermined by social anxiety disorder (SAD). SAD is a common and impairing condition, with negative impacts on occupational functioning. In response to these documented employment-related impairments, in a previous project, we produced and tested an eight-session work-related group cognitive-behavioral therapy provided alongside vocational services as usual (WCBT+VSAU). WCBT is delivered by vocational service professionals and is designed in a context and style that overcomes accessibility and stigma-related obstacles with special focus on employment-related targets. Our previous project found that WCBT+VSAU significantly improved social anxiety, depression, and a range of employment-related outcomes compared to a control group of socially anxious job-seekers who received vocational services as usual without WCBT (VSAU-alone). Participants in this study were all homeless, primarily African American job-seekers with high levels of psychiatric comorbidity and limited education and employment histories. The present, two-region study addresses whether WCBT+VSAU enhances job placement, job retention and mental health outcomes in a larger sample assessed over an extended follow-up period. In addition, this trial evaluates whether the effects of WCBT+VSAU generalize to a new population of urban-based, racially diverse job-seekers with vocational and educational histories that differ from our original sample. This study also investigates the system-effects of WCBT+VSAU in a new site that will be informative for broad implementation of WCBT+VSAU. Finally, this project involves a refined, technology-assisted form of WCBT+VSAU designed to be delivered more easily by vocational services professionals.

P3841Real world outcomes for clopidogrel versus ticagrelor treated patients with acute coronary syndrome: a systematic literature review and meta-analysis

Abstract Introduction The ischemic benefit of ticagrelor over clopidogrel seen in randomized trials has not been fully reproduced in real world cohorts. The discrepancy between these two treatments may be influenced by differences in prescribing. Purpose To provide insights in patient care for patients with high levels of comorbidities. Methods A systematic literature review and meta-analysis were conducted to compare clinical outcomes for clopidogrel vs. ticagrelor in real-world populations with acute coronary syndrome. MEDLINE and Embase were searched from inception to January 2018. Pairwise meta-analyses were performed using unadjusted random-effects models for both outcomes and patient characteristics to test for differences. Heterogeneity was assessed using the I2 statistic. Results The search identified 17 studies for analysis from 1,771 publications (TOTAL N=66,198; CLO N=54,175; TIC N=12,023). Clopidogrel-treated patients were more likely to have diabetes (33% vs. 24%), hypertension (59% vs. 47%), hyperlipidaemia/dyslipidaemia (45% vs. 39%), and prior stroke/transient ischemic attack (TIA) (8% vs. 5%). A slightly higher risk of myocardial infarction (MI) was observed for clopidogrel (4.5% vs. 3.5%; OR 1.29 [1.15–1.46]) and included clopidogrel patients had significantly more comorbidities (Figure 1). No statistical difference between clopidogrel and ticagrelor was found for risk of MACE, defined as the composite of cardiovascular (CV) death, MI or stroke, (13.6% vs. 10.1%; OR 1.41 [95% confidence interval 0.93–2.14]), despite clopidogrel patients having significantly more diabetes and hypertension (p≤0.01). Similarly, the risks of CV death (2.3% vs. 2.1%; OR 1.11 [0.58–2.13]), stroke (1.2% vs. 1.1%; OR 1.11 [0.56–2.17]), and stent thrombosis (1.3% vs. 1.0%; OR 1.34 [0.88–2.06]) were not statistically differentiable, despite clopidogrel patients having significantly more hyperlipidaemia in studies analysed for CV death (p&lt;0.05); significantly more diabetes, hypertension, peripheral arterial disease (PAD), hyperlipidaemia, and prior stroke/TIA in studies analysed for stroke (p&lt;0.05); and significantly more hyperlipidaemia and prior stroke/TIA in studies analysed for stent thrombosis (p&lt;0.01). There were no significant differences in all bleeding events (major or minor, as defined by study) (2.0% vs. 2.7%; OR 0.74 [0.54–1.00]) or major bleeding (2.9% vs. 2.7%; OR 1.07 [0.85–1.33]). Included clopidogrel patients had significantly more diabetes, hypertension, PAD, and prior stroke/TIA (p&lt;0.05). Significant heterogeneity (I2 &gt;60%) was observed for MACE, CV death, stroke and bleeding. Figure 1. Comorbidities in MI Conclusion This analysis suggests clopidogrel-treated patients had more comorbidities than ticagrelor-treated patients, which may introduce a bias with negative impact on their outcomes. Despite this circumstance, with the exception of MI, this analysis showed no statistical difference in efficacy and safety between clopidogrel and ticagrelor. Acknowledgement/Funding This analysis was funded by Sanofi.

Vers un rapprochement du syndrome de Klinefelter et de la psychopathie en psychiatrie légale

Klinefelter syndrome (KS) (47,XXY) is the most common aneuploidy (1/650) of sexual chromosome among male (0,1 à 0,2 % of male population) (Hong and Reiss, 2014). Because its large physical phenotypic variability (high tall, sparse hairiness, gynecomastia), this syndrome is largely underdiagnosed (less than 25 % of affected persons) (Samango-Sprouse et al., 2018). Nevertheless, cognitive variability is smaller. Normal to low average total IQ, low verbal IQ, social problems and high levels of psychiatric comorbidities including early aggressiveness are commonly described (Hong and Reiss, 2014). In Denmark, higher risks of committing sexual crime and arson (compared to criminal controls) was recently reported (Stochholm et al., 2012). Quite a few clinically relevant cases reports scattered in the literature, suggests the presence of a pattern of a specific subtype of KS inpatients among forensic population (Bénézech, 1975). However, very few studies provide quantitative or qualitative pertaining to robust results. KS well-documented neurobiological (van Rijn, 2018) (e.g. low levels of testosterone), neuropsychological (Bénézech, 1975; Hong and Reiss, 2014; Samango-Sprouse et al., 2018; Savic, 2012; Seara-Cardoso et al., 2016; Senon, 2005; Stochholm et al., 2012; van Rijn, 2018; van Rijn et al., 2008; van Rijn et al., 2018; van Rijn et al., 2014; van Rijn et al., 2012) [29] (e.g. alterations of both complex cerebral — attention, empathy — and behavioral regulation functions - inhibition, mental flexibility, emotional response modulation, control of own actions) and neuroanatomical (Hong and Reiss, 2014; Itti et al., 2003; Savic, 2012; van Rijn et al., 2008; van Rijn et al., 2012) [29] (e.g. limbic system and temporal lobe abnormal volume, hemispheric specialization shortcoming) features may be helpful to understand comorbid symptoms psychopathology. Numbers of recent studies conduct on KS pediatric or adult population provide interesting results on conduct, anxiety, psychotic and autism spectrum disorders. In addition, some authors use genetic and epigenetic specific features of sex chromosome aneuploidies (e.g. X genes neurodevelopmental role; imprinting) in order to clarify genotype-phenotype links of comorbid symptoms (Bruining et al., 2011; Zitzmann et al., 2004;). With Belgian colleagues from the Social Defense Research Center (CRDS, Tournai, Belgium), we are currently recruiting KS inpatients from security hospitals or psychiatric units in Belgium and France. We aim to assess psychopathic traits with the Psychopathy Checklist Revised (PCL-R, Hare) (Hare, 2003). Our first results concerning 3 KS males outline that PCL-R is useful for the characterization of clinical phenotype among KS forensic sample. While three of them present psychopathic traits, two of them present categorical double diagnose “psychopathy-KS” (total PCL-R score>=30/40 (Delannoy et al., 2017)). Moreover, dimensional analysis support our hypothesis of a higher prevalence of “explosive profile” in comparison to other psychopathic profiles in our sample (Delannoy et al., 2017). The present article summarizes historic background (e.g. “psychopathy” disappearance of mental disorder reference classification schemes, “crime chromosome” (Bénézech, 1975)) and current context argues (e.g. French psychiatrists court experts widely refer to psychopathy concept despite a lack of consensual definition (Senon, 2005), weak knowledge and training of PCL-R and its related biopsychological recent findings (Blair, 2013; de Oliveira-Souza et al., 2008; Dotterer et al., 2017; Glenn and Raine, 2014; Hosking et al., 2017; Korponay et al., 2017; Pham, 1995; Pham, 2005; Raine, 2008; Raine et al., 2003); stigma and discrimination apprehensions of KS and psychopath) that motivate our research project. Finally, we discuss the advantages of our research protocol on KS participants assessed with PCL-R, such as tackling stigma and discrimination, better understanding psychopathology, and clarifying murky interactions of biological, psychological and social factors entangled in the development of these two fascinating troubles.

232 The Timing of “Do Not Attempt Resuscitation” Decisions in an Older, Frail Inpatient Population

Abstract Background Ascertaining and discussing resuscitation status should be a routine part of medical practice. However, it is frequently neglected until a patient is acutely unwell. The National Consent Policy1 recommends that discussion around “Do not attempt cardiopulmonary resuscitation” (DNACPR) orders should occur for patients with “an identifiable risk of cardiorespiratory arrest occurring”. The Clinical Frailty Scale is a useful tool for providing predictive information about the risk of death in older patients2. Along with the presence of comorbidities, it can assist with determining prognosis and identifying patients for whom early discussion about resuscitation status is appropriate. Methods A chart review was carried out of all 106 inpatients in a model 3 hospital. Data was extracted on demographic information, frailty score and resuscitation status. Results The average age of inpatients was 79.8 years. On admission, the average Clinical Frailty Scale score was 5 (mildly frail), with 15% having a frailty score of 7 or more, and 28% a diagnosis of dementia. 25.5% of inpatients had a DNACPR order in place. It took an average of 32.4 days (range 0-224 days) from admission until this decision was made. Conclusion As we are caring for an older population with frailty; care planning, including resuscitation status should be discussed at an earlier stage. Ideally, this should occur on admission for certain patients, particularly those with high levels of frailty and multiple comorbidities. Our current practice, in which DNACPR decisions sometimes take place after a prolonged admission, is suboptimal. A change to the medical admission proforma, adding a prompt for discussion of DNACPR orders will be considered.

Perceived stress is associated with a higher symptom burden in cancer survivors.

Although multiple co-occurring symptoms are a significant problem for cancer survivors, to the authors' knowledge little is known regarding the phenotypic characteristics associated with a higher symptom burden. The objectives of the current study were to evaluate the occurrence, severity, and distress associated with 32 symptoms and examine the phenotypic and stress characteristics associated with a higher symptom burden. A total of 623 cancer survivors completed a demographic questionnaire, as well as measures of functional status, comorbidity, and global (Perceived Stress Scale) and cancer-related (Impact of Event Scale-Revised) stress. The Memorial Symptom Assessment Scale was used to evaluate symptom burden. Multiple linear regression analysis was used to determine the phenotypic characteristics associated with a higher symptom burden. The mean number of symptoms was 9.1 (±5.2). The most common, severe, and distressing symptoms were lack of energy, problems with sexual interest/activity, and hair loss, respectively. Poorer functional status, a higher level of comorbidity, and a history of smoking as well as higher Perceived Stress Scale and Impact of Event Scale-Revised scores were associated with a higher symptom burden. The overall model explained approximately 45.6% of the variance in symptom burden. Although cancer survivors report a high number of co-occurring symptoms of moderate severity and distress, in the current study, no disease or treatment characteristics were found to be associated with a higher symptom burden. Clinicians need to assess for general and disease-specific stressors and provide referrals for stress management interventions. Future studies need to examine the longitudinal relationships among symptom burden, functional status, and level of comorbidity, as well as the mechanisms that underlie the associations between stress and symptom burden.

Diagnosing and Treating Depression in Patients with Alzheimer's Disease.

Although cognitive and functional impairment are the hallmark features of Alzheimer’s disease (AD), neuropsychiatric symptoms associated with AD account for increased rates of disability and profoundly impact the quality of life of both patients and their caregivers. This narrative review of current evidence provides practical guidance in diagnosing and managing depression in patients with AD using pharmacological and nonpharmacological interventions. After apathy, depression is the second most common neuropsychiatric symptom in AD. Diagnosing late-life depression (LLD), particularly in those affected by AD, is complicated because older patients may not meet the criteria for a major depressive disorder. Clinically, late-life depression and dementia can be indistinguishable. Although these two entities are now thought to be related, the pathologic mechanisms remain unclear. Evidence suggests that LLD may be a prodromal symptom of neurodegenerative disease. The various geropsychiatric measures currently used to diagnose, rate the severity of, and monitor the progress of treatment for depression are imperfect. Neuroimaging represents a promising avenue toward understanding the complex pathophysiologic relationships between dementia and LLD, and will support the pursuit of biomarker-driven diagnosis and treatment. Nonpharmacologic interventions to relieve depression in persons with cognitive impairment and dementia include emotion-oriented therapies, behavioral and cognitive-behavioral modification programs, and structured activity programs. Sensory-stimulation therapies and multisensory approaches show some promise for successfully treating depression in patients with dementia, but further rigorous research is needed to establish their validity. Clinical consensus and research appear to support selective serotonin reuptake inhibitors as a first choice for the pharmacological treatment of depression in patients with dementia. However, initial support for these therapies remains variable, and further investigation is needed. Extra care is required in prescribing to this population because of the generally high level of medical and psychiatric comorbidity and the potential difficulty in assessing the cognitively impaired patient’s response.

Gastrointestinal symptoms are associated with trajectories of chemotherapy-induced nausea

Between 19 and 58% of oncology patients experience chemotherapy-induced nausea (CIN). In a sample of outpatients with breast, gastrointestinal (GI), gynecological, and lung cancer, the study purposes were to evaluate for inter-individual differences in the severity of CIN over two cycles of chemotherapy (CTX) and to determine which demographic and clinical characteristics and GI symptoms were associated with higher initial levels as well as with the trajectories of CIN severity. Patients completed study questionnaires at six time points over two cycles of CTX. These questionnaires provided information on demographic and clinical characteristics, as well as the occurrence of twelve GI symptoms. Hierarchical linear modeling based on full maximum likelihood estimation was performed. Of the 1251 patients, 47.2% reported CIN. Across two cycles of CTX, lower functional status scores and higher levels of comorbidity were associated with higher initial levels of CIN. Younger age and emetogenicity of the CTX regimen were associated with higher initial levels as well as worse trajectories of CIN. The occurrence of five GI symptoms (i.e., vomiting, lack of appetite, constipation, feeling bloated, and difficulty swallowing) was associated with higher initial levels of CIN. The occurrence of mouth sores was associated with higher initial levels as well as with worst trajectories of CIN. This study is the first to identify distinct demographic, clinical, and GI symptom characteristics associated with CIN severity. These findings suggest that the etiology of CIN is complex and may warrant interventions beyond standard antiemetics.

Premature mortality of people with personality disorder in the Nottingham Study of Neurotic Disorder.

It is known that people with personality disorders die prematurely. This may be connected to high levels of co-morbidity with other psychiatric disorders. To test whether mortality was independent, deaths were examined in a 31-year cohort study of anxious and depressed patients (Nottingham Study of Neurotic Disorder) who also had their personality status assessed at baseline. The severity of personality disturbance was assessed using a method previously used to separate personality disorders into ICD-11 categories. Over the follow-up period, 71 of the cohort of 201 patients had died. Age at death was 5.1 (M) and 5.2 (F) years younger in those with personality disorder compared with no personality disorder, but after adjusting for age at randomization and clinical diagnosis at baseline, these differences reduced to 1.5 (M) and 1.6 (F) years. The longevity of the group was 12 to 18 years less than the general population (p < 0.0001), reinforcing previous findings of premature mortality in common mental illness. Analysis of causes of death showed no meaningful differences in personality groups. The hypothesis that premature death in personality disturbance is independent of mental health status was not supported in this study, despite other evidence from this cohort that general clinical outcome is worse in those with personality disorder. © 2019 John Wiley & Sons, Ltd.