Influence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study.

BACKGROUND: Non-specific low back pain is a frequent reason for consultation, yet little is known about how general practitioners manage it in France. OBJECTIVES: To describe the healthcare procedures general practitioners prescribe for low back pain in France. MATERIALS AND METHODS: This is an ancillary analysis of an observational, cross-sectional study (ECOGEN) conducted between November 2011 and April 2012 among 128 general practitioners. Adults younger than 65 years consulting for low back pain were included. Patient and general practitioner characteristics, consultation results (diagnosis) and healthcare procedures were collected and coded using the International Classification in Primary Care. Analyses focused on the initial or follow-up consultation, adjusting on age, gender, and socio-occupational category. RESULTS AND DISCUSSION: Out of 11510 consultations, 845 (7.3%) were for low back pain. Of these, 776 (79.5%) resulted in a clinical examination, 634 (73.4%) in medication prescription, and 203 (23.9%) were prescribed sick leave, but imaging and specialist referral were rare. Imaging was more frequent with radiating pain (adjusted odds ratio (aOR) = 1.61; 95% CI [1.07, 2.42]), as were specialist referrals (OR = 2.92; 95% CI [1.40, 6.09]) and sick leave prescription (aOR = 1.52; 95% CI [1.10, 2.09]), but physiotherapist referral was less frequent (aOR = 0.55; 95% CI [0.38, 0.82]). Clinical examinations (aOR = 2.75; 95% CI [1.98, 3.80]), imaging (aOR = 1.61; 95% CI [1.02, 2.31]) and medication prescriptions (aOR = 2.34; 95% CI [1.65, 3.30]) were more common in initial consultations, but specialist referral (aOR = 0.16; 95% CI [0.05, 0.47]) or sick leave prescription (aOR = 0.68; 95% CI [0.48, 0.97]) were rarer. CONCLUSION: Low back pain characteristics could influence healthcare procedures more markedly than patient or general practitioner characteristics.

Dissociation between decision-making under risk and decision-making under ambiguity in premanifest and manifest Huntington's disease.

We investigated decision-making under ambiguity (DM-UA) and decision making under risk (DM-UR) in individuals with premanifest and manifest Huntington's disease (HD). Twenty individuals with premanifest HD and 23 individuals with manifest HD, on one hand, and 39 healthy individuals divided into two control groups, on the other, undertook a modified version of the Iowa Gambling Task (IGT), an adaptation of a DM-UA task, and a modified version of the Game of Dice Task (GDT), an adaptation of a DM-UR task. Participants also filled in a questionnaire of impulsivity and responded to cognitive tests specifically designed to assess executive functions. Compared to controls, individuals with premanifest HD were unimpaired in performing executive tests as well as in decision-making tasks, except for the Stroop task. In contrast, individuals with manifest HD were impaired in both the IGT and executive tasks, but not in the GDT. No sign of impulsivity was observed in individuals with premanifest or manifest HD. Our results suggest that the progression of HD impairs DM-UA without affecting DM-UR, and indicate that decision-making abilities are preserved during the premanifest stage of HD.

Impaired Decision Making and Loss of Inhibitory-Control in a Rat Model of Huntington Disease.

Cognitive deficits associated with Huntington disease (HD) are generally dominated by executive function disorders often associated with disinhibition and impulsivity/compulsivity. Few studies have directly examined symptoms and consequences of behavioral disinhibition in HD and its relation with decision-making. To assess the different forms of impulsivity in a transgenic model of HD (tgHD rats), two tasks assessing cognitive/choice impulsivity were used: risky decision-making with a rat gambling task (RGT) and intertemporal choices with a delay discounting task (DD). To assess waiting or action impulsivity the differential reinforcement of low rate of responding task (DRL) was used. In parallel, the volume as well as cellular activity of the amygdala was analyzed. In contrast to WT rats, 15 months old tgHD rats exhibited a poor efficiency in the RGT task with difficulties to choose advantageous options, a steep DD curve as delays increased in the DD task and a high rate of premature and bursts responses in the DRL task. tgHD rats also demonstrated a concomitant and correlated presence of both action and cognitive/choice impulsivity in contrast to wild type (WT) animals. Moreover, a reduced volume associated with an increased basal cellular activity of the central nucleus of amygdala indicated a dysfunctional amygdala in tgHD rats, which could underlie inhibitory dyscontrol. In conclusion, tgHD rats are a good model for impulsivity disorder that could be used more widely to identify potential pharmacotherapies to treat these invasive symptoms in HD.

Theory of mind and empathy in preclinical and clinical Huntington's disease.

We investigated cognitive and affective Theory of Mind (ToM) and empathy in patients with premanifest and manifest Huntington's disease (HD). The relationship between ToM performance and executive skills was also examined. Sixteen preclinical and 23 clinical HD patients, and 39 healthy subjects divided into 2 control groups were given a French adaptation of the Yoni test (Shamay-Tsoory, S.G., Aharon-Peretz, J. (2007). Dissociable prefrontal networks for cognitive and affective theory of mind: a lesion study. Neuropsychologia, 45(3), 3054-67) that examines first- and second-order cognitive and affective ToM processing in separate conditions with a physical control condition. Participants were also given questionnaires of empathy and cognitive tests which mainly assessed executive functions (inhibition and mental flexibility). Clinical HD patients made significantly more errors than their controls in the first- and second-order cognitive and affective ToM conditions of the Yoni task, but exhibited no empathy deficits. However, there was no evidence that ToM impairment was related to cognitive deficits in these patients. Preclinical HD patients were unimpaired in ToM tasks and empathy measures compared with their controls. Our results are consistent with the idea that impaired affective and cognitive mentalizing emerges with the clinical manifestation of HD, but is not necessarily part of the preclinical stage. Furthermore, these impairments appear independent of executive dysfunction and empathy.

Reduced impact of emotion on choice behavior in presymptomatic BACHD rats, a transgenic rodent model for Huntington Disease.

Executive dysfunction and psychiatric symptoms are hallmarks of Huntington disease (HD), a neurodegenerative disorder genetically characterized by expanded CAG repeats in the HTT gene. Using the BACHD rat model of HD (97 CAG-CAA repeats), the present research seeks to characterize the progressive emergence of decision-making impairments in a rat version of the Iowa Gambling Task (RGT) and the impact of emotional modulation, whether positive or negative, on choice behavior. The choice efficiency shown both by WT rats (independent of their age) and the youngest BACHD rats (2 and 8months old) evidenced that they are able to integrate outcomes of past decisions to determine expected reward values for each option. However, 18months old BACHD rats made fewer choices during the RGT session and were less efficient in choosing advantageous options than younger animals. Presenting either chocolate pellets or electrical footshocks half-way through a second RGT session reduced exploratory activity (inefficient nose-poking) and choices with a weaker effect on BACHD animals than on WT. Choice efficiency was left intact in transgenic rats. Our results bring new knowledge on executive impairments and impact of emotional state on decision-making at different stages of the disease, increasing the face-validity of the BACHD rat model.