The impact of body composition parameters on ipilimumab toxicity and survival in patients with metastatic melanoma.

BACKGROUND: Body composition is an important predictor of drug toxicity and outcome. Ipilimumab (Ipi), a monoclonal antibody used to treat metastatic melanoma, has specific toxicities. No validated biomarkers that predict Ipi toxicity and efficacy exist. Also, the impact of Ipi on body composition has not been established. METHODS: Patients with metastatic melanoma treated with Ipi between 2009 and 2015 were included. Body composition was assessed by computed tomography at baseline and after four cycles of Ipi. Sarcopenia and low muscle attenuation (MA) were defined using published cut-points. All adverse events (AEs) and immune-related AEs (irAEs) were recorded (Common Terminology Criteria For Adverse Event V.4.0). RESULTS: Eighty-four patients were included in this study (62% male, median age 54 years). At baseline, 24% were sarcopenic and 33% had low MA. On multivariate analysis, sarcopenia and low MA were significantly associated with high-grade AEs (OR=5.34, 95% CI: 1.15-24.88, P=0.033; OR=5.23, 95% CI: 1.41-19.30, P=0.013, respectively), and low MA was associated with high-grade irAEs (OR=3.57, 95% CI: 1.09-11.77, P=0.036). Longitudinal analysis (n=59) revealed significant reductions in skeletal muscle area (SMA), total body fat-free mass, fat mass (all P<0.001) and MA (P=0.030). Mean reduction in SMA was 3.3%/100 days (95% CI: -4.48 to -1.79%, P<0.001). A loss of SMA ⩾7.5%/100 days (highest quartile) was a significant predictor of overall survival in multivariable Cox regression analysis (HR: 2.1, 95% CI: 1.02-4.56, P=0.046). CONCLUSIONS: Patients with sarcopenia and low MA are more likely to experience severe treatment-related toxicity to Ipi. Loss of muscle during treatment was predictive of worse survival. Treatments to increase muscle mass and influence outcome warrant further investigation.

Serum ferritin in plateletpheresis and whole blood donors.

BACKGROUND AND OBJECTIVES: We performed a prospective analysis of iron status in plateletpheresis donors, using whole blood donors as a control group, to assess the haematinic effects of regular anti-coagulated extracorporeal circulation and platelet collection. MATERIALS AND METHODS: Ferritin levels were measured in samples from 31 regular male plateletpheresis donors and from 14 first time male whole blood donors, immediately before and immediately after donation, and immediately before the next donation. An additional 33 regular male plateletpheresis donors and 17 first time male whole blood donors had serum ferritin levels checked predonation. RESULTS: Male plateletpheresis donors had a statistically significant fall in serum ferritin after donation (P = 0.005)*. In addition, male platelet donors had significantly lower serum ferritin levels than first time male blood donors: ferritin <20 µg/L was found in 6/64 (9%) of regular platelet donors and 1/31 (3%) of first time blood donors (P < 0.001)*. DISCUSSION: Our studies support the value of serum ferritin measurement in apheresis donor management.

Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations and case recognition.

BACKGROUND: Previous studies have indicated a prevalence of dementia in older admissions of ∼42% in a single London teaching hospital, and 21% in four Queensland hospitals. However, there is a lack of published data from any European country on the prevalence of dementia across hospitals and between patient groups. OBJECTIVE: To determine the prevalence and associations of dementia in older patients admitted to acute hospitals in Ireland. METHODS: Six hundred and six patients aged ≥70 years were recruited on admission to six hospitals in Cork County. Screening consisted of Standardised Mini-Mental State Examination (SMMSE); patients with scores <27/30 had further assessment with the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Final expert diagnosis was based on SMMSE, IQCODE and relevant medical and demographic history. Patients were screened for delirium and depression, and assessed for co-morbidity, functional ability and nutritional status. RESULTS: Of 598 older patients admitted to acute hospitals, 25% overall had dementia; with 29% in public hospitals. Prevalence varied between hospitals (P < 0.001); most common in rural hospitals and acute medical admissions. Only 35.6% of patients with dementia had a previous diagnosis. Patients with dementia were older and frailer, with higher co-morbidity, malnutrition and lower functional status (P < 0.001). Delirium was commonly superimposed on dementia (57%) on admission. CONCLUSION: Dementia is common in older people admitted to acute hospitals, particularly in acute medical admissions, and rural hospitals, where services may be less available. Most dementia is not previously diagnosed, emphasising the necessity for cognitive assessment in older people on presentation to hospital.

The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents.

BACKGROUND: Becoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood. OBJECTIVES: We aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PROs trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care. METHODS: B2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PROs trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health. IMPLICATIONS: If B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Strategy for the reduction of Trichloromethane residue levels in farm bulk milk.

High fat dairy products, such as butter and margarine can be contaminated during the milk production process with a residue called Trichloromethane (TCM), which results from the use of chlorine based detergent solutions. Although, TCM concentrations in Irish products are not at levels that are a public health issue, such contamination can cause marketing difficulties in countries to which Irish products are being exported. In an attempt to reduce such milk residues, a template procedure was developed, tried and tested on 43 farms (from 3 processing companies). This involved identifying farms with high TCM milk, applying corrective action in the form of advice and recommendations to reduce TCM and re-measuring milks from these farms. Trichloromethane in milk was measured by head-space gas chromatography with electron capture detector. The TCM reduction strategy proved successful in significantly reducing the levels in milk in the farms tested, e.g. TCM was reduced from 0.006 to the target of 0.002 mg/kg (P < 0.05). The strategy was then applied to farms who supplied milk to six Irish dairy processors with the objective of reducing TCM in those milks to a level of ≤ 0.002 mg/kg. Initially, milk tankers containing milks from approximately 10-15 individual farms were sampled and analysed and tankers with high TCM (>0.002 mg/kg) identified. Individual herd milks contributing to these tankers were subsequently sampled and analysed and farms supplying high TCM identified. Guidance and advice was provided to the high TCM milk suppliers and levels of TCM of these milk supplies were monitored subsequently. A significant reduction (minimum P < 0.05) in milk TCM was observed in 5 of the 6 dairy processor milks, while a numerical reduction in TCM was observed in the remaining processor milk.

The Reasoning and Regulating Medication Adherence Instrument for patients with coronary artery disease: development and psychometric evaluation.

BACKGROUND: Many patients experience difficulty taking medications resulting in suboptimal adherence. Ambiguity surrounding adherence issues in chronic illness has been exacerbated by a lack of patient-centered, medication-specific, and theoretically integrative measurement instruments. AIM: To develop a reliable and valid instrument to measure the factors that influence adherence in patients prescribed pharmacotherapy for coronary artery disease. METHODS: Phase 1 involved the development of instrument structure and content. Constructs to be measured were defined through an analysis of adherence literature and qualitative interviews with patients. Phase 2 established the psychometric properties of the instrument. Exploratory factor analyses, reliability, and validity estimations were undertaken with a sample of patients (n = 404) from 3 tertiary cardiology referral centers. RESULTS: Factor analyses resulted in a logically coherent, 16-item, three-factor solution that explained 50.5% variance. The factors were labelled: "Medication Planning Strategies," "Health Risk, and Health Protection." Internal consistency reliability met acceptable standards (alpha = .700 to alpha = .785). Fair to excellent intraclass correlations for temporal stability were demonstrated (.498-.882). Preliminary construct validity was supported by promising findings in relation to content validity results and factor structure stability. CONCLUSIONS: A new adherence instrument for patients on pharmacotherapy for coronary artery disease has been developed and initial psychometric properties have been established. Additional instrument validation will be directed at further establishing construct and criterion-related validity. It is intended that this measure will be useful in identifying factors that impede or facilitate adherent behavior and contribute to advancing the science of instrument development within adherence research.

Classification of array CGH data using smoothed logistic regression model.

Array comparative genomic hybridization (aCGH) provides a genome-wide information of DNA copy number that is potentially useful for disease classification. One immediate problem is that the data contain many features (probes) but only a few samples. Existing approaches to overcome this problem include features selection, ridge regression and partial least squares. However, these methods typically ignore the spatial characteristic of aCGH data. To explicitly make use of this spatial information we develop a procedure called smoothed logistic regression (SLR) model. The procedure is based on a mixed logistic regression model, where the random component is a mixture distribution that controls smoothness and sparseness. Conceptually such a procedure is straightforward, but its implementation is complicated due to computational problems. We develop a fast and reliable iterative weighted least-squares algorithm based on the singular value decomposition. Simulated data and two real data sets are used to illustrate the procedure. For real data sets, error rates are calculated using the leave-one-out cross validation procedure. For both simulated and real data examples, SLR achieves better misclassification error rates compared with previous methods.

The Patient-Held Active Record of Medication Status (PHARMS) study: a mixed-methods feasibility analysis.

BACKGROUND: Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue. AIM: To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge. DESIGN AND SETTING: A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland. METHOD: The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process. RESULTS: In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders. CONCLUSION: The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error.

Robust smooth segmentation approach for array CGH data analysis.

MOTIVATION: Array comparative genomic hybridization (aCGH) provides a genome-wide technique to screen for copy number alteration. The existing segmentation approaches for analyzing aCGH data are based on modeling data as a series of discrete segments with unknown boundaries and unknown heights. Although the biological process of copy number alteration is discrete, in reality a variety of biological and experimental factors can cause the signal to deviate from a stepwise function. To take this into account, we propose a smooth segmentation (smoothseg) approach. METHODS: To achieve a robust segmentation, we use a doubly heavy-tailed random-effect model. The first heavy-tailed structure on the errors deals with outliers in the observations, and the second deals with possible jumps in the underlying pattern associated with different segments. We develop a fast and reliable computational procedure based on the iterative weighted least-squares algorithm with band-limited matrix inversion. RESULTS: Using simulated and real data sets, we demonstrate how smoothseg can aid in identification of regions with genomic alteration and in classification of samples. For the real data sets, smoothseg leads to smaller false discovery rate and classification error rate than the circular binary segmentation (CBS) algorithm. In a realistic simulation setting, smoothseg is better than wavelet smoothing and CBS in identification of regions with genomic alterations and better than CBS in classification of samples. For comparative analyses, we demonstrate that segmenting the t-statistics performs better than segmenting the data. AVAILABILITY: The R package smoothseg to perform smooth segmentation is available from http://www.meb.ki.se/~yudpaw.

Self-collected versus health professional-collected genital swabs to identify the prevalence of group B streptococcus: a comparison of patient preference and efficacy.

OBJECTIVE: This study aims to determine the prevalence of genital tract group B streptococcus (GBS) colonization in a cohort of pregnant Irish women and to compare patient preference and efficacy of self-collected versus health professional-collected swabs. STUDY DESIGN: In this prospective cohort study, 600 pregnant women attending public and private antenatal clinics at the Unified Maternity Services, Cork were included. At 35-37 weeks of pregnancy, these women self-collected an ano-vaginal swab and a health professional-collected a second swab on same clinic visit. The women filled a questionnaire to indicate their preferences. Statistical analysis was performed on SPSS Version 13. RESULT: The cumulative prevalence of maternal GBS colonization was 11.7% (95% CI, 9.3-14.6). The sensitivity of the self-collected swab was 84.3% (95% CI, 73.2-91.5) and that of health professional-collected swab was 94.3% (95% CI, 85.3-98.2). While good agreement in efficacy was found between health professional and patient-collected swabs (Kappa=0.87, p<0.001, 97.5% measure of concordance), only 28.5% women preferred self-collection, while 43.2% preferred a health professional to collect the swab and 28.3% had no preference. CONCLUSION: In our study the concordance between health professional and self-collected swab was excellent. However, pregnant women mainly prefer a health professional to collect their ano-vaginal swabs.

Surgical and visual outcomes following exchange of opacified Hydroview intraocular lenses.

AIM: To report the clinical and surgical outcomes following exchange of opacified Hydroview intraocular lenses (IOLs), and to relate the final visual and anatomic results to clinical and surgical variables. METHODS: This is a prospective study of seventy-three eyes that underwent exchange of opacified Hydroview IOLs in Waterford Regional Hospital, Ireland. Preoperative, intraoperative and postoperative details were recorded. RESULTS: This study comprised 73 eyes of 71 consecutive patients undergoing IOL exchange, performed at mean (+/-SD) intervals of 36.64 (+/-9.9) months following the primary cataract surgery. The mean (+/-SE) follow-up following the exchange procedure was 13 (+/-1) months (range: 1-45 months). The secondary IOL was placed in the capsular bag, in the sulcus, and in the anterior chamber in 22 (30.1%), 24 (32.9%) and 27 (37%) cases, respectively. The IOL exchange procedure was uneventful in 36 eyes (49.3%), whereas intraoperative events such as posterior capsule rupture, vitreous loss and zonular dehiscence were seen in the remainder (50.7%). Following the IOL exchange procedure, a significant improvement in best corrected visual acuity (BCVA) was noted at one and at three months, and at the final visit (Wilcoxon signed ranks test: p<0.001, p = 0.006, and p<0.001, respectively). Following exclusion of eyes with visually consequential ocular comorbidity, a better final BCVA was noted among those eyes where the secondary IOL was placed in the capsular bag or in the sulcus when compared with placement of the secondary IOL in the anterior chamber (IOL in the bag or sulcus: 26 eyes (35.6%), median (IQR) final BCVA: 0.2 (0.10-0.40); IOL in the anterior chamber: 19 eyes (26.02%), median (IQR) final BCVA: 0.5 (0.20-0.60); Mann Whitney U Test: p = 0.004). CONCLUSION: IOL exchange is a technically challenging, but visually rewarding procedure. However, placement of the secondary IOL in the anterior chamber is associated with a poorer visual outcome when compared with placement of the secondary IOL in the sulcus or in the capsular bag.

Prospective evaluation of the referral pattern to restorative dentistry consultation clinics in Ireland.

The objective of this study was to analyse pattern of referral to Restorative Dentistry Consultation Clinics in a Dental Teaching Hospital. Patient demographic details and referral information were collected on new patient clinics. The majority of patients were female (62.1%). The greatest proportion of patients, 41.6%, was referred from the adjacent urban area. The highest percentage of referrals was from general practitioners, (37.6%). The main referral reasons were periodontal (24.7%), fixed prosthodontics (18.6%), endodontics (10.7%) and removable prosthodontics (8.3%). The study clearly showed that the majority of patients referred were female and from close proximity to the Hospital. Patients were referred for a broad range of restorative reasons.

The relationship between information carrying words, memory and language skills in school age children with specific language impairment.

The receptive language measure information-carrying word (ICW) level, is used extensively by speech and language therapists in the UK and Ireland. Despite this it has never been validated via its relationship to any other relevant measures. This study aims to validate the ICW measure by investigating the relationship between the receptive ICW score of children with specific language impairment (SLI) and their performance on standardized memory and language assessments. Twenty-seven children with SLI, aged between 5;07 and 8;11, completed a sentence comprehension task in which the instructions gradually increased in number of ICWs. The children also completed subtests from The Working Memory Test Battery for children and The Clinical Evaluation of Language Fundamentals- 4. Results showed that there was a significant positive relationship between both language and memory measures and children's ICW score. While both receptive and expressive language were significant in their contribution to children's ICW score, the contribution of memory was solely determined by children's working memory ability. ICW score is in fact a valid measure of the language ability of children with SLI. However therapists should also be cognisant of its strong association with working memory when using this construct in assessment or intervention methods.

Body Composition by Computed Tomography as a Predictor of Toxicity in Patients With Renal Cell Carcinoma Treated With Sunitinib.

BACKGROUND: Sunitinib is a standard first-line option for metastatic renal cell carcinoma (mRCC). Body composition is a prognostic factor in cancer patients and patients with loss of skeletal muscle mass and fat-free mass (FFM) are prone to dose-limiting toxicity (DLT) during targeted drug therapy. We investigated whether body composition by computed tomography predicted DLT from sunitinib in mRCC. METHODS: Patients with clear cell mRCC receiving sunitinib (50 mg) were included. Skeletal muscle cross-sectional area at L3 was measured by computed tomography. Sarcopenia was defined using published cutoffs. Toxicity was assessed after 4 cycles of the drug. RESULTS: Fifty-five patients (43 male), mean age 64 years were included. Overall, 33% (N=18) of all patients were sarcopenic and of these 12.7% (N=7) were sarcopenic and overweight or obese. DLT occurred in <6 months in 53% of patients (44% male vs. 83% female) and those who experienced DLT were older (68 vs. 60 y), had a lower skeletal muscle index (51.7 vs. 59.4 cm/m), a lower FFM (51.4 vs. 57.7 kg), and received a higher drug dose in mg/kg FFM (0.9 vs. 0.8). Patients with the lowest compared with the highest measurements of skeletal muscle mass experienced more DLT, respectively, 92% versus 57% and experienced on average 5 toxicities versus 2. CONCLUSIONS: Sarcopenia is prevalent in patients with mRCC, is an occult condition in patients with normal/high body mass index, and is a significant predictor of DLT in patients receiving sunitinib. Our results highlight the potential use of baseline body composition to predict toxicity.

Design and evaluation of a novel subatmospheric pressure bioreactor for the preconditioning of tissue-engineered vascular constructs.

PURPOSE: The pre-conditioning of tissue-engineered vascular scaffolds with mechanical stimuli is being recognised as an essential step in producing a functional vascular construct. In this study we design and evaluate a novel bioreactor, which exerts a mechanical strain on developing vascular scaffolds via subatmospheric pressure. METHODS: We design and construct a bioreactor, which exerts subatmospheric pressure via a vacuum assisted closure unit. Vascular scaffolds seeded with human umbilical endothelial cells were evaluated for structural integrity, microbial contamination, cellular viability, von Willebrand factor (VWF) production, cell proliferation and morphology under a range of subatmospheric pressures (75-200mmHg). RESULTS: The bioreactor produced sustained subatmospheric pressures, which exerted a mechanical strain on the vascular scaffold. No microbial contamination was found during the study. The structural integrity of the vascular construct was maintained. There was no difference in cellular viability between control or subatmospheric pressure groups (p = 0.817). Cells continued to produce VWF under a range of subatmospheric pressures. Cells subjected to subatmospheric pressures of 125mmHg and 200mmHg exhibited higher levels of growth than cells in atmospheric pressure at 24 (p≤0.016) and 48 hour (p≤0.001). Negative pressure affected cellular morphology, which were more organised, elongated and expanded when exposed to subatmospheric pressure. CONCLUSIONS: We have constructed and validated a novel subatmospheric bioreactor. The bioreactor maintained a continuous subatmospheric pressure to the vascular scaffolds in a stable, sterile and constant environment. The bioreactor exerted a strain on the vascular sheets, which was shown to alter cellular morphology and enhance cellular proliferation.

Impact of body composition parameters on clinical outcomes in patients with metastatic castrate-resistant prostate cancer treated with docetaxel.

BACKGROUND: Body composition may influence clinical outcomes of certain chemotherapeutic agents. We examined the prognostic significance of skeletal muscle mass and adipose tissue on docetaxel toxicity and overall survival in patients with metastatic castrate resistant prostate cancer (mCRPC). METHODS: A retrospective review of patients medical records with mCRPC, treated with docetaxel was conducted. Body composition parameters (skeletal muscle mass, muscle attenuation [MA], visceral and subcutaneous adipose tissue) were measured at L3 by computed tomography (CT) and defined using previously established cut points. Toxicity profile was assessed after 3 cycles of the drug and graded according to the National Cancer Institute Common Toxicity Criteria (version 4). Overall survival was analysed. RESULTS: Overall 63 patients, mean age 69 years (SD 8.3), were included. Sarcopenia was present in 47% (n = 30) and of these 26.7% (8/30) were sarcopenic obese. Common toxicities (all grades) observed included fatigue (80.9%), pain (46%), and constipation (34.9%). DLT occurred in 22 (34.9%) patients; of these 10 patients (15.8%) experienced dose reductions and 12 patients (19%) experienced dose terminations. Measurements of adiposity were not predictive of DLT, however 59.1% patients who had a combination of both sarcopenia and low MA experienced DLT compared to 29.3% of patients without sarcopenia and low MA (p = 0.021). Skeletal muscle index and MA were significantly lower in patients who experienced neutropenia (grade I-II) (46.5 cm2/m2 vs. 51.2 cm2/m2, p = 0.005) compared to their counterparts (24.6 HU vs. 32.2 HU, p = 0.044). Neither sarcopenia nor sarcopenic obesity was associated with overall survival. In multivariate analysis, BMI ≥25 kg/m2 (HR: 0.349, CI: 0.156-0.782, p = 0.010) was a significant predictor of longer overall survival and both visceral fat index ≥ median 58.7 cm2/m2 (HR: 2.266 CI: 1.066-4.814, p = 0.033) and anaemia (HR: 2.81, CI: 1.297-6.091, p = 0.009) were significant predictors of shorter overall survival. CONCLUSIONS: Sarcopenia and low MA are associated with neutropenia (grade I-II). Furthermore, presence of anaemia, high volume of visceral fat and BMI <25 kg/m2 are associated with reduced survival in patients with castrate resistant prostate cancer being treated with docetaxel chemotherapy.

Virtually driving: are the driving environments "real enough" for exposure therapy with accident victims? An explorative study.

There is a small but growing body of research supporting the effectiveness of computer-generated environments in exposure therapy for driving phobia. However, research also suggests that difficulties can readily arise whereby patients do not immerse in simulated driving scenes. The simulated driving environments are not "real enough" to undertake exposure therapy. This sets a limitation to the use of virtual reality (VR) exposure therapy as a treatment modality for driving phobia. The aim of this study was to investigate if a clinically acceptable immersion/presence rate of >80% could be achieved for driving phobia subjects in computer generated environments by modifying external factors in the driving environment. Eleven patients referred from the Accident and Emergency Department of a general hospital or from their General Practitioner following a motor vehicle accident, who met DSM-IV criteria for Specific Phobia-driving were exposed to a computer-generated driving environment using computer driving games (London Racer/Midtown Madness). In an attempt to make the driving environments "real enough," external factors were modified by (a) projection of images onto a large screen, (b) viewing the scene through a windscreen, (c) using car seats for both driver and passenger, and (d) increasing vibration sense through use of more powerful subwoofers. Patients undertook a trial session involving driving through computer environments with graded risk of an accident. "Immersion/presence" was operationally defined as a subjective rating by the subject that the environment "feels real," together with an increase in subjective units of distress (SUD) ratings of >3 and/or an increase of heart rate of >15 beats per minute (BPM). Ten of 11 (91%) of the driving phobic subjects met the criteria for immersion/presence in the driving environment enabling progression to VR exposure therapy. These provisional findings suggest that the paradigm adopted in this study might be an effective and relatively inexpensive means of developing driving environments "real enough," to make VR exposure therapy a viable treatment modality for driving phobia following a motor vehicle accident (MVA).

Exploring the use of computer games and virtual reality in exposure therapy for fear of driving following a motor vehicle accident.

Specific phobia, situational type-driving, induced by accident (accident phobia) occurs in 18-38% of those involved in a vehicular accident of sufficient severity to warrant referral to the emergency departments of a general hospital. The objective is to investigate, in an open study, the effectiveness of the combined use of computer generated environments involving driving games (game reality [GR]) and a virtual reality (VR) driving environment in exposure therapy for the treatment of driving phobia following a motor vehicle accident (MVA) program. Fourteen subjects who met DSM-IV criteria for Simple Phobia/Accident Phobia and were referred from the emergency department of a general hospital were exposed to a Virtual Driving Environment (Hanyang University Driving Phobia Environment) and computer driving games (London Racer/Midtown Madness/Rally Championship). Patients who experienced "immersion" (i.e., a sense of presence with heightened anxiety) in one of the driving simulations (defined as an increase in SUD ratings of 3 and/or an increase of heart rate > 15 BPM in a 1-h trial session of computer simulation driving) were exposed to a cognitive behavioral program of up to 12 1-h sessions involving graded driving simulation tasks with self-monitoring, physiological feedback, diaphragmatic breathing and cognitive reappraisal. Subjects were assessed at the beginning and end of therapy with measurements of: physiological responsivity (heart rate), subjective ratings of distress (SUD), rating scales for severity of fear of driving (FDI), Posttraumatic Stress Disorder (CAPS) and depression (HAM-D) and achievement of target behaviors. Of all patients 7/14 (50%) became immersed in the driving environments. This immersed group (n = 7) completed the exposure program. Pre- and post-treatment comparisons showed significant post treatment reductions on all measures SUDS (p = 0.008), FDI (p = 0.008), CAPS (p = 0.008), HR (p = 0.008), CAPS (p = 0.008), HAM-D (p = 0.031). Further analysis of the FDI showed significant reductions in all three subscales: travel distress (p = 0.008), travel avoidance (p = 0.008), and maladaptive driving strategies (p = 0.016). The findings of this study suggest that VR and GR may have a useful role in the treatment of driving phobia post-accident even when co-morbid conditions such as post-traumatic stress disorder and depression are present.

Delirium in an adult acute hospital population: predictors, prevalence and detection.

BACKGROUND: To date, delirium prevalence and incidence in acute hospitals has been estimated from pooled findings of studies performed in distinct patient populations. OBJECTIVE: To determine delirium prevalence across an acute care facility. DESIGN: A point prevalence study. SETTING: A large tertiary care, teaching hospital. PATIENTS: 311 general hospital adult inpatients were assessed over a single day. Of those, 280 had full data collected within the study's time frame (90%). MEASUREMENTS: Initial screening for inattention was performed using the spatial span forwards and months backwards tests by junior medical staff, followed by two independent formal delirium assessments: first the Confusion Assessment Method (CAM) by trained geriatric medicine consultants and registrars, and, subsequently, the Delirium Rating Scale-Revised-98 (DRS-R98) by experienced psychiatrists. The diagnosis of delirium was ultimately made using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria. RESULTS: Using DSM-IV criteria, 55 of 280 patients (19.6%) had delirium versus 17.6% using the CAM. Using the DRS-R98 total score for independent diagnosis, 20.7% had full delirium, and 8.6% had subsyndromal delirium. Prevalence was higher in older patients (4.7% if <50 years and 34.8% if >80 years) and particularly in those with prior dementia (OR=15.33, p<0.001), even when adjusted for potential confounders. Although 50.9% of delirious patients had pre-existing dementia, it was poorly documented in the medical notes. Delirium symptoms detected by medical notes, nurse interview and patient reports did not overlap much, with inattention noted by professional staff, and acute change and sleep-wake disturbance noted by patients. CONCLUSIONS: Our point prevalence study confirms that delirium occurs in about 1/5 of general hospital inpatients and particularly in those with prior cognitive impairment. Recognition strategies may need to be tailored to the symptoms most noticed by the detector (patient, nurse or primary physician) if formal assessments are not available.