Introduction of a homeless health outreach team in Northern New South Wales: is acute service usage reduced?

OBJECTIVE: To examine if there is a relationship between introducing a Homeless Health Outreach Team (HHOT) and reduced acute Mental Health service usage. METHODS: Electronic Medical Record (EMR) data were collected on a group of clients of the Tweed Byron HHOT 6 months before and after establishing the service. The data were evaluated for demographics, and differences in Emergency Department (ED) presentations, mental health admissions, length of stay and community mental health engagement. RESULTS: The introduction of the team coincided with a significant reduction in ED presentations and an increase in community mental health engagement. There was an overall reduction in bed days but an increase in mean length of stay for those admitted post-intervention. CONCLUSIONS: The establishment of the HHOT coincided with reduced acute mental health service usage via ED and inpatient Mental Health Units (MHU). There is scope for expansion of such a service as well as exploration of costings analysis. A long-term focus on 'housing first' and outreach approaches to homeless service provision could improve individual and service provision outcomes.

Transdiagnostic internet-delivered CBT and mindfulness-based treatment for depression and anxiety: A randomised controlled trial.

AIM: To examine the efficacy of transdiagnostic internet-delivered cognitive behavioural therapy (iCBT), mindfulness-enhanced iCBT, and stand-alone online mindfulness training compared with a usual care control group (TAU) for clinical anxiety and depression. METHOD: Individuals (N = 158) with a DSM-5 diagnosis of a depressive and/or anxiety disorder were randomised to one of the three clinician-guided online interventions, or TAU over a 14-week intervention period. The primary outcomes were self-reported depression (PHQ-9) and anxiety (GAD-7) severity at post-treatment. Secondary outcomes included adherence rates, functional impairment (WHODAS-II), general distress (K-10), and diagnostic status at the 3-month follow-up (intervention groups). RESULTS: All three programs achieved significant and large reductions in symptoms of depression (g = 0.89-1.53), anxiety (g = 1.04-1.40), and distress (g = 1.25-1.76); and medium to large reductions in functional impairment (g = 0.53-0.98) from baseline to post-treatment and 3-month follow-up. Intention-to-treat linear mixed models showed that all three online programs were superior to usual care at reducing symptoms of depression (g = 0.89-1.18) and anxiety (g = 1.00-1.23). CONCLUSION: Transdiagnostic iCBT, mindfulness-enhanced iCBT and online mindfulness training are more efficacious for treating depression and anxiety disorders than usual care, and represent an accessible treatment option for these disorders.

Reboot Online: A Randomized Controlled Trial Comparing an Online Multidisciplinary Pain Management Program with Usual Care for Chronic Pain.

OBJECTIVE: Chronic pain is a prevalent and burdensome condition. Reboot Online was developed to address treatment barriers traditionally associated with accessing face-to-face chronic pain management programs. It is a comprehensive multidisciplinary online treatment program, based on an existing and effective face-to-face multidisciplinary pain program (the Reboot program). DESIGN & PARTICIPANTS: A CONSORT-compliant randomized controlled trial was conducted, enrolling adults who had experienced pain for three months or longer. METHODS: Participants were randomly allocated to either an eight-lesson multidisciplinary pain management program, Reboot Online (N = 41), or to a usual care (UC) control group (N = 39). Clinical oversight was provided by a multidisciplinary team remotely, including physiotherapists and clinical psychologists. Participants were measured at baseline, post-treatment (week 16), and three-month follow-up (week 28). RESULTS: Intention-to-treat analyses revealed that Reboot Online was significantly more effective than UC at increasing pain self-efficacy (g = 0.69) at post-treatment, and these gains were maintained at follow-up. Similarly, Reboot Online was significantly more effective than UC on several secondary measures at post-treatment and follow-up, including movement-based fear avoidance and pain-related disability, but it did not significantly reduce pain interference or depression compared with UC. Clinician input was minimal, and adherence to Reboot Online was moderate, with 61% of participants (N = 25) completing all eight lessons. CONCLUSIONS: Reboot Online presents a novel approach to multidisciplinary pain management and offers an accessible, efficacious alternative and viable treatment option for chronic pain management.

Steroids versus No Steroids in Nonarteritic Anterior Ischemic Optic Neuropathy: A Randomized Controlled Trial.

PURPOSE: To examine the role of oral steroid therapy in the treatment of nondiabetic cases of acute nonarteritic anterior ischemic optic neuropathy (NAAION). DESIGN: Randomized double-blind clinical trial. PARTICIPANTS: Thirty-eight patients with acute nondiabetic NAAION divided into 2 arms of 19 patients each. One arm constituted the cases and the other constituted the controls. METHODS: Cases received oral steroid therapy and were designated the steroid group, whereas controls received placebo and were designated the nonsteroid group. Best-corrected visual acuity (BCVA), visual evoked response (VER), and OCT were performed at baseline, 1 month, 3 months, and 6 months after recruitment into the trial. MAIN OUTCOME MEASURES: Best-corrected visual acuity, VER, and retinal nerve fiber layer changes on OCT. RESULTS: Both groups showed significant improvement in BCVA, VER latency, and resolution of disc edema on OCT parameters over 6 months. Final outcome showed no statistically significant difference with regard to visual acuity, although VER was better in the steroid group (P = 0.011). Best-corrected visual acuity, VER amplitude, and VER latency (P = 0.02, P = 0.02, and P = 0.04, respectively) showed a greater percentage improvement in the steroid group, which also saw a faster resolution of disc edema on OCT (1-month follow-up). CONCLUSIONS: Oral steroids in acute NAAION did not improve the visual acuity significantly at 6 months. However, they improved resolution of disc edema significantly and enabled a greater improvement in VER parameters. This subtle benefit of oral steroids in NAAION is clinically unimportant and does not provide support for its use.

LV Mass Independently Predicts Mortality and Need for Future Revascularization in Patients Undergoing Diagnostic Coronary Angiography.

OBJECTIVES: The goal of this study was to assess associations between left ventricular (LV) mass, all-cause mortality, and need for revascularization in patients undergoing coronary angiography. BACKGROUND: LV hypertrophy is associated with adverse cardiovascular outcomes in healthy subjects. However, its influence in those with known or suspected coronary artery disease is poorly understood. METHODS: A total of 3,754 patients (mean age 59.3 ± 13.1 years) undergoing invasive coronary angiography and cardiac magnetic resonance (CMR) (mean interval 1.0 ± 1.5 months) were studied. LV mass and volumes were determined from cine images and indexed to body surface area. Analyses were adjusted for CMR variables, medical comorbidities, and severity of coronary artery disease (Duke Jeopardy Score) and were stratified to LV function. RESULTS: At a median of 44.9 months, 315 patients (8.4%) died and 168 patients (4.5%) underwent revascularization. Multivariable analysis showed that each 10 g/m2 increase in LV mass index was associated with a 6% greater risk of mortality (hazard ratio: 1.06; 95% confidence interval [CI]: 1.01 to 1.11; p = 0.02) and a 10% greater need for revascularization (hazard ratio: 1.10; 95% CI: 1.04 to 1.17; p < 0.01). According to pre-defined thresholds, moderate to severe hypertrophy was associated with a 1.7-fold risk of mortality (95% CI: 1.2 to 2.3) and 1.8-fold need for revascularization (95% CI: 1.18 to 2.67). These findings were predominantly observed in those with a left ventricular ejection fraction >35% with respective hazard ratios of 2.93 (95% CI: 1.92 to 4.47) and 2.20 (95% CI: 1.21 to 3.98). CONCLUSIONS: LV mass index is an independent predictor of all-cause mortality and need for revascularization. This finding establishes relevance for LV mass measurements in clinical decision-making surrounding both the need and timing of revascularization in this population.

Long-Term Evaluation of Specular Microscopic Changes Following Nd: YAG Iridotomy in Chronic Primary Angle-Closure Glaucoma Eyes.

AIM: The aim of this study was to evaluate specular microscopy of chronic primary angle-closure glaucoma (CPACG) eyes at least 1 year after Nd:YAG iridotomy, and compare them with CPACG eyes without an iridotomy and age-matched, normal eyes. PATIENTS AND METHOD: Consecutive patients of CPACG at the Glaucoma service were screened. All patients underwent slit-lamp biomicroscopy, +90 D examination, and applanation tonometry. A total of 100 eyes of 100 consecutive patients of CPACG with an Nd:YAG iridotomy performed ≥1 year before, who met all inclusion/exclusion criteria, 60 consecutive CPACG eyes without an iridotomy, and 60 age and refraction-matched control eyes were enrolled. A specular microscopy was performed in one eye of each patient by an observer masked to diagnosis. RESULTS: CPACG patients had a mean age of 62±8 years, a mean intraocular pressure of 18±5.3 mm Hg, a mean specular count of 2536±224 cells/mm, and mean duration after iridotomy of 3.2±2 years. There was a significant correlation of specular endothelial counts with age (r=-0.39; P<0.001) and interval after iridotomy (r=-0.25; P=0.01). CPACG eyes without an iridotomy had a mean age of 62±5 years and a mean specular count of 2469±199 cells/mm. Normal control eyes with a mean age of 61±6 years had a mean specular count of 2729±299 cells/mm. There was no significant difference in specular count between CPACG eyes with or without an iridotomy (P=0.19); however, both CPACG groups had a specular count significantly lower than controls (P=0.01 and 0.02, respectively). There was no statistically significant difference seen in polymegathism (coefficient of variation) and pleomorphism (% of hexagonal cells) in endothelial cells among the 3 groups. CONCLUSIONS: An Nd:YAG iridotomy in CPACG eyes did not lead to any significant changes in central corneal specular microscopy in the long term as compared with patients who did not undergo iridotomy. Eyes with CPACG, without and after an iridotomy, had a lower specular count compared with age-matched controls.

Fluid Retention and Utility of Practical Hydration Markers to Detect Three Levels of Recovery Fluid Intake in Male Runners.

Runners are unlikely to consume fluid during training bouts increasing the importance of recovery rehydration efforts. This study assessed urine specific gravity (USG) responses following runs in the heat with different recovery fluid intake volumes. Thirteen male runners completed 3 evening running sessions resulting in approximately 2,200 ± 300 ml of sweat loss (3.1 ± 0.4% body mass) followed by a standardized dinner and breakfast. Beverage fluid intake (pre/postbreakfast) equaled 1,565/2,093 ml (low; L), 2,065/2,593 ml (moderate; M) and 2,565/3,356 mL (high; H). Voids were collected in separate containers. Increased urine output resulted in no differences (p > .05) in absolute mean fluid retention for waking or first postbreakfast voids. Night void averages excluding the first void postrun (1.025 ± 0.008; 1.013 ± 0.008; 1.006 ± 0.003), first morning (1.024 ± 0.004; 1.015 ± 0.005; 1.014 ± 0.005), and postbreakfast (1.022 ± 0.007; 1.014 ± 0.007; 1.008 ± 0.003) USG were higher (p < .05) for L versus M and H respectively and more clearly differentiated fluid intake volume between L and M than color or thirst sensation. Waking (r = -0.66) and postbreakfast (r = -0.71) USG were both significantly correlated (p < .001) with fluid replacement percentage, but not absolute fluid retention. Fluid intake M was reported as most similar to normal consumption (5.6 ± 1.0 on 0-10 scale) after breakfast and equaled 122 ± 16% of sweat losses. Retention data suggests consumption above this level is not warranted or actually practiced by most runners drinking ad libitum, but that periodic prerun USG assessment may be useful for coaches to detect runners that habitually consume low levels of fluids between training bouts in warm seasons.

Relation Between Family History of Premature Coronary Artery Disease and the Risk of Death in Patients With Coronary Artery Disease.

Family history (FHx) of premature coronary artery disease (CAD) is a risk factor for development of incident cardiovascular disease. However the association between FHx and outcomes in patients with established CAD is unclear. We followed 84,373 patients with angiographic CAD enrolled in the inclusive Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry between April 2002 and March 2013. Overall, 25,566 (30%) self-reported an FHx of CAD, defined as a first-degree relative with premature CAD (men, age <55 years; women, age <65 years). We tested the association between FHx and all-cause mortality using multivariable Cox proportional hazards regression. After adjusting for baseline differences in clinical characteristics, indication, and extent of CAD, FHx was associated with reduced all-cause mortality over a median 5.6 years in follow-up (hazard ratio [HR] 0.77 [95% CI 0.73 to 0.80]). The magnitude of this protective association was weaker in those with versus without a previous myocardial infarction (HR 0.87 [95% CI 0.81 to 0.93] versus 0.72 [0.69 to 0.76], interaction p <0.0001) and slightly stronger in those presenting with versus without an acute coronary syndrome (HR 0.74 [0.70 to 0.79] versus 0.80 [0.75 to 0.85], interaction p = 0.08). There was attenuation of association with increasing age, but FHx remained protective even in those aged older than 80 years (HR 0.86 [0.77 to 0.95]). In conclusion, in patients with angiographic CAD, self-reported FHx of premature CAD is associated with improved long-term survival rate, independent of clinical characteristics, mode of presentation, and extent of disease. Further investigation of potential patient- and system-level mediators of this seemingly paradoxical relation is required.

Differences in Optic Disc Characteristics of Primary Congenital Glaucoma, Juvenile, and Adult Onset Open Angle Glaucoma Patients.

OBJECTIVE: To comparatively evaluate morphometric features of the optic discs of primary congenital glaucoma (PCG), juvenile onset primary open angle glaucoma (JOAG), and adult onset primary open angle glaucoma (POAG) using scanning laser ophthalmoscopy (HRT3). METHODS: Optic discs of previously treated 89 PCG, 136 JOAG, and 139 adult onset POAG patients, were evaluated. One eye of each patient was analyzed in the study.The optic disc characteristics studied included disc area, cup area, rim area, cup depth, cup volume, cup to disc area ratio, horizontal cup to disc ratio, vertical cup to disc ratio, and mean retinal nerve fiber layer (RNFL). A regression analysis was performed to assess the effect of age, sex, and disc area on the disc characteristics in the 3 categories of primary glaucomas. RESULTS: Mean disc area of PCG, JOAG and POAG eyes was 2.58±0.75, 2.61±0.51, and 2.44±0.58 mm, respectively. The cup characteristics that demonstrated significantly greater means among JOAG compared with POAG and PCG eyes, included cup depth (P=0.001), cup volume (P=0.024), and cup to disc area ratio (P=0.049). The mean horizontal cup to disc ratio=0.73 was greater than mean vertical cup to disc ratio=0.61 (P=0.026) among PCG eyes as well as among JOAG eyes (P=0.001). For POAG, the mean horizontal cup to disc ratio=0.73 was not different from the mean vertical cup to disc ratio=0.69 (P=0.077). CONCLUSIONS: The optic discs of juvenile onset open angle glaucoma tend to be larger in size than adult onset POAG discs. A 3-dimensional enlargement of the cup is seen among treated JOAG discs compared with POAG and PCG eyes. The greater horizontal cup disc ratio in PCG and JOAG compared with POAG eyes indicates a concentric enlargement of the cup in these patients.

Aniridic Glaucoma: Long-term Visual Outcomes and Phenotypic Associations.

PURPOSE: The aim of this study was to evaluate long-term visual outcomes in patients with aniridic glaucoma. DESIGN: Retrospective noncomparative observational case series. MATERIALS AND METHODS: A review of medical records of 128 eyes of 64 consecutive patients with aniridic glaucoma, diagnosed after the age of 5 years was analyzed. The parameters studied included age at presentation, family history, baseline intraocular pressure (IOP), type and the number of surgical interventions, and associated comorbidities. PRIMARY OUTCOME MEASURE: Best corrected visual acuity (BCVA) in the better eye. RESULTS: Mean age at presentation was 15.86±10.11 years (range, 5 to 47 y). The average follow-up was 7.69±4.98 years (range, 1 to 17 y). At the final follow up only 18 patients had BCVA better than 6\60 and only 5 patients had BCVA of >6/18. Seventeen of the 64 (26.5%) patients developed phthisis in 1 eye. The final visual outcomes were not associated with age at presentation (P=0.64) or sex (P=0.76); however, those with a higher baseline IOP (P=0.017), those with familial aniridia (P=0.037), and those who underwent more number of surgical interventions had poorer visual outcomes (P=0.004). Kaplan-Meier analysis demonstrated the probability of bilateral blindness to be 69.8% and 97.6% at 5 and 10 years, respectively. CONCLUSIONS: Long-term visual outcomes after therapy among aniridic glaucoma patients remain poor. Higher baseline IOP, the presence of familial aniridia, and a history of greater number of surgical interventions are associated with poorer long-term visual outcomes.

Test retest variability of TonoPen AVIA.

The study was conducted to evaluate the intra-session repeatability of Tonopen AVIA (TPA). 180 eyes of 180 patients (50 eyes with glaucoma, 130 eyes of controls) were recruited for this observational study. The mean age of patients enrolled in the study was 43.9 ± 16.7 yrs (84 males, 96 females). Mean IOP recorded with Tonopen AVIA was 19.5 ± 9.5 mmHg, 19.4 ± 9.6 mmHg and 19.3 ± 9.2 mmHg, respectively in the first, second and third instances (P = 0.656). The intraclass correlation coefficient (ICC) ranged from 0.996 (95% CI: 0.956 - 0.998) for glaucoma subjects to 0.958 (95% CI: 0.934 - 0.975) for controls. The coefficient of variation in the study population ranged from 3.47% (glaucoma patients) to 8.10% (healthy controls), being 6.07% overall. The coefficient of repeatability varied between 2.96 (glaucoma patients), 3.35 (healthy controls) to 3.24 (overall). Thus, the Tonopen Avia shows good intrasessional repeatability of IOP in both glaucomatous patients and healthy subjects.

Donor Bone Marrow Infusion in Deceased and Living Donor Renal Transplantation

The infusion and persistence in a transplant recipient of donor-derived bone marrow cells (DBMC) of multi-lineage can lead to a state of permanent chimerism. In solid vascular organ transplantation, the donor bone marrow lineage cells can even be derived from the transplant organ, and these cells can be detected in very small numbers in the recipient. This has been called microchimerism. Much controversy has developed with respect to the function of chimeric cells in organ transplantation. One idea is that the occurrence of these donor cells found in microchimerism in the recipient are coincidental and have no long-term beneficial effect on engraftment. A second and opposing view, is that these donor cells have immunoregulatory function that affect both the acute and chronic phases of the recipient anti-donor responses. It follows that detecting quantitative changes in chimerism might serve as an indication of the donor-specific alloimmune or regulatory response that could occur in concert with or independent of other adaptive immune responses. The latter, including autoimmune native disease, need to be controlled in the transplant organ. The safety and immune tolerance potential of DBMC infusion with deceased and living donor renal transplants was evaluated in a non-randomized trial at this center and compared with non-infused controls given identical immunosuppression. Overall DBMC infusions were well tolerated by the recipients. There were no complications from the infusion (s), no episodes of graft-vs-host disease (GVHD) and no increase infections or other complications. In the deceased DBMC- kidney trial, actuarial graft survival at 5 years was superior especially when graft survival was censored for recipient death. Acute rejections were significant reduced in patients given two DBMC infusions, and chronic rejection was dramatically reduced in all DBMC treated patients. The most interesting finding was that the degree of microchimerism slowly increased over the years the DBMC group that had exhibited no rejection episodes. In the DBMC-living related trial, the incidence of acute rejection did not differ between groups. However, DBMC chimerism in recipient iliac crest marrow had increased more rapidly than might be predicted from results previously seen in the cadaver group, despite four times fewer DBMC infused, with the generation of T- regulartory cells in-vitro assays.