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OBJECTIVES/GOALS: Highly Active Antiretroviral Therapy (HAART) is beneficial for managing HIV infection, however the long-term use of HAART may be problematic for healthy weight maintenance. The aim of the study was to investigate the association of race, weight status, and co-morbidities among individuals with HIV. METHODS/STUDY POPULATION: Self-reported data from 283 participants who completed the Symptom Checklist, the Co-Morbidity Questionnaire, and the Sociodemographic Questionnaire were included in the data analyses. Data were analyzed using Latent Class Analysis on JMP 13. Approximately 50% of participants self-identified as Black, 69% as male, and 35% as having AIDS. Participants’ age ranged from 25 to 66 years (mean age = 43.70 years, SD = 8.14). Participants were grouped by race (self- reported Black or non-Black), and then each group was clustered based on the top three most prevalent symptoms. The clusters identified were least symptomatic, weight gain, and weight loss. RESULTS/ANTICIPATED RESULTS: The non-Black weight gain cluster reported a higher incidence of AIDS (70.6% vs 38.2%), nausea (70.6% vs 17.6%), diarrhea (70.6% vs 26.5%), and shortness of breath (58.8% vs 20.6%) compared to the Black weight gain cluster. The Black weight loss cluster reported a higher incidence of cardiovascular symptoms including chest palpitations (42.2% vs 2.7%), chest pain (44.4% vs 8.1%), and shortness of breath (73.3% vs 35.1%) and a higher incidence of all GI symptoms with the most prominent being diarrhea (71.1% vs 48.6%) compared to the non-Black weight loss cluster. DISCUSSION/SIGNIFICANCE OF IMPACT: Future studies supporting these results will assist practitioners to target treatments that may prevent adverse health outcomes for individuals with HIV on HAART. Further studies will also assist with setting standards that allow practitioners to provide personalized care for individuals with HIV on HAART.
Patients who can be treated in Primary care should receive their treatment in Primary Care.
We aim to identify depression treatments used by Bedford East Community Psychiatric Team (BECMHT) and hence identify those patients who could be appropriately managed in Primary care.
We identified 299 patients from the BECMHT database with depression (F32,F33, F41.2 and uncoded). Potential patient groups to discharge were identified by analysing these patients’ data; their medications were compared to NICE guidelines and other evidence-based-treatments.
Many patients were on different combinations of medications but there were 153 (51.2%) on one antidepressant only. Half of the patients’ medication was in accordance with NICE guidelines (157/52.5%), 11 patients were on medication with a different evidence-base and 101 patients were on medication without either of these. However, 36.5% of patients had an inter-current psychiatric diagnosis.
Prescribing patterns within BECMHT demonstrate groups of patients who are more likely to need Secondary care, including those with inter-current psychiatric diagnosis and patients on medications that are not backed by NICE or a known evidence-base. Provided adequate symptom control, the patients who could be discharged include those on one antidepressant and patients on medications in conformity with NICE guidelines who do not need monitoring in secondary care. The patient's notes should be reviewed before discharge to ensure adequate future treatment. There should be good communication with Primary care, with joint protocols and the possibility for patients to easily access services appropriate to their needs.
Depression treatment outcomes within British Community Mental Health Teams have not been adequately described.
To describe factors which influence outcome of depression within Bedford East CMHT.
Patients with Depression F32, Recurrent Depression F33, and Depression and Anxiety F42.1 were identified from a database. Factors affecting outcomes, including Suicidal ideation, Alcohol problems, Drug problems, and use of Augmentation therapy, were identified. Outcome as measured by patient discharge was compared in the three groups.
The percentage of each group discharged was 12.24 for F32, 30.53 for F33, and 29.17 for F42.1.
For F32 patients, the percentage of patients with suicidal ideation was 55.10, with alcohol problems was 32.65, with illicit drug problems was 14.28, while the percentage of patients on augmentation strategies was 38.77.
For F33 patients, the percentage of patients with suicidal ideation was 27.37, with alcohol problems was 9.47, with illicit drug problems was 1.05, while the percentage of patients on augmentation strategies was 27.37.
For F42.1 patients, the percentage of patients with suicidal ideation was 25, with alcohol problems was 8.33, with illicit drug problems was 8.33, while the percentage of patients on augmentation strategies was 54.17.
Fewer discharges occurred from the F32 group, mirroring increased suicidality and drug and alcohol use in this group. There is no significant difference in the number of patients using augmentation strategies between the F32 and F33 groups. It does not appear that augmentation strategies for treating depression are having a clear influence on outcomes.
Whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care.
Aims and methods
An Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression.
Of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy.
There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and ‘other suicide risk factors’.
Generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.
In recent years there has been a move towards treating depressed patients in the community.One factor that may reduce the likelihood of discharge from secondary care is suicidality. The aim of this audit was to identify factors associated with continued suicidality among Community patients.
Subjects and methods
We searched an anonymised database of patients and identified all those with previously documented suicidal thoughts or attempts. We also noted the presence of factors such as alcohol problems, drug problems, augmentation therapy and ‘other risk’ factors (e.g. financial problems or homelessness). We assessed the latest clinic letter, to see if patients were still reporting suicidality. We compared the aforementioned factors between the group of patients in which suicidality was still present (group N) and the group of patients in which suicidality was no longer a feature (group Y).
Of the 56 patients with suicidal thoughts or attempts there were 44 in group N (79%) and 12 in group Y (21%). Alcohol problems, drug problems and ‘other’ risk factors were more common among group Y than group N. Conversely, the percentage of patients on augmentation therapy was greater in group N than group Y.
The audit provides an insight into the factors that might influence outcomes among depressed patients.
Although the results are suggestive, it is difficult to make firm conclusions about patient outcomes on the present data. The audit provides a useful starting point, especially in considering the treatment of patients within the CMHT.
Strategies for the treatment of refractory depression include “switching” and “augmentation”. in recent years, there has been particular interest in the use of augmentation.
The purpose of this audit was to define patient factors among people receiving augmentation therapy with either mirtazepine or atypical antipsychotics.
Subjects and methods:
We searched an anonymised database of patients and identified those receiving augmentation with mirtazepine (group A), atypical antipsychotics (group B) or both (group C). for each of the three groups we recorded the following factors: (1) age, (2) sex, (3) suicidal ideation, (4) alcohol problems, (5) drug problems, (6) domestic problems (e.g. debts, child abuse & domestic violence) (7) psychotic symptoms and (8) co-existing physical diagnoses.
Group B spanned a wider range of ages than either of the other two groups. Group A contained the highest proportion of patients with suicidal ideation than either. Alcohol problems were most common in group A, drug problems most common in group B and domestic problems most common in group C. Perhaps unsurprisingly psychotic symptoms were present in a relatively high percentage of patients in group B. there was little difference in physical co-morbidities between the three groups.
The audit reveals some interesting differences in patient factors between the three groups. Knowledge about such differences is useful in practical terms because it allows doctors in the BCMHT to target therapy for different patients towards their specific needs.
Potential augmentation regimes include the addition of atypical antipsychotics or other antidepressants (e.g. mirtazepine). there is growing evidence in the literature to support the efficacy of both the aforementioned augmentation strategies.
The purpose of this audit was to compare patient outcomes between groups receiving different augmentation strategies.
Subjects and methods:
We searched an anonymised database of patients and identified those receiving augmentation with mirtazepine (group A), atypical antipsychotics (group B) or both (group C). for each patient we noted
(1) The discharge status and
(2) The presence of suicidal ideation.
We then looked at clinical notes to find out whether or not patients were still reporting suicidality.
The proportion of patients who had been discharged was highest in group A. the percentage of patients still reporting suicidal thoughts was higher in group B than in groups A or C.
Augmentation with mirtazepine resulted in better outcomes in terms of both discharge rates and in terms of reduction in suicidality than augmentation with atypical antipsychotics. One explanation for this is that mirtazepine augmentation is a more effective method of treatment in patients with refractory depression. However, it is also possible that differences in patient factors (e.g. age and drug problems) between the different treatment groups could contribute to variability in outcomes. A previous audit (Holt et al, 2011) has already confirmed that such differences do exist among the patients being analysed in this audit.
Out of hours, there is only one on-site junior doctor. First year psychiatry trainees (CT1s) and GP trainees may have no prior experience in psychiatry. On-call shifts are therefore potentially daunting for new trainees.
Expand the resources available for trainees when on-call.
We issued questionnaires to CT1s asking if they would have appreciated more information about on-call scenarios and in what format.
Based on the questionnaire results we implemented some changes. These were:
– a printed “pocket-guide” summarising common on-call scenarios;
– a training video on common on-call scenarios.
The handout was given to new trainees in February 2016 and in August 2016. The video was shown to new trainees in August 2016. Trainees provided feedback on the resources.
Of 24 CT1s, 15 (63%) were “neutral” or “disagreed” that they had felt prepared for on-calls.
CT1s wanted additional resources, especially a paper handout or phone download.
Feedback on the “pocket-guide” from trainees in February 2016 (n = 8) was positive (62.5% reported increased confidence in on-call situations). Feedback is also being collected from trainees who received the guide in August 2016.
Trainees in August 2016 (n = 36) liked the video – no trainees “disagreed” with statements asking if the video had been useful.
The video improved the confidence of trainees about on-call situations by an average of 2.8 points.
We have expanded available resources relating to on-calls and improved confidence. Further improvements would include making resources more easily available in downloadable formats.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans’ Health Administration clinics.
We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.
Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.
Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians’ perceptions of antibiotic prescribing practices and should enhance their patient communication skills.
The Australian prime lamb industry is seeking to improve lean meat yield (LMY) as a means to increasing efficiency and profitability across the whole value chain. The LMY of prime lambs is affected by genetics and on-farm nutrition from birth to slaughter and is the total muscle weight relative to the total carcass weight. Under the production conditions of south eastern Australia, many ewe flocks experience a moderate reduction in nutrition in mid to late pregnancy due to a decrease in pasture availability and quality. Correcting nutritional deficits throughout gestation requires the feeding of supplements. This enables the pregnant ewe to meet condition score (CS) targets at lambing. However, limited resources on farm often mean it is difficult to effectively manage nutritional supplementation of the pregnant ewe flock. The impact of reduced ewe nutrition in mid to late pregnancy on the body composition of finishing lambs and subsequent carcass composition remains unknown. This study investigated the effect of moderately reducing ewe nutrition in mid to late gestation on the body composition of finishing lambs and carcass composition at slaughter on a commercial scale. Multiple born lambs to CS2.5 target ewes were lighter at birth and weaning, had lower feedlot entry and exit weights with lower pre-slaughter and carcass weights compared with CS3.0 and CS3.5 target ewes. These lambs also had significantly lower eye muscle and fat depth when measured by ultrasound prior to slaughter and carcass subcutaneous fat depth measured 110 mm from the spine along the 12th rib (GR 12th) and at the C-site (C-fat). Although carcasses were ~5% lighter, results showed that male progeny born to ewes with reduced nutrition from day 50 gestation to a target CS2.5 at lambing had a higher percentage of lean tissue mass as measured by dual energy X-ray absorptiometry and a lower percentage of fat during finishing and at slaughter, with the multiple born progeny from CS3.0 and CS3.5 target ewes being similar. These data suggest lambs produced from multiple bearing ewes that have had a moderate reduction in nutrition during pregnancy are less mature. This effect was also independent of lamb finishing system. The 5% reduction in carcass weight observed in this study would have commercially relevant consequences for prime lamb producers, despite a small gain in LMY.
The Interplay of Genes and Environment across Multiple Studies (IGEMS) is a consortium of 18 twin studies from 5 different countries (Sweden, Denmark, Finland, United States, and Australia) established to explore the nature of gene–environment (GE) interplay in functioning across the adult lifespan. Fifteen of the studies are longitudinal, with follow-up as long as 59 years after baseline. The combined data from over 76,000 participants aged 14–103 at intake (including over 10,000 monozygotic and over 17,000 dizygotic twin pairs) support two primary research emphases: (1) investigation of models of GE interplay of early life adversity, and social factors at micro and macro environmental levels and with diverse outcomes, including mortality, physical functioning and psychological functioning; and (2) improved understanding of risk and protective factors for dementia by incorporating unmeasured and measured genetic factors with a wide range of exposures measured in young adulthood, midlife and later life.
The crystal structure of cefprozil monohydrate has been solved and refined using synchrotron X-ray powder diffraction data and optimized using density functional techniques. Cefprozil monohydrate crystallizes in space group P21 (#4) with a = 11.26513(6), b = 11.34004(5), c = 14.72649(11) Å, β = 90.1250(4)°, V = 1881.262(15) Å3, and Z = 4. Although a reasonable fit was obtained using an orthorhombic model, closer examination showed that many peaks were split and/or had shoulders, and thus the true symmetry was monoclinic. DFT calculations revealed that one carboxylic acid proton moved to an amino group. The structure thus contains one ion pair and one pair of neutral molecules. This protonation was confirmed by infrared spectroscopy. There is an extensive array of hydrogen bonds resulting in a three-dimensional network. The powder pattern has been submitted to ICDD® for inclusion in the Powder Diffraction File™.
The crystal structure of prednicarbate has been solved and refined using synchrotron X-ray powder diffraction data, and optimized using density functional techniques. Prednicarbate crystallizes in space group P212121 (#19) with a = 7.69990(3), b = 10.75725(3), c = 31.36008(11) Å, V = 2597.55(1) Å3, and Z = 4. In the crystal structure the long axis of the steroid ring system lies roughly parallel to the c-axis. The oxygenated side chains are orientated roughly perpendicular to the steroid ring system and are adjacent to each other, parallel to the ab-plane. The only traditional hydrogen bond donor in the prednicarbate molecule is the hydroxyl group O32–H33, but this does not participate in an O–H···O hydrogen bond. The nearest oxygen atoms to O32 are symmetry-related O32 at 4.495 Å, precluding the expected O–H···O hydrogen bond. The powder pattern has been submitted to ICDD® for inclusion in the Powder Diffraction File™.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
The National Academy of Sciences-National Research Council (NAS-NRC) Twin Registry is one of the oldest, national population-based twin registries in the USA. It comprises 15,924 White male twin pairs born in the years 1917–1927 (N = 31.848), both of whom served in the armed forces, chiefly during World War II. This article updates activities in this registry since the most recent report in Twin Research and Human Genetics (Page, 2006). Records-based data include information from enlistment charts and Veterans Administration data linkages. There have been three major epidemiologic questionnaires and an education and earnings survey. Separate data collection efforts with the NAS-NRC registry include the National Heart, Lung, and Blood Institute (NHLBI) subsample, the Duke Twins Study of Memory in Aging and a clinically based study of Parkinson’s disease. Progress has been made on consolidating the various data holdings of the NAS-NRC Twin Registry. Data that had been available through the National Academy of Sciences are now freely available through National Archive of Computerized Data on Aging (NACDA).
Parma's history evolved within the complicated politics among Spain, France, and the Habsburg Empire, forming the complex backdrop of Du Tillot's auspicious plan to create a new type of opera. Although the French presence in Parma has long provided fertile ground for historians and musicologists, some aspects of it with links to Du Tillot's plan deserve a closer look. The somewhat conflicting aspirations of Philippe de Bourbon and his wife, Louise Élisabeth, and the contributions made toward theatrical innovation by two of Parma's key creative personnel, Jean-Philippe Delisle, the director of Parma's French troupe, and Jacques-Simon Mangot, director of Parma's court music, all affected French musical theater in Parma in ways that merit further exploration.
Parma and Its History
A brief overview will help contextualize these particular factors. The Bourbon dynasty had become linked with Spain in the early eighteenth century. In 1714 Phillip V of Spain, the country's first Bourbon king, married Elisabetta Farnese, his second wife. Parma came under Bourbon control in 1731, when Charles, their oldest son, became duke. In 1734, with the aid of Spain, Charles captured Naples from the Austrians and moved to Naples, taking with him many of the Farnese dynasty's possessions that had established Parma's prominence as an artistic and intellectual center. Charles's achievements in Naples influenced Parma in the envy they were to create in his younger brother, Philippe, second son of the Spanish king. The Habsburgs annexed the duchy of Parma in 1738, and the Bourbons regained it in 1748 by the terms of the Treaty of Aixla- Chapelle. Philippe de Bourbon was installed in Parma as the duchy's new sovereign, arriving in the city in 1749 and ruling there until his death in 1766.
His wife, Marie Louise Élisabeth de Bourbon (1727–59), was King Louis XV's eldest daughter. Duchess Louise Élisabeth maintained her close ties with France, often visiting her father at Versailles. The enhancement of Parma's French artistic life during the Bourbon period was achieved in large measure through her intervention and she exerted a strong influence in diplomatic spheres as well. That mid-eighteenth-century Parma can be considered “a mirror of France in Italy” had a great deal to do with Louise Élisabeth's involvement in matters ranging from the aesthetic to the political.
When did reform end in Parma? Scholars disagree; for some, it occurred with Traetta's third reform opera, Le feste d'Imeneo, the opéra-ballet given for the wedding of Princess Isabella of Parma to Archduke Joseph II of Austria in September 1760. For others, Enea e Lavinia of the following spring (1761), the fourth opera modeled on a tragédie lyrique, brings the reform efforts to a close. The problem of marking the end of the era lies, in part, in the dissimilarity of Traetta's last two works for Parma. But while these pieces exhibit discontinuity in relation to each other, they also reflect a certain degree of consistency in relation to the prior adaptations. Du Tillot declared the period of innovation to have definitively concluded in 1762: “Le projet de nos opéras sur un nouveau plan est abandonné.” The end of the end, as it might be termed, encompassed the eventful period between I tindaridi and Du Tillot's letter to Algarotti, with whom he had shared similar aspirations for the fusion of French and Italian operatic styles.
Le feste d'Imeneo premiered in September 1760, just three months after I tindaridi's closure. The short gestation period of Traetta's third reform opera meant that things happened fast. Perhaps the most important practical change that occurred was the renovation of the Teatro Ducale during summer 1760 in preparation for the wedding festivities. The French architect Jean-Antoine Morand was summoned from Lyon (as Mangot had been before him) to direct and oversee the renovations. He enlarged the auditorium and transformed the stage machinery, raising the theater's level of technical sophistication to match the high degree of aesthetic refinement to which Du Tillot had long aspired. Although the details of the renovation are unknown, Parma's new theatrical machines now allowed for descents from the heavens and into the underworld and for the undulation of the waves from the sea. Specific features of the wedding opera's stage spectacle seem calculated to show off the new capabilities of Parma's theater to delight and astound the spectators. Le feste d'Imeneo is nothing short of a tour de force of visual display.
Parma's Wedding Opera: Le feste d'Imeneo
The work represents a new genre, the opéra-ballet, which had been seen occasionally during the French troupe's tenure, but never before in an Italianate version.
On 5 June 1758 Du Tillot received the news from Bonnet in Paris that the troupe's residence would soon be coming to an end. A flurry of activity ensued, one that represented a transition affecting the repertory in decisive ways. In the space of some eleven months, an almost complete overhaul of personnel occurred: the French singers, actors, some of the dancers, and Delisle left Parma; new dancers, a new French choreographer, and new Italian singers arrived; and Traetta came and composed Solimano (for carnival 1759) and Ippolito ed Aricia (premiering 2 May 1759). Mangot represents the thread of consistency that runs through this changeover; he is the single most influential source of continuity between the French troupe's departure and Traetta's arrival, and between the French entertainments and the Italian operas with French components. Important links were forged during this period of transition: those between the French troupe's presence and Traetta's first two reform operas, Ippolito ed Aricia and I tindaridi, and those between the two works themselves. The troupe's performances established precedents that profoundly influenced Ippolito ed Aricia and I tindaridi not only in certain aspects of shared personnel and in repertorial overlaps, as we have seen, but in the way Parma's audiences must have experienced these two operas. Ippolito ed Aricia and I tindaridi have more in common with each other than either does with any other of Traetta's works for Parma; most obviously, they are Italian adaptations of Rameau's first two tragédies en musique (Hippolyte et Aricie and Castor et Pollux), Parma gave them in the same performance season (spring, and not carnival), they share the same Italian solo singers, the same dancers and choristers, and they were linked in the minds of those who were concerned with the revenue they generated, as newly explored evidence demonstrates. It makes sense to view these two as a pair, of sorts. Yet they contrast greatly with each other in one important way: while Parma's audiences were well-acquainted with Castor et Pollux, having experienced the troupe's many performances of it, they had never before met Hippolyte et Aricie. This reality led the two operas to serve different purposes, a fact revealed mostly starkly by the element that at once links the works mostly closely and sets them apart from each other: their reuse of Rameau's music.