Comparing Diagnosis and Treatment of Pulmonary Hypertension Patients at a Pulmonary Hypertension Center versus Community Centers

Once patients are diagnosed with pulmonary hypertension it is important to identify the correct diagnostic group as it will have implications on the disease state management. Pulmonary hypertension is increasingly diagnosed and treated in general medical practices; however, evidence-based guidelines recommend evaluation and treatment in pulmonary hypertension centers for accurate diagnosis and appropriate treatment recommendations. We conducted a retrospective cohort study of 509 random patients 18 years and older who were evaluated in our pulmonary hypertension clinic from January 2005 to December 2018. 68.4% (n = 348) had their diagnostic group clarified or changed. Pulmonary hypertension was deemed an incorrect diagnosis in 12.4% (n = 63). A total of 114 patients (22.4%) had been initiated on pulmonary hypertension specific treatment prior to presentation. Pulmonary hypertension specific medication was stopped in 57 (50.0%) cases. The estimated monthly saving of the stopped medication based on wholesale acquisition costs was USD 396,988.05–419,641.05, a monthly saving of USD 6964.70–7362.12 per patient. Evaluation outside of a pulmonary hypertension center may lead to misdiagnosis and inappropriate or inadequate treatment. Pulmonary arterial hypertension directed therapy improves median survival, but inappropriate therapy may cause harm; therefore, patients benefit from a specialized center with multiple resources to secure an accurate diagnosis and tailored treatment for their condition.

Depression and/or PTSD Comorbidity Affects Response to Antidepressants in Those With Alcohol Use Disorder

Objective: Depression and post-traumatic stress disorder (PTSD) highly co-occur with alcohol use disorder (AUD). The comparative effects of noradrenergic vs. serotonergic antidepressants on drinking and depressive outcomes for those with AUD and co-occurring depression and/or PTSD are not well known.Methods: This study was an analysis of a randomized control trial of 128 patients with AUD who had co-occurring depression and/or PTSD. They were randomized to treatment with paroxetine vs. desipramine and naltrexone vs. placebo leading to four groups: paroxetine plus naltrexone, paroxetine plus placebo, desipramine plus naltrexone, and desipramine plus placebo. Outcomes were percent of drinking days, percent heavy drinking days, drinks per drinking day (Time Line Follow-back Method), and depressive symptoms (Hamilton Depression Scale). Groups compared were (1) depression without PTSD (depression group; n = 35), (2) PTSD without depression (PTSD group; n = 33), and (3) both depression and PTSD (comorbid group; n = 60).Results: There were no overall significant differences in drinking outcomes by medication in the entire sample, and no significant interaction when diagnostic groups were not considered. However, when diagnostic groups were included in the model, the interactions between time, diagnostic group, and medication (desipramine vs. paroxetine) were significant for percent drinking days (p = 0.042), and percent heavy drinking days (p = 0.036); paroxetine showed better drinking outcomes within the depression group, whereas desipramine showed better drinking outcomes in the PTSD and comorbid groups. Regarding depressive symptoms, paroxetine was statistically superior to desipramine in the total sample (p = 0.007), but there was no significant interaction of diagnostic group and medication. Naltrexone led to a decrease in craving but no change in drinking outcomes.Conclusions: The results of this study suggest that drinking outcomes may respond differently to desipramine and paroxetine depending on comorbid MDD and/or PTSD.

The colors of our brain: an integrated approach for dimensionality reduction and explainability in fMRI through color coding (i-ECO)

Several systematic reviews have highlighted the role of multiple sources in the investigation of psychiatric illness. For what concerns fMRI, the focus of recent literature preferentially lies on three lines of research, namely: functional connectivity, network analysis and spectral analysis. Data was gathered from the UCLA Consortium for Neuropsychiatric Phenomics. The sample was composed by 130 neurotypicals, 50 participants diagnosed with Schizophrenia, 49 with Bipolar disorder and 43 with ADHD. Single fMRI scans were reduced in their dimensionality by a novel method (i-ECO) averaging results per Region of Interest and through an additive color method (RGB): local connectivity values (Regional Homogeneity), network centrality measures (Eigenvector Centrality), spectral dimensions (fractional Amplitude of Low-Frequency Fluctuations). Average images per diagnostic group were plotted and described. The discriminative power of this novel method for visualizing and analyzing fMRI results in an integrative manner was explored through the usage of convolutional neural networks. The new methodology of i-ECO showed between-groups differences that could be easily appreciated by the human eye. The precision-recall Area Under the Curve (PR-AUC) of our models was > 84.5% for each diagnostic group as evaluated on the test-set – 80/20 split. In conclusion, this study provides evidence for an integrative and easy-to-understand approach in the analysis and visualization of fMRI results. A high discriminative power for psychiatric conditions was reached. This proof-of-work study may serve to investigate further developments over more extensive datasets covering a wider range of psychiatric diagnoses.

Heterogeneity in major depression and its melancholic and atypical specifiers: a secondary analysis of STAR*D

Objectives The melancholic and atypical specifiers for a major depressive episode (MDE) are supposed to reduce heterogeneity in symptom presentation by requiring additional, specific features. Fried et al. (2020) recently showed that the melancholic specifier may increase the potential heterogeneity in presenting symptoms. In a large sample of outpatients with depression, our objective was to explore whether the melancholic and atypical specifiers reduced observed heterogeneity in symptoms. Methods We used baseline data from the Inventory of Depression Symptoms (IDS), which was available for 3,717 patients, from the Sequenced Alternatives to Relieve Depression (STAR*D) trial. A subsample met criteria for MDE on the IDS (“IDS-MDE”; N =2,496). For patients with IDS-MDE, we differentiated between those with melancholic, non-melancholic, non-melancholic, atypical, and non-atypical depression. We quantified the observed heterogeneity between groups by counting the number of unique symptom combinations pertaining to their given diagnostic group (e.g., counting the melancholic symptoms for melancholic and non-melancholic groups), as well as the profiles of DSM-MDE symptoms (i.e., ignoring the specifier symptoms). Results When considering the specifier and depressive symptoms, there was more observed heterogeneity within the melancholic and atypical subgroups than in the IDS-MDE sample (i.e., ignoring the specifier subgroups). The differences in number of profiles between the melancholic and non-melancholic groups were not statistically significant, irrespective of whether focusing on the specifier symptoms or only the DSM-MDE symptoms. The differences between the atypical and non-atypical subgroups were smaller than what would be expected by chance. We found no evidence that the specifier groups reduce heterogeneity, as can be quantified by unique symptom profiles. Most symptom profiles, even in the specifier subgroups, had five or fewer individuals. Conclusion We found no evidence that the atypical and melancholic specifiers create more symptomatically homogeneous groups. Indeed, the melancholic and atypical specifiers introduce heterogeneity by adding symptoms to the DSM diagnosis of MDE.

A-94 Characterization of Million Veteran Program (MVP) Enrollees with Comprehensive TBI Evaluation (CTBIE) Data: An Analysis of Neurobehavioral Symptoms

Objective Using a large sample of U.S. Veterans enrolled in the Million Veteran Program (MVP), we sought to evaluate neurobehavioral symptoms obtained from the Veterans Health Administration’s Comprehensive Traumatic Brain Injury Evaluation (CTBIE). Method Eligible participants (N = 12,144) included MVP-enrolled Veterans who completed the CTBIE, a clinician-administered interview that assesses for historical, deployment-related TBIs and evaluates current symptoms using the Neurobehavioral Symptom Inventory (NSI). Clinicians completing the CTBIE made clinical determinations about each participant’s TBI diagnostic status (n = 7631 CTBIE+, n = 4513 CTBIE-) as well as likely symptom etiology (TBI: n = 612, Behavioral Health: n = 4965, Combination TBI and Behavioral Health [Comorbid]: n = 2773, Symptom Resolution; n = 750; and Other: n = 1282). We evaluated the association of TBI diagnostic group and symptom etiology group with neurobehavioral symptoms using ANCOVAs adjusted for sociodemographic characteristics. Results Results showed a significant effect of TBI on the NSI total score (p < 0.001, ηp2 = 0.02), with CTBIE+ Veterans endorsing greater symptoms than CTBIE- Veterans. There was also a significant association of symptom etiology group with the NSI total score (p < 0.001, ηp2 = 0.07). Post-hoc analyses showed that the Behavioral Health and Comorbid groups endorsed significantly greater symptoms compared to the TBI, Symptom Resolution, and Other groups. A similar pattern of results was found for all NSI symptom domain scores (vestibular, somatic, cognitive, and affective) and symptom breadth scores. Conclusions Findings from this large epidemiologic MVP study bolster prior work suggesting that behavioral health (e.g., depression, PTSD) greatly contributes to post-concussive symptom endorsement in chronic TBI. Results further highlight the importance of prioritizing mental health treatment in this vulnerable population.

A-12 Racial Differences in Performance Validity Test Failure Rates

Objective Embedded performance validity tests (PVTs) may show increased false positive rates in racially diverse examinees. This study examined false positive rates by race in an older adult sample. Method The project involved secondary analysis of a deidentified dataset (N = 22,688) from the National Alzheimer’s Coordinating Center (NACC). Participants were included if their identified race was African American or white. Exclusion criteria included diagnosis of mild cognitive impairment (MCI; n = 5160) or dementia (n = 5550). The initial sample included 11,114 participants grouped as cognitively normal (89.9%) or impaired but not MCI of whom 16.4% identified as African American. Propensity score matching was conducted by diagnostic group to match African American and white participants on age, education, gender, and MMSE score. The final sample included 3024 and 482 participants in normal and impaired groups, respectively, with 50% of participants identifying as African American in each group. Failure rates on five embedded PVTs in the NACC cognitive test battery were examined by race and by diagnosis. Results Age, education, gender, and MMSE score were not significantly different by race in either diagnostic group. In the normal group, 4.7% of African American and 1.9% of white participants failed two or more PVTs (p < 0.001). In the impaired group, 9.5% of African American and 5.8% of white participants failed two or more PVTs (n.s.). Conclusions PVT failure rates were significantly higher among African American participants in the normal group but not in the impaired group. Failure rates remained below a common false positive threshold of 10%.

A-184 Performance Validity Test Failure Rates in Bilingual Individuals Evaluated in English

Objective Classification accuracy of embedded performance validity tests (PVTs) is unknown in cases involving bilingual examinees evaluated in English. This study examined false positive rates in bilingual individuals in an older adult sample. Method The project involved secondary analysis of a deidentified dataset (N = 22,688) from the National Alzheimer’s Coordinating Center (NACC). Exclusion criteria were diagnosis of mild cognitive impairment (MCI; n = 5160) or dementia (n = 5550). The initial sample included 11,513 participants grouped as cognitively normal (89.6%) or impaired but not MCI. A subset of 275 participants was identified with a primary language other than English who were evaluated in English. Propensity score matching was conducted by diagnostic group to match bilingual to monolingual participants on age, education, gender, and MMSE score. The final sample included 450 and 100 participants in normal and impaired groups, respectively. Failure rates on five embedded PVTs in the NACC cognitive test battery were examined by language and by diagnosis. Results Age, education, gender, and MMSE score were not significantly different by language in either diagnostic group. In the normal group, 4.9% of bilingual and 2.2% of monolingual participants failed two or more PVTs (n.s.). In the impaired group, 12% of bilingual and 6% of monolingual participants failed two or more PVTs (n.s.). Conclusions PVT failure rates were not significantly different between bilingual participants evaluated in English and monolingual participants in either diagnostic group. Failure rates, however, increased slightly above a common false positive threshold of 10% in bilingual participants in the impaired group.

The Role of Negative Affect in Emotional Processing of Food-Related Images in Eating Disorders and Obesity

The aim of the present study was to analyze differences in the emotional processing (valence, arousal, and dominance) of food-related information in patients with eating disorders (ED), patients with obesity, and healthy women. Moreover, the mediator role of negative affect and the moderating role of the diagnostic group (ED vs. non-ED) were analyzed. Method: The sample consisted of 94 women (39 with eating disorders, 19 with obesity, and 36 healthy participants). Measures: International Affective Picture System (IAPS) food picture exposure task; Self-Assessment Manikin Analog-Visual Scale (SAM) appraising Arousal, Valence, and Dominance; Eating Attitudes Test (EAT-26); Positive and Negative Affect Schedule (PANAS). Results: Patients with purging symptomatology rated food images as more unpleasant than healthy women. Patients with purging and restrictive eating symptomatology showed higher levels of arousal and less dominance over the emotions experienced, compared to patients with obesity and healthy women. The mediation analysis showed that negative affect mediated the relationship between eating symptomatology (EAT-26) and the Valence of food images, as well as the control over the emotions experienced when viewing food images (Dominance). For the moderation analysis participants were regrouped into two groups (ED patients vs. non-ED patients). The direct relationship between eating symptomatology and food image valence was moderated by the diagnostic group. However, the group did not moderate the direct relationship between the EAT-26 and dominance over experienced emotions, or the indirect effect on eating symptomatology through negative affect. These results show the relevance of negative affect in the emotional processing of food-related information, and they support an eating disorder-disordered eating dimensional perspective.

Understanding treatment delay: Perceived barriers preventing treatment-seeking for eating disorders

Objective: Only a small proportion of individuals with an eating disorder will receive targeted treatment for their illness. The aim of this study was to examine the length of delay to treatment-seeking and determine the barriers preventing earlier access and utilisation of eating disorder treatment for each diagnostic group – anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding or eating disorder. Method: Participants were recruited as part of the TrEAT multi-phase consortium study. One hundred and nineteen Australians (13–60 years; 96.9% female) with eating disorders currently accessing outpatient treatment for their illness completed an online survey comprised of self-report measures of eating disorder severity, treatment delay and perceived barriers to treatment-seeking. The treating clinician for each participant also provided additional information (e.g. body mass index and diagnosis). Results: Overall, the average length of delay between onset of eating disorder symptoms and treatment-seeking was 5.28 years. Controlling for age, latency to treatment-seeking was significantly longer for individuals with bulimia nervosa and binge eating disorder compared to anorexia nervosa. However, when perceived barriers to treatment-seeking were investigated, there were no significant differences between the diagnostic groups in regard to the perceived barriers they experienced. Stigma was rated as the most impactful barrier for each diagnostic group. Conclusion: Findings suggest that individuals with eating disorders face substantial delays in accessing appropriate treatment and that latency to treatment-seeking is often magnified for counter-stereotypical eating disorder presentations. Further research is required to investigate other factors contributing to this delay.

Catheter to vein ratio and risk of peripherally inserted central catheter (PICC)-associated thrombosis according to diagnostic group: a retrospective cohort study

ObjectivesDetermine the effect of the catheter to vein ratio (CVR) on rates of symptomatic thrombosis in individuals with a peripherally inserted central catheter (PICC) and identify the optimal CVR cut-off point according to diagnostic group.DesignRetrospective cohort study.Setting4 tertiary hospitals in Australia and New Zealand.ParticipantsAdults who had undergone PICC insertion.Primary outcome measureSymptomatic thrombus of the limb in which the PICC was inserted.Results2438 PICC insertions were included with 39 cases of thrombosis (1.6%; 95% CI 1.14% to 2.19%). Receiver operator characteristic analysis was unable to be performed to determine the optimal CVR overall or according to diagnosis. The association between risk of thrombosis and CVR cut-offs commonly used in clinical practice were analysed. A 45% cut-off (≤45% versus ≥46%) was predictive of thrombosis, with those with a higher ratio having more than twice the risk (relative risk 2.30; 95% CI 1.202 to 4.383; p=0.01). This pattern continued when only those with malignancy were included in the analysis, those with cancer had twice the risk of thrombosis with a CVR greater than 45%. Whereas the 33% CVR cut-off was not associated with statistically significant results overall or in those with malignancy. Neither the 33% or 45% CVR cut-off produced statistically significant results in those with infection or other non-malignant conditions.ConclusionsAdherence to CVR cut-offs are an important component of PICC insertion clinical decision making to reduce the risk of thrombosis. These results suggest that in individuals with cancer, the use of a CVR ≤45% should be considered to minimise risk of thrombosis. Further research is needed to determine the risk of thrombosis according to malignancy type and the optimal CVR for those with a non-malignant diagnosis.