Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.

106 Background: The drive to move complex surgeries into the ambulatory setting will impact the cancer population. In anticipation, we developed an “ambulatory extended recovery” (AXR) program for pathway-based management of patients undergoing procedures with traditional 1-4 day hospital stays. Then in 2016 we opened the Josie Robertson Surgery Center (JR), a freestanding ambulatory surgical facility designed for complex cancer surgeries with one overnight stay. Methods: Using hospital databases we identified AXR cases eligible to be performed at JR and examined pathway completion (discharge home on POD 1), and 30-day institutional urgent care center (UCC) visits and readmissions. We compared AXR program results before and after opening JR in January 2016. Results: The most frequent AXR procedures were mastectomy ± immediate reconstruction, thyroidectomy, and minimally invasive prostatectomy, nephrectomy, and hysterectomy. 3307 and 2359 AXR procedures were done in 2015 and Jan-Sep 2016. In 2016 74% of AXR cases were performed at JR with the remainder at Memorial Hospital (MH), primarily for scheduling considerations or patient or surgical complexity. Pathway completion was 92% in 2015 and 95% in 2016 (p < 0.001). 30-day UCC visits/readmission rates were 8.8%/3.7% in 2015 and 8.6%/3.1% in 2016 (ns). Comparing cases at JR vs MH in 2016, pathway completion rates were 98.3% at JR vs 86.4% at MH (p < 0.001). Patient satisfaction was high for care provided at both facilities. Conclusions: Many complex cancer surgeries may be safely completed with a single overnight stay at a freestanding ambulatory facility. UCC visits and readmissions were not different between years, suggesting that quality of care was maintained in the ambulatory setting. The difference in pathway completion in 2016 at JR compared to MH may reflect successful triage of more medically complex patients and/or surgically complex procedures to MH.

Whether counterfactual preventability cognitions are adaptive may depend on mental health history. Predictive modelling may be useful in targeting high-risk women for preventive interventions.

Patients presenting with assault injuries are at risk for injury recurrence, have high levels of past psychological trauma, and should be screened for psychosocial risk. Further research is needed to assess the role of past psychological trauma in risk for assault injury, and clarify treatment needs. The role of EC-based interventions in injury prevention and mental health requires increased recognition in South African policy and practice. (PsycINFO Database Record

Olfactory reference syndrome is characterised by the erroneous belief that one emits an unpleasant body odour. This results in significant distress and is often accompanied by repetitive behaviour such as frequent showering in an attempt to camouflage the perceived odour. The body odour concerns may have a delusional quality and do not respond to simple reassurance or counterexample. Herein, we report the case of an olfactory reference disorder (ORD) patient who had received multiple medical interventions and undergone polysurgery prior to an accurate diagnosis being established. ORD may lead to significant disability, yet often goes unrecognised for many years. For many patients, poor insight will contribute to their reluctance to consider psychiatric treatment. This case demonstrated that a multimodal treatment approach comprising judicious medication use, combined with cognitive behavioural therapy, in the context of a therapeutic alliance yielded therapeutic success.

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

Introduction: There is limited data on the role of therapeutic drug monitoring (TDM) in patients receiving therapy with vedolizumab for Crohn's disease (CD) or ulcerative colitis (UC). The aim of this study was to assess the relationship of serum vedolizumab trough levels (VTL) during induction and disease remission after 22 weeks of therapy. We also sought to investigate the presence of antibodies to vedolizumab (ATV). Methods: Prospective cohort study including patients with active UC and CD starting therapy with vedolizumab. Predictive variables included demographics, VTL and ATV (measured using a validated drugtolerant assay at weeks 2, 6 and 14), C-reactive protein (CRP), albumin level, Harvey Bradshaw index (HBI) in CD and Mayo Clinical Score (MCS) in UC. Simple endoscopic score-CD (SES-CD) in CD and Mayo endoscopic score (MES) in UC. Primary outcome was disease remission at week 22, defined as an HBI < 5 (in CD)/MCS < 3 (in UC), normal CRP and SES-CD≤2 (in CD) or MES≤1 (in UC). Secondary outcome was steroid-free remission (SFR) defined as remission while off steroids at week 22. Results: Forty-five patients were included. VTL at weeks 2, 6 and 14 were higher on those patients that had achieved remission at week 22, even though only the difference at weeks 2 and 6 were statistically significant (Figure 1). VTL at weeks 2 and 6, and baseline albumin level best correlated with remission (Table 1). Patients with a VTL ≥24 ug/mL (second quartile of week 2 VTL) at week 2 and ≥ 10.6 (first quartile of week 6 VTL) were more likely to be in remission at week 22 (OR: 5 [95%CI:1.4-17.8], p:0.001 and OR: 13.5 [95%CI: 1.5-118.7], p=0.005 respectively). Three patients had detectable ATV - none of them were on an immunomodulator: one patient at week 2 and the other two at week 6. All antibodies became negative by week 14. Patients that were receiving immunomodulators in combination with vedolizumab had higher VTL at weeks 2, 6 and 14, even though only the difference at week 2 reached statistical significance (Figure 2). Patients with CD were more likely to be on combination therapy and had lower VTL at week 2 (Table 2).Figure: Vedolizumab levels at weeks 2, 6 and 14 in patients with and without remission at week 22.Figure: Trough vedolizumab levels by week in patients on and off combination therapy.Table: Table. Correlation between study variables and disease remission at week 22Table: Table. Differences between patients with Crohn's disease and ulcerative colitisConclusion: Higher vedolizumab levels during induction are associated with better response to therapy at week 22 and are correlated with remission while the rate of immunogenicity against vedolizumab was low and transient. TDM may have a role in patients with CD or UC receiving vedolizumab and early optimization may potentially be of benefit in these patients.

Abstract There has been renewed interest in psychiatric classification, with the recent development of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the 11th edition of the International Classification of Disease (ICD-11), and the Research Domain Criteria (RDoC) framework. This chapter will consider issues relevant to cognitive enhancement, particularly interventions for individuals with subthreshold symptoms, from the perspective of debates in psychiatric classification. DSM-5, ICD-11, and RDoC each take a somewhat different approach to delineation of the normal from the pathological, and so to the conceptualization of individuals with subthreshold symptoms. For the foreseeable future, an integrative approach to the assessment and treatment of patients with subthreshold symptoms will emphasize the fuzziness of the boundary between enhancement and treatment, will incorporate DSM, ICD, RDoC and a range of other constructs, and will weigh up a broad range of relevant facts and values in clinical decision-making.

Problem substance use makes a significant contribution to the burden of injuries and noncommunicable diseases in South Africa. In 2012, the Western Cape Department of Health funded a randomised controlled trial of substance use SBIRT in emergency centres (ECs). Based on the promising results, the programme was implemented in 2016 in three ECs, offering motivational interviewing-based counselling delivered at the acute EC visit by lay counsellors. This study utilised data from a novel EC SBIRT service (1 August 2016 – 31 July 2017) and compared the characteristics, process and substance use outcome data for injured and non-injured patients. A screening questionnaire was administered to less seriously ill or injured adult patients, and those scoring at moderate-high risk on the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were eligible and received a motivational-interviewing-based session. Data collected included sociodemographics, presenting complaint, substance use days and the ASSIST. A three-month follow-up phone call was conducted to evaluate substance use in a small sample of service users. Process data was collected on the numbers of: patients screened, eligible patients, and sessions given. In total, 13 136 patients were screened. Over half were male, the mean age was 37 years and 43% presented with an injury. Of the non-injured patients, 23% met criteria for problem substance use, compared to 56% of injured patients. Of the eligible patients, 74% were male and 83% received a counselling session. At three-month follow-up there was a significant reduction in substance use days for all patients and injured patients’ alcohol use scores decreased by 6.4 points, compared to 4.7 in the non-injured patients. This EC SBIRT service delivered a substance use intervention to over 80% of eligible patients. Injured patients were more likely to report problem substance use, and showed a greater decrease in substance use scores.