Clinical records anonymisation and text extraction (CRATE): an open-source software system.

BACKGROUND: Electronic medical records contain information of value for research, but contain identifiable and often highly sensitive confidential information. Patient-identifiable information cannot in general be shared outside clinical care teams without explicit consent, but anonymisation/de-identification allows research uses of clinical data without explicit consent. RESULTS: This article presents CRATE (Clinical Records Anonymisation and Text Extraction), an open-source software system with separable functions: (1) it anonymises or de-identifies arbitrary relational databases, with sensitivity and precision similar to previous comparable systems; (2) it uses public secure cryptographic methods to map patient identifiers to research identifiers (pseudonyms); (3) it connects relational databases to external tools for natural language processing; (4) it provides a web front end for research and administrative functions; and (5) it supports a specific model through which patients may consent to be contacted about research. CONCLUSIONS: Creation and management of a research database from sensitive clinical records with secure pseudonym generation, full-text indexing, and a consent-to-contact process is possible and practical using entirely free and open-source software.The project was funded in part by the UK National Institute of Health Research Cambridge Biomedical Research Centre. The work was conducted within the Behavioural and Clinical Neuroscience Institute, University of Cambridge, supported by the Wellcome Trust and the UK Medical Research Council

Neuropsychology of reinforcement processes in the rat

This thesis investigated the role played by regions of the prefrontal cortex and ventral striatum in the control of rats’ behaviour by Pavlovian conditioned stimuli, and in their capacity to choose delayed reinforcement. First, the function of the anterior cingulate cortex (ACC) in simple Pavlovian conditioning tasks was addressed. The ACC is a subdivision of prefrontal cortex that has previously been suggested to be critical for the formation of stimulus–reward associations. It was found that lesions of the ACC did not prevent rats from learning a simple conditioned approach response to a conditioned stimulus (CS) predictive of food reward, or from utilizing that CS as a conditioned reinforcer subsequently. Additionally, these subjects successfully acquired a conditioned freezing response to a CS predicting footshock. However, the same animals were impaired at the acquisition of autoshaped behaviour, an impairment that has been demonstrated previously. An autoshaping deficit was also observed when lesions were made following training. The phenomenon of Pavlovian–instrumental transfer was intact in these subjects. The hypothesis was developed that the ACC is not critical for the formation of stimulus–reward associations per se, but is critical when multiple stimuli must be discriminated on the basis of their differential association with reward. In support of this hypothesis, animals with lesions of the ACC were impaired on a version of the conditioned approach task in which a second, neutral stimulus, perceptually similar to the CS, was added; the lesioned subjects exhibited reduced discrimination. Second, the role of the nucleus accumbens (Acb) in Pavlovian–instrumental transfer was investigated. The nucleus accumbens core, together with a larger amygdalar–striatal network of which it is a component, has previously been shown to be necessary for the expression of ‘simple’ Pavlovian–instrumental transfer. Rats with lesions of the nucleus accumbens core (AcbC) and shell (AcbSh) were tested on a ‘response-specific’ Pavlovian–instrumental transfer task, in which a Pavlovian CS selectively enhances instrumental responding for the outcome with which the CS was originally paired. AcbC lesions impaired the response specificity of this effect, while AcbSh lesions abolished Pavlovian–instrumental transfer entirely. These results are consistent with some — but not all — previous results in suggesting that the shell provides ‘vigour’ and the core provides ‘direction’ for the potentiation of behaviour by Pavlovian CSs. Third, an attempt was made to train rats on a task for assessing preference for delayed reinforcement, using the ‘adjusting-delay’ paradigm. It was not immediately apparent that the rats reacted to the contingencies operative in this task, and mathematical analysis of their behaviour was conducted to establish whether their behaviour was sensitive to the delay, and what ‘molar’ features of performance on this task could be explained by delay-independent processes. Fourth, a different delayed reinforcement choice task was developed, modifying a previously published task in which the subject is repeatedly offered a choice, in discrete trials, of a small reward delivered immediately, and a large reward delivered after a delay, with the delays systematically varied by the experimenter. Rats were trained on versions of this task in which the large, delayed reinforcer was or was not explicitly signalled by a cue present during the delay. The behavioural basis of performance on this task was examined, and d-amphetamine, chlordiazepoxide, and alpha-flupenthixol were administered systemically. It was found that the effects of d-amphetamine depended on whether the delayed reinforcer was signalled or unsignalled, increasing preference for signalled delayed reinforcement at some doses, but decreasing preference for unsignalled delayed reinforcement. These results may resolve contradictions in the literature, and are suggested to reflect the known effect of amphetamine to potentiate responding for conditioned reinforcers. Fifth, rats that had been trained on this task (with no explicit signals present during the delay) were given lesions of the ACC, AcbC, or medial prefrontal cortex (mPFC). ACC-lesioned rats were no different from sham-operated controls in their ability to choose a large, delayed reinforcer. Lesions of mPFC reduced the tendency of subjects to shift from one lever to the other during the course of a session, but mPFC-lesioned subjects responded normally to removal of the delays, suggesting a loss of stimulus control. However, rats with lesions of the AcbC were severely impaired on this task, preferring the small, immediate reward, even though they discriminated the reinforcers. Additionally, the effects of intra-Acb amphetamine were assessed using a different version of the delayed reinforcement choice task, and found to have slight but inconsistent effects to reduce preference for the delayed reinforcer, though this effect did not depend on whether the delayed reward was signalled or unsignalled. These results suggest that the AcbC contributes significantly to the rat’s ability to choose a delayed reward, a finding that has important implications for the understanding of Acb function. It is suggested that dysfunction of the AcbC may be a key element in the pathology of impulsivity.Supported by a UK Medical Research Council (MRC) research studentship, 1997–2000, and a James Baird award, University of Cambridge School of Clinical Medicine, 1997–2000

Neural systems involved in delay and risk assessment in the rat

This thesis investigated the contribution of the nucleus accumbens core (AcbC) and the hippocampus (H) to choice and learning involving reinforcement that was delayed or unlikely. Animals must frequently act to influence the world even when the reinforcing outcomes of their actions are delayed. Learning with action–outcome delays is a complex problem, and little is known of the neural mechanisms that bridge such delays. Impulsive choice, one aspect of impulsivity, is characterized by an abnormally high preference for small, immediate rewards over larger delayed rewards, and is a feature of attention-deficit/hyperactivity disorder (ADHD), addiction, mania, and certain personality disorders. Furthermore, when animals choose between alternative courses of action, seeking to maximize the benefit obtained, they must also evaluate the likelihood of the available outcomes. Little is known of the neural basis of this process, or what might predispose individuals to be overly conservative or to take risks excessively (avoiding or preferring uncertainty, respectively), but risk taking is another aspect of the personality trait of impulsivity and is a feature of a number of psychiatric disorders, including pathological gambling and some personality disorders. The AcbC, part of the ventral striatum, is required for normal preference for a large, delayed reward over a small, immediate reward (self-controlled choice) in rats, but the reason for this is unclear. Chapter 3 investigated the role of the AcbC in learning a free-operant instrumental response using delayed reinforcement, performance of a previously learned response for delayed reinforcement, and assessment of the relative magnitudes of two different rewards. Groups of rats with excitotoxic or sham lesions of the AcbC acquired an instrumental response with different delays (0, 10, or 20 s) between the lever-press response and reinforcer delivery. A second (inactive) lever was also present, but responding on it was never reinforced. The delays retarded learning in normal rats. AcbC lesions did not hinder learning in the absence of delays, but AcbC-lesioned rats were impaired in learning when there was a delay, relative to sham-operated controls. Rats were subsequently trained to discriminate reinforcers of different magnitudes. AcbC-lesioned rats were more sensitive to differences in reinforcer magnitude than sham-operated controls, suggesting that the deficit in self-controlled choice previously observed in such rats was a consequence of reduced preference for delayed rewards relative to immediate rewards, not of reduced preference for large rewards relative to small rewards. AcbC lesions also impaired the performance of a previously learned instrumental response in a delay-dependent fashion. These results demonstrate that the AcbC contributes to instrumental learning and performance by bridging delays between subjects’ actions and the ensuing outcomes that reinforce behaviour. When outcomes are delayed, they may be attributed to the action that caused them, or mistakenly attributed to other stimuli, such as the environmental context. Consequently, animals that are poor at forming context–outcome associations might learn action–outcome associations better with delayed reinforcement than normal animals. The hippocampus contributes to the representation of environmental context, being required for aspects of contextual conditioning. It was therefore hypothesized that animals with H lesions would be better than normal animals at learning to act on the basis of delayed reinforcement. Chapter 4 tested the ability of H-lesioned rats to learn a free-operant instrumental response using delayed reinforcement, and their ability to exhibit self-controlled choice. Rats with sham or excitotoxic H lesions acquired an instrumental response with different delays (0, 10, or 20 s) between the response and reinforcer delivery. H-lesioned rats responded slightly less than sham-operated controls in the absence of delays, but they became better at learning (relative to shams) as the delays increased; delays impaired learning less in H-lesioned rats than in shams. In contrast, lesioned rats exhibited impulsive choice, preferring an immediate, small reward to a delayed, larger reward, even though they preferred the large reward when it was not delayed. These results support the view that the H hinders action–outcome learning with delayed outcomes, perhaps because it promotes the formation of context–outcome associations instead. However, although lesioned rats were better at learning with delayed reinforcement, they were worse at choosing it, suggesting that self-controlled choice and learning with delayed reinforcement tax different psychological processes. Chapter 5 examined the effects of excitotoxic lesions of the AcbC on probabilistic choice in rats. Rats chose between a single food pellet delivered with certainty (probability p = 1) and four food pellets delivered with varying degrees of uncertainty (p = 1, 0.5, 0.25, 0.125, and 0.0625) in a discrete-trial task, with the large-reinforcer probability decreasing or increasing across the session. Subjects were trained on this task and then received excitotoxic or sham lesions of the AcbC before being retested. After a transient period during which AcbC-lesioned rats exhibited relative indifference between the two alternatives compared to controls, AcbC-lesioned rats came to exhibit risk-averse choice, choosing the large reinforcer less often than controls when it was uncertain, to the extent that they obtained less food as a result. Rats behaved as if indifferent between a single certain pellet and four pellets at p = 0.32 (sham-operated) or at p = 0.70 (AcbC-lesioned) by the end of testing. When the probabilities did not vary across the session, AcbC-lesioned rats and controls strongly preferred the large reinforcer when it was certain, and strongly preferred the small reinforcer when the large reinforcer was very unlikely (p = 0.0625), with no differences between AcbC-lesioned and sham-operated groups. These results suggest that the AcbC contributes to action selection by promoting the choice of uncertain, as well as delayed, reward

Accessibility and efficiency of mental health services, United Kingdom of Great Britain and Northern Ireland.

ProblemMental ill health in the United Kingdom of Great Britain and Northern Ireland has been a major driver of labour market exclusion through sickness absence, reduced productivity and job loss.ApproachA government-supported programme for improving access to psychological therapies was launched in 2008 and expanded across England in 2010. The aim was to provide evidence-based treatments for people with common mental disorders through three principal strategies: (i) routine session-by-session outcome monitoring; (ii) integration with the wider care system; and (iii) delivery of psychological therapies as part of a stepped-care approach.Local settingAccess to effective psychological therapies was previously low in the United Kingdom. In 2010, only about 35% of people with moderately severe mental disorders were in specialist or non-specialist treatment.Relevant changesThe accessibility of quality mental health services has increased, as has the efficiency of the country's mental health system. The numbers of people entering treatment have increased steadily from 0.43 million in 2012-2013 to 1.09 million in 2018-2019. The recovery rate of patients in treatment increased from 42.8% to 52.1% during 2012-2018. The number of people moved off sick pay and benefits rose from 3683 to 18 039 over the same period.Lessons learntA clinical guideline on psychological therapies is a prerequisite for increasing the accessibility and efficiency of mental health services. An integrated approach allows mental health services to have better reach. Routine collection of patient-level outcome data plays an important role in the value and function of the mental health care system

Nucleus accumbens core lesions retard instrumental learning and performance with delayed reinforcement in the rat.

BACKGROUND: Delays between actions and their outcomes severely hinder reinforcement learning systems, but little is known of the neural mechanism by which animals overcome this problem and bridge such delays. The nucleus accumbens core (AcbC), part of the ventral striatum, is required for normal preference for a large, delayed reward over a small, immediate reward (self-controlled choice) in rats, but the reason for this is unclear. We investigated the role of the AcbC in learning a free-operant instrumental response using delayed reinforcement, performance of a previously-learned response for delayed reinforcement, and assessment of the relative magnitudes of two different rewards. RESULTS: Groups of rats with excitotoxic or sham lesions of the AcbC acquired an instrumental response with different delays (0, 10, or 20 s) between the lever-press response and reinforcer delivery. A second (inactive) lever was also present, but responding on it was never reinforced. As expected, the delays retarded learning in normal rats. AcbC lesions did not hinder learning in the absence of delays, but AcbC-lesioned rats were impaired in learning when there was a delay, relative to sham-operated controls. All groups eventually acquired the response and discriminated the active lever from the inactive lever to some degree. Rats were subsequently trained to discriminate reinforcers of different magnitudes. AcbC-lesioned rats were more sensitive to differences in reinforcer magnitude than sham-operated controls, suggesting that the deficit in self-controlled choice previously observed in such rats was a consequence of reduced preference for delayed rewards relative to immediate rewards, not of reduced preference for large rewards relative to small rewards. AcbC lesions also impaired the performance of a previously-learned instrumental response in a delay-dependent fashion. CONCLUSIONS: These results demonstrate that the AcbC contributes to instrumental learning and performance by bridging delays between subjects' actions and the ensuing outcomes that reinforce behaviour.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Hippocampal lesions facilitate instrumental learning with delayed reinforcement but induce impulsive choice in rats.

BACKGROUND: Animals must frequently act to influence the world even when the reinforcing outcomes of their actions are delayed. Learning with action-outcome delays is a complex problem, and little is known of the neural mechanisms that bridge such delays. When outcomes are delayed, they may be attributed to (or associated with) the action that caused them, or mistakenly attributed to other stimuli, such as the environmental context. Consequently, animals that are poor at forming context-outcome associations might learn action-outcome associations better with delayed reinforcement than normal animals. The hippocampus contributes to the representation of environmental context, being required for aspects of contextual conditioning. We therefore hypothesized that animals with hippocampal lesions would be better than normal animals at learning to act on the basis of delayed reinforcement. We tested the ability of hippocampal-lesioned rats to learn a free-operant instrumental response using delayed reinforcement, and what is potentially a related ability -- the ability to exhibit self-controlled choice, or to sacrifice an immediate, small reward in order to obtain a delayed but larger reward. RESULTS: Rats with sham or excitotoxic hippocampal lesions acquired an instrumental response with different delays (0, 10, or 20 s) between the response and reinforcer delivery. These delays retarded learning in normal rats. Hippocampal-lesioned rats responded slightly less than sham-operated controls in the absence of delays, but they became better at learning (relative to shams) as the delays increased; delays impaired learning less in hippocampal-lesioned rats than in shams. In contrast, lesioned rats exhibited impulsive choice, preferring an immediate, small reward to a delayed, larger reward, even though they preferred the large reward when it was not delayed. CONCLUSION: These results support the view that the hippocampus hinders action-outcome learning with delayed outcomes, perhaps because it promotes the formation of context-outcome associations instead. However, although lesioned rats were better at learning with delayed reinforcement, they were worse at choosing it, suggesting that self-controlled choice and learning with delayed reinforcement tax different psychological processes

Effects of lesions of the nucleus accumbens core on choice between small certain rewards and large uncertain rewards in rats

BACKGROUND: Animals must frequently make choices between alternative courses of action, seeking to maximize the benefit obtained. They must therefore evaluate the magnitude and the likelihood of the available outcomes. Little is known of the neural basis of this process, or what might predispose individuals to be overly conservative or to take risks excessively (avoiding or preferring uncertainty, respectively). The nucleus accumbens core (AcbC) is known to contribute to rats' ability to choose large, delayed rewards over small, immediate rewards; AcbC lesions cause impulsive choice and an impairment in learning with delayed reinforcement. However, it is not known how the AcbC contributes to choice involving probabilistic reinforcement, such as between a large, uncertain reward and a small, certain reward. We examined the effects of excitotoxic lesions of the AcbC on probabilistic choice in rats. RESULTS: Rats chose between a single food pellet delivered with certainty (p = 1) and four food pellets delivered with varying degrees of uncertainty (p = 1, 0.5, 0.25, 0.125, and 0.0625) in a discrete-trial task, with the large-reinforcer probability decreasing or increasing across the session. Subjects were trained on this task and then received excitotoxic or sham lesions of the AcbC before being retested. After a transient period during which AcbC-lesioned rats exhibited relative indifference between the two alternatives compared to controls, AcbC-lesioned rats came to exhibit risk-averse choice, choosing the large reinforcer less often than controls when it was uncertain, to the extent that they obtained less food as a result. Rats behaved as if indifferent between a single certain pellet and four pellets at p = 0.32 (sham-operated) or at p = 0.70 (AcbC-lesioned) by the end of testing. When the probabilities did not vary across the session, AcbC-lesioned rats and controls strongly preferred the large reinforcer when it was certain, and strongly preferred the small reinforcer when the large reinforcer was very unlikely (p = 0.0625), with no differences between AcbC-lesioned and sham-operated groups. CONCLUSION: These results support the view that the AcbC contributes to action selection by promoting the choice of uncertain, as well as delayed, reinforcement

Osteomalacia and vitamin D deficiency in a psychiatric rehabilitation unit: case report and survey.

BACKGROUND: Vitamin D deficiency is common and predisposes to many serious diseases, yet often goes unrecognized. FINDINGS: We describe a case of severe vitamin D deficiency with osteomalacia in a patient resident in a psychiatric hospital for more than 35 years, and discuss causes and complications. We assayed the serum 25-hydroxyvitamin D levels of all patients under our care on one old-age psychiatry rehabilitation unit. Ten of twelve (83%) of patients had vitamin D deficiency, and 92% had suboptimal vitamin D levels. Vitamin D status was strongly predicted by dietary supplementation. Of those not on vitamin D supplements, 100% had vitamin D deficiency, with vitamin D levels significantly below those of historical controls. Age, sex, and duration of admission did not predict vitamin D status in this group. CONCLUSION: We advocate vitamin D screening in all patients admitted to psychogeriatric units, and discuss treatment options given the current problems affecting high-dose vitamin D supply to the United Kingdom.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Mental health outcomes after SARS-CoV-2 vaccination in the United States: A national cross-sectional study.

Funder: NIHR Cambridge Biomedical Research CentreFunder: National Institute for Health Research (NIHR)BACKGROUND: Worsening of anxiety and depressive symptoms have been widely described during the COVID-19 pandemic. It can be hypothesized that vaccination could link to reduced symptoms of anxiety and/or depression. However, to date, no study has assessed this. This study aims to examine anxiety and depressive symptoms after vaccination in US adults, meanwhile test sociodemographic disparities in these outcomes. METHODS: Data from the January 6-June 7 2021, cross-sectional Household Pulse Survey were analyzed. Using survey-weighted logistic regression, we assessed the relationships between SARS-CoV-2 vaccination and anxiety and/or depressive symptoms, both on overall and sociodemographic subgroups. We controlled for a variety of potential socioeconomic and demographic confounding factors. RESULTS: Of the 453,167 participants studied, 52.2% of the participants had received the COVID-19 vaccine, and 26.5% and 20.3% of the participants reported anxiety and depression, respectively. Compared to those not vaccinated, the vaccinated participants had a 13% lower odds of anxiety (adjusted odds ratio [AOR] = 0.85, 95%CI 0.83-0.90) and 17% lower odds of depression (AOR = 0.83, 95%CI 0.79-0.85). Disparities on the above associations were identified in age, marital status, education level, ethnic/race, and income level, but not on gender. LIMITATIONS: The causal inference was not able to be investigated due to the cross-sectional study design. CONCLUSION: Being vaccinated for SARS-CoV-2 was associated with lower odds of anxiety and/or depressive symptoms. While those more middle-aged or more affluent, were more likely to show these negative associations, the contrary was observed in ethnic minorities and those with lower educational attainment. More strategic and demography-sensitive public health communications could perhaps temper these issues

Association between antipsychotic/antidepressant drug treatments and hospital admissions in schizophrenia assessed using a mental health case register.

BACKGROUND: The impact of psychotropic drug choice upon admissions for schizophrenia is not well understood. AIMS: To examine the association between antipsychotic/antidepressant use and time in hospital for patients with schizophrenia. METHODS: We conducted an observational study, using 8 years' admission records and electronically generated drug histories from an institution providing secondary mental health care in Cambridgeshire, UK, covering the period 2005-2012 inclusive. Patients with a coded ICD-10 diagnosis of schizophrenia were selected. The primary outcome measure was the time spent as an inpatient in a psychiatric unit. Antipsychotic and antidepressant drugs used by at least 5% of patients overall were examined for associations with admissions. Periods before and after drug commencement were compared for patients having pre-drug admissions, in mirror-image analyses correcting for overall admission rates. Drug use in one 6-month calendar period was used to predict admissions in the next period, across all patients, in a regression analysis accounting for the effects of all other drugs studied and for time. RESULTS: In mirror-image analyses, sulpiride, aripiprazole, clozapine, and olanzapine were associated with fewer subsequent admission days. In regression analyses, sulpiride, mirtazapine, venlafaxine, and clozapine-aripiprazole and clozapine-amisulpride combinations were associated with fewer subsequent admission days. CONCLUSIONS: Use of these drugs was associated with fewer days in hospital. Causation is not implied and these findings require confirmation by randomized controlled trials.RNC was supported by the Wellcome Trust. EFE was supported by a NARSAD Young Investigator Award. The CPFT Research Database was supported by the UK National Institute of Health Research Cambridge Biomedical Research Centre. The work was conducted within the Behavioural and Clinical Neuroscience Institute, supported by the Wellcome Trust and the UK Medical Research Council.This is the final version of the article. It first appeared from Nature Publishing Group via http://dx.doi.org/10.1038/npjschz.2015.3