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Addiction is regarded as a disorder of inflexible choice with behavior dominated by immediate positive rewards over longer-term negative outcomes. However, the psychological mechanisms underlying the effects of self-administered drugs on behavioral flexibility are not well understood. To investigate whether drug exposure causes asymmetric effects on positive and negative outcomes we used a reversal learning procedure to assess how reward contingencies are utilized to guide behavior in rats previously exposed to intravenous cocaine self-administration (SA). Twenty-four rats were screened for anxiety in an open field prior to acquisition of cocaine SA over six daily sessions with subsequent long-access cocaine SA for 7 days. Control rats (n = 24) were trained to lever-press for food under a yoked schedule of reinforcement. Higher rates of cocaine SA were predicted by increased anxiety and preceded impaired reversal learning, expressed by a decrease in lose-shift as opposed to win-stay probability. A model-free reinforcement learning algorithm revealed that rats with high, but not low cocaine escalation failed to exploit previous reward learning and were more likely to repeat the same response as the previous trial. Eight-day withdrawal from high cocaine escalation was associated, respectively, with increased and decreased dopamine receptor D2 (DRD2) and serotonin receptor 2C (HTR2C) expression in the ventral striatum compared with controls. Dopamine receptor D1 (DRD1) expression was also significantly reduced in the orbitofrontal cortex of high cocaine-escalating rats. These findings indicate that withdrawal from escalated cocaine SA disrupts how negative feedback is used to guide goal-directed behavior for natural reinforcers and that trait anxiety may be a latent variable underlying this interaction.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The East London Foundation Trust (ELFT) psychiatric liaison team (PLT) at Newham University Hospital (NUH) is responsible for referring adult patients they have reviewed, on to community mental health services on discharge where appropriate, and also to notify their existing team for follow-up on discharge when already under the care of a community service. This should then lead to appropriate ongoing management of the patient’s mental health needs in terms of continued support and assessment of risk, further assessment of mental state, titration of medications and prevention of further admissions.Following an ELFT incident review where it was noted that a patient was not referred to community services on discharge, a retrospective case note review was undertaken over an 11-month period to define the baseline efficacy of current referrals. Quality improvement (QI) methods were used to understand the issue, create a more robust process and measure the improvements made. We set up regular QI Project meetings and we used driver diagram, process mapping, PDSA cycles and run charts. The change ideas included moving from a white board based system to using Microsoft Excel, CRS millennium patient lists, Microsoft TEAMS and additional admin support. We studied the results for the following 14 months.The percentage of patients being appropriately referred in terms of timeliness and correct documentation increased from a run chart baseline of 35% to 88% during the project period, and the number of patients with some evidence of referral having been completed increased from 83% to 100%.The previous system used was ineffective in managing onward referrals for mental health patients from PLT. QI methods have allowed sustainable improvement in both the percentage of patients referred and those correctly documented, improving follow up and care for mental health patients who are admitted to NUH.

IntroductionN-terminal-pro hormone of Brain Natriuretic Peptide (NT-proBNP) is a sensitive rule-out test for new-onset acute heart failure (HF) with a high negative predictive value. However, it is not specific and can be influenced by various factors including cardiac (e.g. ACS, arrhythmia) and non-cardiac (advancing age and co-morbidities such as chronic kidney disease and anaemia). These factors must be taken into account when utilising NT-proBNP as a screening tool.Due to the high demand on echocardiography services, the British Society of Echocardiography (BSE) have recommended a triage criteria for inpatient echocardiography requests, including an age-specific NT-proBNP concentration cut-off for those with suspected HF.Our aim was to evaluate the effectiveness and safety of using these BSE recommendations for the inpatient diagnosis of HF when triaging echocardiography requests, and their potential impact on the inpatient demand for echocardiography.MethodWe retrospectively analysed and compared NT-proBNP results and inpatient echocardiogram findings reported between 1st and 15th March 2024 at two centres in the East of England. Patients were divided into the three BSE NT-proBNP cut-off levels: ≥ 450 ng/l in those under 50 years of age, ≥ 900 ng/l for those between 50 and 75 years of age (inclusive), and ≥ 1800 ng/l for those over 75 years of age, for comparison.Results159 patient records were analysed to determine if their NT-proBNP concentration met the BSE criteria to trigger an inpatient echocardiogram. The mean age was 80±13.04 years. 47.8% (76) were women. 100 (62.9%) patients had an NT-proBNP concentration that met the BSE criteria. 65 (65%) of these had an inpatient echocardiogram. Of the remaining 59 (37.1%) who did not meet the criteria, 49.2% (29) had an echocardiogram.Of those who met the criteria and had an echocardiogram, 39 (60%) were diagnosed with HF. Of those who did not meet the criteria and had an echocardiogram, 9 (30.4%) were diagnosed with HF.Abstract 5-018 Table 1Results summary Number of Patients Met BSE criteria for inpatient TTE (n=100) Did not meet BSE criteria for inpatient TTE (n=59) P value Had Echo 65 (65%) 29 (49.2%) Positive HF Diagnosis 39 (60%) 9 (30.4%) 0.014 Numbers (%)A review of these nine cases found that in 7 there were valid reasons other than elevated NT-proBNP for these requests, including strong clinical suspicion of HF based on clinical presentation, new acute coronary syndrome presentation and ventricular tachycardia. Allowances in the BSE criteria mean that these patients would still have qualified for an inpatient echocardiogram despite a below-threshold NT-proBNP. In two patients with a reportedly abnormal echocardiogram, a subsequent cardiac MRI was normal. No cases of HF were, therefore, truly missed.Abstract 5-018 Table 2Diagnosis after review of the nine cases who would not have met BSE age-specific NT-proBNP criteria Number of patients Reasons 3 Known HF on treatment 2 Subsequent inpatient Cardiac MRI was normal 1 Duplicate patient 1 Acute Coronary Syndrome 1 New diagnosis of HF with clinical presentation highly suggestive of HF 1 Ventricular Tachycardia ConclusionsWith a sensitivity and specificity of 81% and 43% respectively, our data suggests that the BSE’s age-related NT-proBNP criteria for inpatient echocardiography provides a safe and viable framework for triaging inpatient requests towards a diagnosis of HF. This approach could reduce the burden on over stretched services, allowing resources to be directed more appropriately.