Patients' and clinicians' perspectives towards primary care consultations for shoulder pain: qualitative findings from the Prognostic and Diagnostic Assessment of the Shoulder (PANDA-S) programme.

BACKGROUND: Clinical management of musculoskeletal shoulder pain can be challenging due to diagnostic uncertainty, variable prognosis and limited evidence for long-term treatment benefits. The UK-based PANDA-S programme (Prognostic And Diagnostic Assessment of the Shoulder) is investigating short and long-term shoulder pain outcomes. This paper reports linked qualitative research exploring patients' and clinicians' views towards primary care consultations for shoulder pain. METHODS: Semi-structured interviews were conducted with 24 patients and 15 primary care clinicians. Twenty-two interviews (11 patients, 11 clinicians) were conducted as matched patient-clinician 'dyads'. Data were analysed thematically. RESULTS: Clinicians reported attempts to involve patients in management decisions; however, there was variation in whether patients preferred treatment choice, or for decisions to be clinician-led. Some patients felt uncertain about the decisions made, due to a lack of discussion about available management options. Many General Practitioners expressed a lack of confidence in diagnosing the underlying cause of shoulder pain. Patients reported either not being given a diagnosis, or receiving different diagnoses from different professionals, resulting in confusion. Whilst clinicians reported routinely discussing prognosis of shoulder pain, patients reported that prognosis was not raised. Patients also expressed concern that their shoulder pain could be caused by serious pathology; however, clinicians felt that this was not a common concern for patients. CONCLUSIONS: Findings showed disparities between patients' and clinicians' views towards shoulder pain consultations, indicating a need for improved patient-clinician communication. Findings will inform the design of an intervention to support treatment and referral decisions for shoulder pain that will be tested in a randomised controlled trial.

Determining sample size for progression criteria for pragmatic pilot RCTs: the hypothesis test strikes back!

BACKGROUND: The current CONSORT guidelines for reporting pilot trials do not recommend hypothesis testing of clinical outcomes on the basis that a pilot trial is under-powered to detect such differences and this is the aim of the main trial. It states that primary evaluation should focus on descriptive analysis of feasibility/process outcomes (e.g. recruitment, adherence, treatment fidelity). Whilst the argument for not testing clinical outcomes is justifiable, the same does not necessarily apply to feasibility/process outcomes, where differences may be large and detectable with small samples. Moreover, there remains much ambiguity around sample size for pilot trials. METHODS: Many pilot trials adopt a 'traffic light' system for evaluating progression to the main trial determined by a set of criteria set up a priori. We construct a hypothesis testing approach for binary feasibility outcomes focused around this system that tests against being in the RED zone (unacceptable outcome) based on an expectation of being in the GREEN zone (acceptable outcome) and choose the sample size to give high power to reject being in the RED zone if the GREEN zone holds true. Pilot point estimates falling in the RED zone will be statistically non-significant and in the GREEN zone will be significant; the AMBER zone designates potentially acceptable outcome and statistical tests may be significant or non-significant. RESULTS: For example, in relation to treatment fidelity, if we assume the upper boundary of the RED zone is 50% and the lower boundary of the GREEN zone is 75% (designating unacceptable and acceptable treatment fidelity, respectively), the sample size required for analysis given 90% power and one-sided 5% alpha would be around n = 34 (intervention group alone). Observed treatment fidelity in the range of 0-17 participants (0-50%) will fall into the RED zone and be statistically non-significant, 18-25 (51-74%) fall into AMBER and may or may not be significant and 26-34 (75-100%) fall into GREEN and will be significant indicating acceptable fidelity. DISCUSSION: In general, several key process outcomes are assessed for progression to a main trial; a composite approach would require appraising the rules of progression across all these outcomes. This methodology provides a formal framework for hypothesis testing and sample size indication around process outcome evaluation for pilot RCTs.

Metabolic risk factors and the incidence and progression of radiographic hand osteoarthritis: a population-based cohort study.

OBJECTIVE: To determine whether selected metabolic factors are associated with greater amounts of radiographic hand osteoarthritis (OA) incidence and progression. METHODS: The study identified 706 adults, aged 50-69 years, with hand pain and hand radiographs at baseline, from two population-based cohorts. Metabolic factors (body mass index, hypertension, dyslipidaemia, and diabetes) were ascertained at baseline by direct measurement and medical records. Analyses were undertaken following multiple imputation of missing data, and in complete cases (sensitivity analyses). Multivariable regression models estimated associations between metabolic factors and two measures of radiographic change at 7 years for all participants, individuals free of baseline radiographic OA, and in baseline hand OA subsets. Estimates were adjusted for baseline values and other covariates. RESULTS: The most consistent and strong associations observed were between the presence of diabetes and the amount of radiographic progression in individuals with nodal OA [adjusted mean differences in Kellgren-Lawrence summed score of 4.50 (-0.26, 9.25)], generalized OA [3.27 (-2.89, 9.42)], and erosive OA [3.05 (-13.56, 19.67)]. The remaining associations were generally weak or inconsistent, although numbers were limited for analyses of incident radiographic OA and erosive OA in particular. CONCLUSION: Overall metabolic risk factors were not independently or collectively associated with greater amounts of radiographic hand OA incidence or progression over 7 years, but diabetes was associated with radiographic progression in nodal, and possibly generalized and erosive OA. Diabetes has previously been associated with prevalent but not incident hand OA. Further investigation in hand OA subsets using objective measures accounting for disease duration and control is warranted.

Demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot.

OBJECTIVE: To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA). DESIGN: Adults aged ≥50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months were invited to undergo a clinical assessment and weight-bearing dorso-plantar and lateral radiographs of both feet. Radiographic first MTPJ OA in the most severely affected foot was graded into four categories using a validated atlas. Differences in selected demographic and clinical factors were explored across the four radiographic severity subgroups using analysis of variance (ANOVA) and ordinal regression. RESULTS: Clinical and radiographic data were available from 517 participants, categorised as having no (n = 105), mild (n = 228), moderate (n = 122) or severe (n = 62) first MTPJ OA. Increased radiographic severity was associated with older age and lower educational attainment. After adjusting for age, increased radiographic first MTPJ OA severity was significantly associated with an increased prevalence of dorsal hallux and first MTPJ pain, hallux valgus, first interphalangeal joint (IPJ) hyperextension, keratotic lesions on the dorsal aspect of the hallux and first MTPJ, decreased first MTPJ dorsiflexion, ankle/subtalar joint eversion and ankle joint dorsiflexion range of motion, and a trend towards a more pronated foot posture. CONCLUSIONS: This cross-sectional study has identified several dose-response associations between radiographic severity of first MTPJ OA and a range of demographic and clinical factors. These findings highlight the progressive nature of first MTPJ OA and provide insights into the spectrum of presentation of the condition in clinical practice.

Subsets of symptomatic hand osteoarthritis in community-dwelling older adults in the United Kingdom: prevalence, inter-relationships, risk factor profiles and clinical characteristics at baseline and 3-years.

OBJECTIVE: To compare the population prevalence, inter-relationships, risk factor profiles and clinical characteristics of subsets of symptomatic hand osteoarthritis (OA) with a view to understanding their relative frequency and distinctiveness. METHOD: 1076 community-dwelling adults with hand symptoms (60% women, mean age 64.7 years) were recruited and classified into pre-defined subsets using physical examination and standardised hand radiographs, scored with the Kellgren & Lawrence (K&L) and Verbruggen-Veys grading systems. Detailed information on selected risk factors was obtained from direct measurement (Body Mass Index (BMI)), self-complete questionnaires (excessive use of hands, previous hand injury) and medical record review (hypertension, dyslipidaemia, type 2 diabetes). Hand pain and disability were self-reported at baseline and 3-year follow-up using Australian/Canadian Osteoarthritis Hand Index (AUSCAN). RESULTS: Crude population prevalence estimates for symptomatic hand OA subsets in the adult population aged 50 years and over were: thumb base OA (22.4%), nodal interphalangeal joint (IPJ) OA (15.5%), generalised hand OA (10.4%), non-nodal IPJ OA (4.9%), erosive OA (1.0%). Apart from thumb base OA, there was considerable overlap between the subsets. Erosive OA appeared the most distinctive with the highest female: male ratio, and the most disability at baseline and 3-years. A higher frequency of obesity, hypertension, dyslipidaemia, and metabolic syndrome was observed in this subset. CONCLUSION: Overlap in the occurrence of hand OA subsets poses conceptual and practical challenges to the pursuit of distinct phenotypes. Erosive OA may nevertheless provide particular insight into the role of metabolic and cardiovascular risk factors in the pathogenesis of OA.

Hall effect measurements on Bridgman-grown CuInSe2 with sodium.

The presence of sodium, either in the substrate or as a co-evaporant during absorber deposition, has been shown to improve the performance of polycrystalline photovoltaic devices made with Cu(In, Ga)Se(2), as well as the ternary CuInSe(2). Investigations have shown Na or Na compounds deposited on the grain boundaries, but none have been found within intact crystal grains, leading to suggestions that grain boundaries may play a role in the improved performance of the cells. Therefore, in this study, ingots containing large monocrystals of CuInSe(2) have been grown, using a vertical-Bridgman method, from melts that also include a varying quantity of sodium. In order to simulate the conditions under which cells are constructed, a proportion of Se above stoichiometry has been added to some of the melts. Resistivity and Hall effect measurements were then performed on the material after growth. The results show no large change in either resistivity or majority hole concentration in either set of samples, although a slight decrease in the latter value was apparent in the excess Se samples with 0.2 and 0.3 at.% Na additions. No clear trend in hole mobility could be discerned, although an increase was seen with 0.2 at.% Na addition for both samples.

Alternatively spliced tissue factor induces angiogenesis through integrin ligation.

The initiator of coagulation, full-length tissue factor (flTF), in complex with factor VIIa, influences angiogenesis through PAR-2. Recently, an alternatively spliced variant of TF (asTF) was discovered, in which part of the TF extracellular domain, the transmembrane, and cytoplasmic domains are replaced by a unique C terminus. Subcutaneous tumors produced by asTF-secreting cells revealed increased angiogenesis, but it remained unclear if and how angiogenesis is regulated by asTF. Here, we show that asTF enhances angiogenesis in matrigel plugs in mice, whereas a soluble form of flTF only modestly enhances angiogenesis. asTF dose-dependently upregulates angiogenesis ex vivo independent of either PAR-2 or VIIa. Rather, asTF was found to ligate integrins, resulting in downstream signaling. asTF-alphaVbeta3 integrin interaction induces endothelial cell migration, whereas asTF-dependent formation of capillaries in vitro is dependent on alpha6beta1 integrin. Finally, asTF-dependent aortic sprouting is sensitive to beta1 and beta3 integrin blockade and a TF-antibody that disrupts asTF-integrin interaction. We conclude that asTF, unlike flTF, does not affect angiogenesis via PAR-dependent pathways but relies on integrin ligation. These findings indicate that asTF may serve as a target to prevent pathological angiogenesis.

Radiographic hand osteoarthritis: patterns and associations with hand pain and function in a community-dwelling sample.

OBJECTIVE: Patterns of radiographic osteoarthritis (ROA) of the hand are often examined by row, with the four joints of the thumb studied inconsistently. The objectives of this study were to determine relationships of ROA at different hand joints, use the findings to define radiographic sub-groups and investigate their associations with pain and function. METHODS: Sixteen joints in each hand were scored for the presence of ROA in a community-dwelling cohort of adults, 50-years-and-over, with self-reported hand pain or problems. Principal components analysis (PCA) with varimax rotation was used to study patterns of ROA in the hand joints and identify distinct sub-groups. Differences in pain and function between these sub-groups were assessed using Australian/Canadian Osteoarthritis Index (AUSCAN), Grip Ability Test (GAT) and grip and pinch strength. RESULTS: PCA was undertaken on data from 592 participants and identified four components: distal interphalangeal joints (DIPs), proximal interphalangeal joints (PIPs), metacarpophalangeal joints (MCPs), thumb joints. However, the left thumb interphalangeal (IP) joint cross-loaded with the PIP and thumb groups. On this basis, participants were categorised into four radiographic sub-groups: no osteoarthritis (OA), finger only OA, thumb only OA and combined thumb and finger OA. Statistically significant differences were found between the sub-groups for AUSCAN function, and in women alone for grip and pinch strength. Participants with combined thumb and finger OA had the worst scores. CONCLUSION: Individual thumb joints can be clustered together as a joint group in ROA. Four radiographic sub-groups of hand OA can be distinguished. Pain and functional difficulties were highest in participants with both thumb and finger OA.

Discrepancies between self-report and objective measures for stimulant drug use in HIV: cognitive, medication adherence and psychological correlates.

While it has long been recognized that self-reported drug use may be at variance with objectively obtained evidence such as urine toxicology assays, few studies have explored the behavioral correlates of such discrepancies. Here we compared self-reported and objective measures of stimulant drug use for 162 HIV infected individuals and identified a sub-group with discrepancies between data obtained via the two methods. Results showed poorer neurocognitive performance (attention, learning/memory) and lower medication adherence rates for the discrepant group as compared to those who either acknowledged their drug use or accurately denied recent stimulant use. Using the Millon Clinical Multiaxial Inventory-III, it was also found that those in the discrepant group were more hesitant to reveal psychopathology. Comparisons of self-reported and objectively measured medication adherence data are also discussed.

Regulation of telomerase by human papillomaviruses.

The E6 oncoprotein of human papillomaviruses (HPVs) induces telomerase activity in primary human epithelial cells. This activity is dependent on association of E6 with E6AP, a cellular ubiquitin ligase. E6 activates the transcription of hTERT, the catalytic subunit of telomerase. E boxes near the start of hTERT transcription are required for E6; however, acetylated histones are only present in the E6 cells. We identified two isoforms of NFX1, a new binding partner of E6/E6AP. The NFX1- 91 isoform binds to an X-box motif located adjacent to the proximal E box, binds Sin3A and HDACs, repressing hTERT transcription. It preferentially binds E6/E6AP and is targeted for ubiquitin-mediated degradation. The NFX1-123 isoform has the opposite activity, increasing hTERT transcription or translation. This is the first example of viral oncoproteins disrupting regulation of telomerase, a critical event in tumorigenesis.

'It's difficult being a dentist': stress and health in the general dental practitioner.

OBJECTIVE: The aim of the study was to investigate overall stress, work-stress and health in general dental practitioners (GDPs). DESIGN, SETTING AND SUBJECTS: A nationwide anonymous cross-sectional survey was undertaken using stratified random sampling of 2,441 GDPs in the UK.Main outcome measures Measures included perceived stress, Work Stress Inventory for Dentists, job dissatisfaction, measures of health symptoms and health behaviour, dental and demographic information. RESULTS: The main findings were that perceived stress was significantly correlated with measures of dental stress. Work-related factors: fragility of dentist-patient relationship, time and scheduling pressures, staff and technical problems, job dissatisfaction, percentage NHS, and number of hours worked per week together explained nearly a half of GDPs overall stress in their life (linear multiple regression, adjusted r(2) = 0.48, F (2, 2404) = 509.68, P < 0.0001). Health behaviours such as alcohol use was associated with work stress (r = 0.18, P < 0.001) and over a third of GDPs were overweight or obese. Sixty per cent of GDPs reported being nervy, tense or depressed, 58.3% reported headache, 60% reported difficulty in sleeping and 48.2% reported feeling tired for no apparent reason. These were all related to work stress (one way analysis of variance, F (1,2211) = 241.53 P < 0.0001, F (1,2214) = 86.17 P < 0.0001; F (1, 2215) = 125.55 P < 0.0001; F (1,2211) = 209.67 P < 0.0001 respectively). Levels of minor psychiatric symptoms were high, with 32.0% of cases identified. The amount of backache was also high (reported by 68.3% of GDPs). CONCLUSION: A high percentage of NHS dentistry was associated with high levels of overall stress in GDPs' lives, indicating that the nature of NHS dentistry should be carefully investigated to try to improve GDPs working conditions. A comparatively large number of dentists reported high levels of psychological stress symptoms, such as being nervy, tense and depressed, showing minor psychiatric symptoms, with alcohol use being related to stress. Other factors reported which were not related to stress but may be related to the actual practice of dentistry were that a third of dentists were overweight or obese and over 60% reported backache. Overall, these findings indicate the stressful nature of dentistry and difficulties in working conditions. The next step should be to develop interventions to help dentists to reduce stress in the dental surgery.

Predictors of neuropsychological performance in HIV positive women.

This study examines predictors of neuropsychological (NP) performance in a community sample of 237 HIV seropositive and seronegative women. Consistent with literature describing the NP sequelae of HIV infection in men, we expected that HIV status would predict poorer NP performance on tests assessing verbal memory, psychomotor speed and motor speed. Multiple regression analyses testing the association between HIV serostatus and NP performance and controlling for predictors including age, ethnicity, education, psychological distress, and drug and alcohol use indicated that HIV serostatus was associated with slowed psychomotor speed. Specifically, AIDS diagnosis and HIV seropositivity predicted poorer performance on tests of psychomotor speed relative to HIV seronegatives. Contrary to expectations, no relationship between HIV serostatus and either motor speed or verbal memory performance emerged. Education, ethnicity, depressive distress, recent exposure to drugs as indexed by toxicology, and alcohol use were also associated with NP performance. Given that the HIV seropositive and seronegative samples differed on a number of demographic and drug use variables, a second series of analyses examining a subset of participants (matched on all key demographic factors) and with no illicit drug use during the past year was also conducted. Results of these analyses were similar to those obtained for the full sample, with AIDS diagnosis and HIV seropositivity predicting psychomotor slowing. To date, little work describing the NP sequelae of HIV infection in women has been conducted. This study provides one of the first descriptions of the NP effects of HIV/AIDS in a largely non-injection drug using community sample of women.

The effects of racial stressors and hostility on cardiovascular reactivity in African American and Caucasian men.

This study examined the effects of race-related stressors and hostility on cardiovascular reactivity in 31 African American and 31 Caucasian men. Participants viewed 3 film excerpts that depicted neutral, anger-provoking (but race-neutral), and racist situations. Participants exhibited significantly greater diastolic blood pressure reactivity to anger-provoking and racist stimuli compared with neutral stimuli. In addition, high hostility was associated with higher recovery systolic and diastolic blood pressure levels after exposure to the films. Although the results failed to confirm previous reports of greater reactivity to racism in African Americans, the findings suggest that diastolic blood pressure levels may remain elevated after exposure to racist stimuli. These results indicate that even indirect exposure to interpersonal conflict elicits significant reactivity, which can persist after exposure to the stressor, especially among high-hostile men.

Consultation in the classroom.

The advantages of classroom, playground, and hallway observation are that the diagnosing child and adolescent psychiatrist can directly observe the difficulties the child is having. When the psychiatrist is an employee of the school district, there can be easier access and quicker help for challenging students.

A failed fall prevention study in an acute care setting: lessons from the swamp.

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest-post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.

Behavioral treatment of hypertensive heart disease in African Americans: rationale and design of a randomized controlled trial.

African Americans experience higher morbidity and mortality than Whites do as a result of hypertension and associated cardiovascular disease. Chronic psychosocial stress has been considered an important contributing factor to these high rates. The authors describe the rationale and design for a planned randomized controlled trial comparing Transcendental Meditation, a stress-reduction technique, with lifestyle education in the treatment of hypertension and hypertensive heart disease in urban African Americans. They pretested 170 men and women aged 20 to 70 years over a 3-session baseline period, with posttests at 6 months. Outcomes included clinic and ambulatory blood pressure, quality of life, left ventricular mass measured by M-mode echocardiography, left ventricular diastolic function measured by Doppler, and carotid atherosclerosis measured by beta-mode ultrasound. This trial was designed to evaluate the hypothesis that a selected stress reduction technique is effective in reducing hypertension and hypertensive heart disease in African Americans.

Nurses' use of restraints and their attitudes toward restraint use and the elderly in an acute care setting.

A descriptive correlation study was conducted in an acute-care hospital to explore the relationship between nurses' use of restraints and their attitudes toward restraint use and the elderly. A total of 201 nurses returned a questionnaire that collected demographic information and included two research instruments: (i) Perceptions of Restraint Use Questionnaire and (ii) Attitudes toward the Aged Semantic Differential. Results showed slightly positive attitudes towards the elderly and toward the use of restraints, although there was no correlation between scores on the two scales. Furthermore, nurses' attitudes did not predict their self-reported use of restraints.

Psychosocial predictors of first-onset depression in Chinese Americans.

BACKGROUND: This study examines the longitudinal and concurrent risk factors associated with first-onset major depression in a community sample of 1747 Chinese Americans in Los Angeles. METHODS: The relative contributions of demographic, health, psychiatric, psychosocial, and cultural variables were assessed in a series of longitudinal and concurrent hierarchical multivariable analyses. RESULTS: Results of the longitudinal analyses indicated that the risk for experiencing a first major depressive episode at 18-months follow-up was higher for those who initially rated their health as poor, reported higher depressive symptoms, and perceived higher levels of social support. After controlling for prior health and psychiatric and psychosocial status at time 1, the results of the concurrent analyses indicated that the risk for experiencing a first major depressive episode at time 2 was higher for those who rated their health as poor, had at least one other psychiatric disorder, were bilingual, experienced high levels of life stress, and perceived themselves as having low and/or decreased social supports. CONCLUSIONS: The results of this study confirm previous evidence that psychosocial vulnerabilities, including higher acculturation, greater stress exposure and reduced social supports, are important predictors of risk for first-onset depressive episodes. Prevention and treatment implications are addressed, and future directions for research are offered.

HIV-1, cocaine, and neuropsychological performance in African American men.

The purpose of this study was to examine the independent and interactive effects of HIV-1 serostatus and cocaine on neuropsychological (NP) performance in a sample of 237 gay and bisexual urban-dwelling African American men. Consistent with current evidence, it was expected that the greatest neuropsychological performance deficits would be evident (1) in the symptomatic seropositives (SSPs), especially in domains affected by HIV (i.e., memory and psychomotor speed), and on tests that are sensitive to subtle slowing; (2) in those who are recent and frequent cocaine abusers; and (3) in those who are both HIV seropositive and cocaine abusers. Multivariate analyses controlling for age and alcohol use confirmed expectations, with symptomatic seropositives (SSPs) evidencing significantly poorer psychomotor speed than the seronegatives (SNs), and slower reaction time and poorer nonverbal memory than the asymptomatic seropositives (ASPs). Moderate to heavy recent cocaine use was associated with slower psychomotor speed. However, contrary to expectations, no interaction of serostatus and cocaine was noted for any NP domain, and the expected serostatus and cocaine effects on verbal memory and frontal systems were not obtained. Level of alcohol consumption exacerbated the detrimental effects of HIV-1 on a computerized reaction time test which is especially sensitive to subtle slowing. This study provides one of the first descriptions of the neuropsychological effects of HIV-AIDS in a non-injection drug-using community sample of gay and bisexual African American men.

Neuropsychiatric disturbance is associated with executive dysfunction in HIV-1 infection.

Prominent apathy and/or irritability are frequently observed among individuals infected with the human immunodeficiency virus (HIV). Although these symptoms often occur as part of a mood disorder, compelling evidence suggests that they may occur independently of depression in neurologic disease/disorder. The current study examined the prevalence of both apathy and irritability among a sample of HIV-infected individuals and explored the degree to which these neuropsychiatric (NP) phenomena were associated with performance on neuro-cognitive measures thought to be sensitive to the potential CNS effects of HIV-1. Clinician-administered rating scales assessing apathy and irritability were administered to 65 HIV-seropositive (HIV+) and 21 HIV-seronegative (HIV-) participants who also completed a dual-task reaction time paradigm and the Stroop task. NP disturbance was significantly more prevalent among HIV+ participants compared with HIV- controls and was associated with specific neuro-cognitive deficits suggestive of executive dysfunction. Relative to both HIV- controls and to neuro-psychiatrically intact HIV+ participants, those HIV+ individuals with evidence of prominent apathy and/or irritability showed deficits in dual-task, but not single-task, performance and on the interference condition of the Stroop. Unexpectedly, NP disturbance did not show a robust relationship with HIV disease stage. These results suggest that the presence of prominent apathy and/or irritability among HIV+ individuals may signify greater HIV-associated CNS involvement. In HIV/AIDS, the disruption of frontal-subcortical circuits may be a common mechanism causing both executive dysfunction and NP disturbance.