Longitudinal associations between alcohol use, smoking, genetic risk scoring and symptoms of depression in the general population: a prospective 6-year cohort study

BACKGROUND

Alcohol consumption, smoking and mood disorders are leading contributors to the global burden of disease and are highly comorbid. Yet, their interrelationships have remained elusive. The aim of this study was to examine the multi-cross-sectional and longitudinal associations between (change in) smoking and alcohol use and (change in) number of depressive symptoms.

METHODS

In this prospective, longitudinal study, 6646 adults from the general population were included with follow-up measurements after 3 and 6 years. Linear mixed-effects models were used to test multi-cross-sectional and longitudinal associations, with smoking behaviour, alcohol use and genetic risk scores for smoking and alcohol use as independent variables and depressive symptoms as dependent variables.

RESULTS

In the multi-cross-sectional analysis, smoking status and number of cigarettes per day were positively associated with depressive symptoms (p < 0.001). Moderate drinking was associated with less symptoms of depression compared to non-use (p = 0.011). Longitudinally, decreases in the numbers of cigarettes per day and alcoholic drinks per week as well as alcohol cessation were associated with a reduction of depressive symptoms (p = 0.001-0.028). Results of genetic risk score analyses aligned with these findings.

CONCLUSIONS

While cross-sectionally smoking and moderate alcohol use show opposing associations with depressive symptoms, decreases in smoking behaviour as well as alcohol consumption are associated with improvements in depressive symptoms over time. Although we cannot infer causality, these results open avenues to further investigate interventions targeting smoking and alcohol behaviours in people suffering from depressive symptoms.

Risk factors and clinical effects of late leaflet thrombosis after transcatheter aortic valve replacement

Background

As the indications for trans-catheter aortic valve replacement (TAVR) expand, it is expected that the number of TAVR patients would increase and the follow-up duration would be longer. It is known that the incidence of leaflet thrombosis is higher in TAVR than in surgical aortic valve replacement (SAVR), but not much is known about the risk factors of late leaflet thrombosis in TAVR.

Aim

Therefore, in this study, the incidence and risk factors of late leaflet thrombosis at late term after TAVR and the effect on clinical course of late leaflet thrombosis would be investigated.

Method

There were 176 patients undergone TAVR from January 2015 to October 2020 in one tertiary hospital of south korea. 94 patients had follow-up cardiovascular computed tomography (CT) between 3 months and 2 years after TAVR. Among 94 patients, late leaflet thrombosis was discovered at 20 patients, and risk factors were analyzed by comparing clinical factors, echocardiographic and cardiovascular CT information, and angiographic data between the group with and without late leaflet thrombosis. And the difference in aortic valve hemodynamics between the group with and without leaflet thrombosis was examined and clinical outcomes were compared. Clinical outcome was defined as the composite of all-cause death, stroke, heart failure (HF) admission, redo-aortic valve (AV) replacement and major bleeding after detection of late leaflet thrombosis.

Results

Indexed mean sinus of Valsalva diameter, AV calcium score and post procedure estimated orifice area (EOA) had predictability of late leaflet thrombosis with AUC value of 0.670 (95% CI [0.546–0.795], p value = 0.020), AUC value of 0.698 (95% CI [0.544–0.851], p value = 0.012) and AUC value of 0.665 (95 percent CI [0.548–0.782], p value = 0.031), respectively (Figure 1).

In echocardiography performed at the time of follow-up CT, AV max velocity and AV mean pressure gradient were higher in thrombosis group and EOA and Doppler velocity index were lower in thrombosis group than in no thrombosis group within normal range (Figure 2). Clinical outcome was not significant different between the two groups (log rank p value = 0.560).

Conclusion

Larger indexed sinus of Valsalva diameter, higher AV calcium score and smaller post procedure AV EOA were risk factors for late leaflet thrombosis after TAVR. Subclinical late leaflet thrombosis have a benign course when properly managed.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary arterial angioplasty in peripheral pulmonary arterial stenosis in RNF213 vasculopathy: effective but high-risk treatment with reperfusion injury

Background

p.Arg4810Lys variant of the ring finger protein 213 (RNF213) vasculopathy is a nonsyndromatic vasculopathy involving multisystemic organs including pulmonary arteries. Peripheral pulmonary arterial stenosis (PPAS) with diffuse stenosis and beaded appearance is a unique feature of this disease and no treatment option has been tried before.

Methods

We performed BPA for PPAS in RNF213 patients (n=7). Severity of pulmonary hypertension was assessed by echocardiography and right heart catheterization at the baseline. Several clinical and hemodynamic parameters were followed up after each BPA sessions.

Results

All of the patients had dyspnea on exertion. Right ventricular dysfunction was observed in six patients and NT-proBNP was elevated (949.2±1148.1 pg/mL). Baseline echocardiography showed severe pulmonary hypertension (70.1±19.2 mmHg). Pulmonary arterial ballooning was performed to all patients, but stenting (n=6) and cutting balloon (n=1) was necessary due to elastic recoil. Improvement of clinical and hemodynamic parameters was achieved in six patients after 5.3 sessions of BPA in average. Reperfusion edema was seen in four patients, eventually leading to death in one patient.

Conclusions

Pulmonary arterial angioplasty, when coupled with stenting, is an effective treatment for PPAS with RNF213 vasculopathy. Although reperfusion injury was common and fatal in a few cases, it is the only modality to improve the patient's symptom and hemodynamics till now. Careful selection of the target population should be preceded to perform the intervention.

Funding Acknowledgement

Type of funding sources: None.

[Patient with a long history of disease in whom service dog contributed to recovery]

We describe a patient who reached recovery, after purchasing a dog and training it into an assistance dog. The patient has a long lasting (over 30 years) history in mental health care and was diagnosed with autism spectrum disorder, posttraumatic stress disorder and borderline personality disorder. All these years the patient did not reach symptomatic improvement or personal or social recovery. The patient suffered from severe emotional instability, feeling misunderstood, sleeping disorder because of nightmares and traumatic re-experiences, feeling unsafe and externalisation. There were repeated conflicts and periodical rejection of caregivers. A range of interventions and support options were offered. Medication intake was considerable aiming for sedation and numbness. After a second opinion an assistance dog was suggested. Two years after the purchase of the dog, her mood had improved, anxiety decreased, she slept better and stopped all medication. She feeled safe. Conflicts with others were reduced, she had some social contacts and the intensity of care had been reduced considerably.

[Use of the Triangle of Care Card and its influence on the cooperation with caregivers and clients]

BACKGROUND

Although there is consensus on the importance of involving informal caregivers of people with severe mental illness, interventions are needed to support this.

AIM

To explore whether the use of the 'Triangle of Care Card', an instrument developed to help strengthen the role of care-givers in their contact with workers, increases quality of cooperation and care.

METHOD

Three outpatient mental health teams and twelve teams for supported housing started working with the card. Information from files and questionnaires were used to monitor change and compare this with the changes during the same year in ten other teams.

RESULTS

Use of the Triangle of Care Card was sparse. When it was used, a broader range of subjects were discussed, including the needs of caregivers. Also, clients were more involved. In teams where the card was introduced, the clients' networks became more apparent and there was an increase in face-to-face meetings with members of this network.

CONCLUSION

Introduction of the Triangle of Care Card leads to change in the involvement of caregivers. However, implementation is problematic and therefore the increase in quality of the cooperation with caregivers and quality of care is yet small.

Tumor repolarization by an advanced liposomal drug delivery system provides a potent new approach for chemo-immunotherapy

Immunosuppressive cells in the tumor microenvironment allow cancer cells to escape immune recognition and support cancer progression and dissemination. To improve therapeutic efficacy, we designed a liposomal oxaliplatin formulation (PCL8-U75) that elicits cytotoxic effects toward both cancer and immunosuppressive cells via protease-mediated, intratumoral liposome activation. The PCL8-U75 liposomes displayed superior therapeutic efficacy across all syngeneic cancer models in comparison to free-drug and liposomal controls. The PCL8-U75 depleted myeloid-derived suppressor cells and tumor-associated macrophages in the tumor microenvironment. The combination of improved cancer cell cytotoxicity and depletion of immunosuppressive populations of immune cells is attractive for combination with immune-activating therapy. Combining the PCL8-U75 liposomes with a TLR7 agonist induced immunological rejection of established tumors. This combination therapy increased intratumoral numbers of cancer antigen-specific cytotoxic T cells and Foxp3^- T helper cells. These results are encouraging toward advancing liposomal drug delivery systems with anticancer and immune-modulating properties into clinical cancer therapy.

P1711The association of multidisciplinary team approach with clinical outcomes in patients with acute myocardial infarction underwent veno-arterial extracorporeal membrane oxygenation

Background

Multidisciplinary team approach is necessary for the management of critically-ill patients. However, limited data are available on the impact of specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock.

Objectives

This study aimed to identify whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients underwent venoarterial ECMO.

Methods

A total of 255 AMI patients underwent venoarterial ECMO from May 2004 to July 2018 were enrolled. In January 2014, multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into pre-ECMO team group (n=131) and post-ECMO team group (n=124). The primary outcome was in-hospital mortality.

Results

In-hospital mortality (54.2% vs. 33.9%, p=0.002) and cardiac intensive care unit mortality (45.0% vs. 25.0%, p=0.001) were significantly lower after the implantation of multidisciplinary ECMO team (pre ECMO team vs. post-ECMO team). On binary logistic regression model, the multidisciplinary ECMO team approach was associated with lower risk of in-hospital mortality (odds ratio 0.36, 95% confidence interval 0.19–0.67, p=0.001). Incidence of all-cause mortality (58.3% vs. 35.2%, p<0.001) and rehospitalization due to heart failure (28.2% vs. 6.4%, p=0.001) at 6-months follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group.

Clinical outcomes Variables Total (N=255) Pre-ECMO team (N=131) Post-ECMO team (N=124) P value In-hospital mortality 113 (44.3) 71 (54.2) 42 (33.9) 0.002 Cardiovascular death 90 (35.3) 59 (45.0) 31 (25.0) 0.001 Noncardiovascular death 23 (9.0) 12 (9.2) 11 (8.9) >0.99 Cardiac intensive care unit mortality 106 (41.6) 68 (51.9) 38 (30.6) 0.001 Successful weaning of ECMO 169 (66.3) 75 (57.3) 94 (75.8) 0.002 Data are presented as n (%). Abbreviations: ECMO, extracorporeal membrane oxygenation.

Incidence of death, readmission for HF

Conclusions

The multidisciplinary ECMO team approach was associated with improved clinical outcomes in AMI patients complicated by cardiogenic shock. Our data support that specialized ECMO team is indispensable to improve outcomes in patients with AMI with refractory cardiogenic shock.

No differences in olanzapine- and risperidone-related weight gain between women and men: a meta-analysis of short- and middle-term treatment

OBJECTIVE

A plethora of data deriving from single studies as well as meta-analyses demonstrates that weight gain is associated with the exposure to the majority of antipsychotics (AP). However, potential sex differences have widely evaded the attention of AP treatment trials. It is hypothesised that female patients gain more weight compared with male patients due to their enhanced susceptibility to adverse drug reactions.

METHOD

A meta-analysis was conducted using clinical trials of AP that reported weight change separately for female and male patients. Duration of AP use was stratified in four categories: <6 weeks, 6-16 weeks, 16-38 weeks and >38 weeks. Forest plots were generated for men and women separately, stratified by AP as well as by duration of use. Sex differences were tested by performing meta-regression.

RESULTS

Data of 26 studies were used in the present analysis because sufficient data were available only for olanzapine, risperidone and the no-medication group. Both female and male patients showed considerable weight gain after switch or initiate of olanzapine or risperidone, but meta-regression analyses did not show significant sex differences.

CONCLUSION

The present meta-analysis revealed that sex differences in AP-related weight gain have been under investigated hampering the detection of sex-specific patterns. In chronic patients switching to olanzapine or risperidone receiving short-or middle-term treatment, AP were associated with weight gain in both sex subgroups and no significant differences were reported.

Does breast screening offer a survival benefit? A retrospective comparative study of oncological outcomes of screen-detected and symptomatic early stage breast cancer cases

INTRODUCTION

Mammography screening reduces breast cancer mortality by up to 32%. However, some recent studies have questioned the impact of non-palpable breast cancer detection on mortality reduction. The aim of this study was to analyse the clinicopathological and long-term follow-up data of early stage screened and symptomatic breast cancer patients.

PATIENTS AND METHOD

The institutional prospectively led database was systematically analysed for breast cancer cases diagnosed via the mammography screening program from 2002 to 2009. As a control group, symptomatic early stage breast cancer patients were collected randomly from the same database and matched for age and follow-up period. All medical records were reviewed retrospectively.

RESULTS

Data from 298 breast cancer patients were collected from 47,718 mammography screenings. In addition, 331 symptomatic breast cancer patients were randomly selected. The screened group presented a significantly lower median tumour size (P < 0.00001). The incidence of negative regional lymph nodes was significantly higher in the screened group (P < 0.0006). The incidence of chemotherapy was 17% higher in the symptomatic group (P = 4*10^-5). At the median follow-up of 65 and 80 months, the screened group did not exhibit better overall (P = 0.717) or disease-free survival (P = 0.081) compared to the symptomatic group.

CONCLUSION

Our results do not suggest that mammography screening does not reduce breast cancer mortality but the mammography screening did not bring any significant improvement in patient overall or disease-free survival for the early stage breast cancer patients compared to the symptomatic group. The drawback of symptomatic early stage tumours compared to non-palpable tumours could be equalized by modern multimodality oncology treatments.

The functional and clinical relevance of childhood trauma-related admixture of affective, anxious and psychosis symptoms

OBJECTIVE

Previous work has shown that across different patient samples, patients with childhood trauma are more likely to have co-occurrence of affective, anxious and psychosis symptoms than non-traumatized patients. However, the clinical relevance of trauma-related admixture remains to be established.

METHOD

We examined patients with mood disorder (NEMESIS-2; n = 1260), anxiety disorder (NEMESIS-2; n = 896) or psychotic disorder (GROUP; n = 532) in terms of symptom profiles, quality of life (QOL) and social functioning.

RESULTS

Results showed that mood disorder patients with both trauma and co-occurrence of affective, anxious and psychosis symptoms had a lower QOL (B-12.6, 95% CI -17.7 to -7.5, P < 0.001), more help-seeking behaviour [odds ratio (OR) 2.5, 95% CI 1.1-5.7, P = 0.031] and higher prevalence of substance use disorders (OR 7.8, 95% CI 1.1-58.0, P = 0.044), compared with patients without trauma history and symptom admixture (Trauma-/CL-). Similar results were found in patients with an anxiety disorder. Traumatized patients with a psychotic disorder and admixture showed lower QOL (B-0.6, 95% CI -0.9 to -0.4, P < 0.001), higher prevalence of drug disorders (OR 2.2, 95% CI 1.2-3.9, P = 0.008) and lower global assessment of functioning (B-12.8, 95% CI -17.1 to -8.5, P < 0.001) than Trauma-/CL- patients.

CONCLUSION

Stratification according to childhood trauma exposure thus identifies a phenotype characterized by admixture of affective, anxiety and psychotic symptoms that, when combined, has clinical relevance. Identification of functionally meaningful aetiological subgroups may aid clinical practice.

Involvement of microRNAs in the inflammatory pathways of pulmonary sarcoidosis

Sarcoidosis is a multi-organ disease in which affected tissues are invaded with non-necrotizing granulomatous structures, mostly consisted of T helper 1 (Th1) cells and multinucleate giant cells. However, the etiology and pathogenesis of sarcoidosis is not known and the diagnosis is usually based on clinical examination involving radiography and histopathological analysis of biopsies of affected organs. Although the knowledge on the molecular background of sarcoidosis is limited, it seems that the important pathways involve transforming growth factor-β (TGF-β) and JAK/STAT, which may influence the interferon-γ (IFN-γ)-mediated signaling. Additionally, recently the role of microRNAs (miRNAs), the small non-coding RNA molecules, has been emphasized in different pathological conditions including autoimmune diseases. This review summarizes the current knowledge on the molecular pathways in the pathogenesis of sarcoidosis with a special emphasis on cytokines and miRNAs controlling immune cells proliferation and differentiation. Moreover, the possible role of T regulatory cells (CD4(+) CD25(+) FoxP3(+)) in this disease has been discussed.

Childhood trauma is associated with a specific admixture of affective, anxiety, and psychosis symptoms cutting across traditional diagnostic boundaries

BACKGROUND

Meta-analyses link childhood trauma to depression, mania, anxiety disorders, and psychosis. It is unclear, however, whether these outcomes truly represent distinct disorders following childhood trauma, or that childhood trauma is associated with admixtures of affective, psychotic, anxiety and manic psychopathology throughout life.

METHOD

We used data from a representative general population sample (NEMESIS-2, n = 6646), of whom respectively 1577 and 1120 had a lifetime diagnosis of mood or anxiety disorder, as well as from a sample of patients with a diagnosis of schizophrenia (GROUP, n = 825). Multinomial logistic regression was used to assess whether childhood trauma was more strongly associated with isolated affective/psychotic/anxiety/manic symptoms than with their admixture.

RESULTS

In NEMESIS-2, largely comparable associations were found between childhood trauma and depression, mania, anxiety and psychosis. However, childhood trauma was considerably more strongly associated with their lifetime admixture. These results were confirmed in the patient samples, in which it was consistently found that patients with a history of childhood trauma were more likely to have a combination of multiple symptom domains compared to their non-traumatized counterparts. This pattern was also found in exposed individuals who did not meet criteria for a psychotic, affective or anxiety disorder and who did not seek help for subclinical psychopathology.

CONCLUSIONS

Childhood trauma increases the likelihood of a specific admixture of affective, anxiety and psychotic symptoms cutting across traditional diagnostic boundaries, and this admixture may already be present in the earliest stages of psychopathology. These findings may have significant aetiological, pathophysiological, diagnostic and clinical repercussions.

Does social defeat mediate the association between childhood trauma and psychosis? Evidence from the NEMESIS-2 Study

OBJECTIVE

Based on theoretical considerations and animal studies, mediation of 'social defeat' (SD) in the association between childhood trauma (CT) and psychosis was investigated.

METHOD

Trained interviewers administered a structured interview assessing CT, psychotic experiences and other psychopathology in 6646 participants in the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2).

RESULTS

Childhood trauma was associated with psychotic experiences making up the extended psychosis phenotype (EPP), as well as with a diagnosis of psychotic disorder (PD). Similarly, CT was associated with a priori selected items indexing SD (discouraged, hopeless, worthless, loss of self-confidence, low self-esteem, better off dead, suicidal thoughts) and with a measure of affective dysregulation (AD), which in turn were also associated with psychosis. While SD and AD individually acted as mediators in the association between CT and EPP, only SD acted as a mediator in the association between CT and PD. Cannabis use did not mediate the association between CT and EPP or PD.

CONCLUSION

The present results suggest a developmental model implicating SD as an important mediator in the link between childhood adverse experiences and later development of psychotic experiences. The combined mediation by SD and AD is compatible with an 'affective pathway' to early psychosis.

Identification and quantification of electrical leakage pathways in floating microelectrode arrays

The long-term reliability of neural recording and stimulation electrode arrays is becoming the limiting factor for neural interfaces. For effective electrode design, electrical connection to the surrounding neural tissue and fluid should be limited to the electrode tips, with all other leakage currents minimized. It is the goal of this study to identify and quantify electrical leakage within commercially available floating microelectrode arrays (FMAs). Both short term and accelerated stress tests were performed on entire FMAs, as well as on individual electrodes typical of such arrays. Preliminary results of these tests indicate that leakage currents are present due to water penetration of their insulation layer initially, but that prolonged water exposure at high temperature may seal the defects that cause these currents. SEM photos taken of the electrode shafts show extensive defect regions that may correlate with the test data.

Allele loss of tumour suppressor genes on chromosome 17 in human testicular germ cell tumours

The molecular genetics of testicular germ cell tumours (TGCT) are still largely unknown. We investigated 20 TGCT tumours for allelic losses (LOH) of tumour supressor genes BRCA1, TP53 and of THRA1 on chromosome 17. We observed an overall loss of 50% for the whole chromosome. Detailed deletion mapping revealed no losses for the BRCA1 gene, 42% LOH for THRA1 and 11% allelic loss for the region telomeric to BRCA1. We observed 11% LOH for TP53. Our results suggest that allelic losses of BRCA1 and TP53 genes do not play a pivotal role in TGCT but that dysfunction of THRA1 or tumour suppressor gene(s) in this region may have an impact in the development of this cancer.

Intracortical visual prosthesis research - approach and progress

Following the early work of Brindley in the late 1960's, the NIH began intramural and extramural funding for stimulation of the primary visual coretex using fine-wire electrodes that are inserted into area VI for the prupose of restoring vision in individuals with blindness. More recently researchers with experience in this projectbecame part of our multi-institutional team with the intention to identify and close technological gaps so that the intracortical approach might be tested in humans on a chronic basis. Our team has formulated an approach for testing a prototype system in a human volunteer. Here, we describe our progress and expectations.

Genetic studies in congenital anterior midline cervical cleft

Congenital anterior midline cervical cleft (CAMCC) is a rare anomaly, with less than 100 cases reported. The cause of CAMCC is unknown, but genetic factors must be considered as part of the etiology. Three cases of CAMCC are presented. This is the first genetic study of isolated CAMCC. Conventional cytogenetics, array-comparative genomic hybridization (CGH) and whole exome sequencing were performed, including a search of relevant syndromes in the Online Mendelian Inheritance in Man (OMIM) database. Array CGH indicated a loss of the PAPPA gene in one of the patients, while exome sequencing showed a mutation in SIX5 in another patient. Both aberrations were inherited from unaffected parents. These results most likely imply that the identified mutations are not disease-causing, although they may be contributing factors if CAMCC has a polygenic inheritance.

[The new curriculum for the University Training Course in Psychiatry in South Limburg and for the Mental Health Services in Eindhoven]

BACKGROUND

The curriculum for the Academic Training Course in Psychiatry in South- Limburg (UOP-ZL) needed to be modernised. There were widely differing views about the purpose and function of psychiatry and about the structure of the curriculum. Trainees failed to attend regularly because of their daily duties.

AIM

Following discussion about the need for modernisation of the course in Psychiatry (HOOP), the UOP-ZL curriculum was thoroughly revised and updated.

METHOD

Further development of HOOP, a careful study of the teaching material and discussion among members of UOP-ZL and the Mental Health Service in Eindhoven, led to the development of more unified views about psychiatry and produced the ingredients for a revised curriculum for training in psychiatry.

RESULTS

In the early stages of their course, trainees are introduced to some basic principles; these include understanding the mechanisms for dimensions of affect, motivation, salience and cognition from a biological, cognitive and ecological perspective, and perceiving the relationship between these factors and normal and abnormal behaviour. The course is a mix of problem based learning and interactive classroom teaching and is delivered by clinical and scientific experts. Every two weeks the trainees in each year-group are given a whole day 'free' (i.e. free of normal duties) when they are required to attend classed and lectures.

CONCLUSION

The two main results of the new curriculum are: diagnosis-related teaching has been replaced by an approach based on explanatory mechanisms for dimensional psychopathology and dysfunction, and the tuition provided is both problem-based and interactive and is given by expert teachers.

Corpus callosum abnormalities, intellectual disability, speech impairment, and autism in patients with haploinsufficiency of ARID1B

Corpus callosum abnormalities are common brain malformations with a wide clinical spectrum ranging from severe intellectual disability to normal cognitive function. The etiology is expected to be genetic in as much as 30–50% of the cases, but the underlying genetic cause remains unknown in the majority of cases. By next-generation mate-pair sequencing we mapped the chromosomal breakpoints of a patient with a de novo balanced translocation, t(1;6)(p31;q25), agenesis of corpus callosum (CC), intellectual disability, severe speech impairment, and autism. The chromosome 6 breakpoint truncated ARID1B which was also truncated in a recently published translocation patient with a similar phenotype. Quantitative polymerase chain reaction (Q-PCR) data showed that a primer set proximal to the translocation showed increased expression of ARID1B, whereas primer sets spanning or distal to the translocation showed decreased expression in the patient relative to a non-related control set. Phenotype–genotype comparison of the translocation patient to seven unpublished patients with various sized deletions encompassing ARID1B confirms that haploinsufficiency of ARID1B is associated with CC abnormalities, intellectual disability, severe speech impairment, and autism. Our findings emphasize that ARID1B is important in human brain development and function in general, and in the development of CC and in speech development in particular.

[Rapid tranquillisation; review of the literature and recommendations]

BACKGROUND

In The Netherlands, no guidelines exist for rapid tranquillisation in the context of acute agitation, excitement or aggression secondary to a psychiatric disorder.

AIM

To generate an overview of medication regimes suitable for rapid tranquillisation.

METHOD

A literature search was conducted focussing on the effect of medical interventions in acute excitement, agitation or aggression. Primary outcome measurements were tranquillity, being calm, sedation, or asleep within two hours. Secondary outcome measures were frequency of re-administration and adverse side effects.

RESULTS

Haloperidol appears as effective as lorazepam; haloperidol in combination with lorazepam does not have added value to lorazepam or haloperidol alone. Dehydrobenzperidol, risperidone, olanzapine and aripiprazole are comparable in effectiveness to lorazepam or haloperidol. Haloperidol in combination with promethazine is associated with a more rapid onset of effect than lorazepam, haloperidol or olanzapine. Midazolam is faster than the combination of haloperidol and promethazine, but requires more frequent re-administration of medication and increases the risk for respiratory depression. The literature on quetiapine was insufficient. The level of evidence, however, is modest.

CONCLUSION

Haloperidol in combination with promethazine, and olanzapine, are effective in psychotic agitation, although haloperidol plus promethazine has a more rapid onset of effect faster; lorazepam is effective in non-psychotic agitation, aggression or excitement as well as in acute agitation of unknown origin.

Active floating micro electrode arrays (AFMA)

Neuroscientists have widely used metal microelectrodes inserted into the cortex to record neural signals from, and provide electrical stimulation to, neural tissue for many years. Recently, the demand for implanting electrode arrays within the cortex, for both stimulation and recording, has rapidly increased. We are developing Active-floating-micro-electrode-arrays (AFMA) that are intended for use as a multielectrode cortical interface while minimizing the number of wires leading from the array to extra-dural circuitry or connectors. When combined with a wireless module, these new microelectrode arrays should allow for simulation and recording within free-roaming animals. This paper mainly discusses the design, fabrication, and packing of the first generation AFMA. Our long-term vision is a wireless-transmission electrode system, for stimulation and recording in free-roaming animals, which uses a family of modular active implantable electrode arrays.

[An observational study of 'assertive outreach' with remission as outcome measure]

BACKGROUND

Systems of intensive care such as the Function Assertive Community Treatment (Function-act) are advocated because they are reported to have achieved very promising results. However, comparative studies aimed at measuring the efficacy of such systems are mainly of short duration and the outcome measure is nearly always the amount of care provided.

AIM

To investigate, via an observational study, changes that occurred in the number of patients going into remission and in the amount of care provided before and after the introduction of f-act.

METHOD

f-act was introduced in Maastricht and the surrounding area (population 220,000) at the beginning of 2002. Cumulative routine measurements of the effect of care in the region had been performed since 1998. These measurements were used to compare the proportion of patients in remission in two non-overlapping patients cohorts, each covering a 4-year period, namely 1998-2001 and 2002-2005. results The proportion of patients who made the transition to remission increased from 19% in the period before the introduction of f-act to 31% in the period after its introduction (or = 2.21; 95% ci: 1.03-4.78), but after controlling for confounders the difference was no longer statistically significant.

CONCLUSION

In routine clinical practice f-act can reduce the intensity of psychopathological symptoms, possibly because the care provided under f-act is less fragmented. However, more research is needed before the claimed beneficial effects of f-act can be proved conclusively.

[A psychosis proneness-persistence-impairment model of psychotic disorders]

There is evidence that the normally transitory developmental expression of psychosis (psychosisproneness) may first of all become abnormally persistent (persistence) and later on become clinically relevant (impairment), depending on the amount of environmental risk to which the person is exposed. According to the psychosis-proneness-persistence impairment model, genetic background factors can impact on a transitory expression of psychosis. Whether or not this will lead to a poor prognosis in terms of persistence and clinical need will depend on the interaction between environmental exposure and genetic risk.

"Safe" charge-injection waveforms for iridium oxide (AIROF) microelectrodes

Use of anodic bias improves the charge-injection limits of activated iridium oxide (AIROF) microelectrodes. Asymmetric waveforms, in which the charge balancing anodic phase is delivered at a lower current density and longer pulse width, has been found to allow for higher values of anodic bias voltages, thus maximizing the AIROF charge-injection capacity. Limiting the voltage excursion of the AIROF below the value at which electrolysis of water occurs is essential to maintaining the long-term viability of implanted electrodes. However, maintaining the electrodes at an anodic bias state while keeping the electrode voltage within these electrochemically "safe" limits complicates the topology of the electronic driver circuitry. We present two possible driver topologies that use compliance-voltage limitation in combination with cathodic current modification.

The dynamics of symptomatic and non-symptomatic coping with psychotic symptoms in the flow of daily life

OBJECTIVE

Previous research has suggested that going along with psychotic symptoms (symptomatic coping) is less effective than other coping strategies with psychotic symptoms. This pilot study aims to validate such findings using a momentary assessment strategy of coping with stress in daily life.

METHOD

Patients with psychosis (n = 35) were studied with the Experience Sampling Method (ESM; a structured diary technique) to assess coping with stress in daily life. This was analysed in relation to coping with psychotic symptoms using a previously validated interview (Maastricht Assessment of Coping Strategies).

RESULTS

Symptomatic and non-symptomatic coping were negatively associated with each other. Symptomatic coping was negatively associated with the level of coping in daily life, whereas a positive association was apparent for non-symptomatic coping. Non-symptomatic coping, but not symptomatic coping, predicted appraisals of distress associated with psychotic symptoms.

CONCLUSION

Effective coping may be associated with the tendency to develop conscious appraisals of distress associated with psychotic symptoms.

[Can the "Camberwell Assessment of Need" predict changes in care consumption?]

BACKGROUND

Because of the shift in the Dutch psychiatric care system towards care based on actual need, we should have some kind of instrument for assessing the future need for care. The Camberwell Assessment of Need (CAN) is such an instrument. It is particularly useful when there is a clear link between the need for care and the consumption of care.

AIM

To study whether the can is a predictor of (changes in) care consumption.

METHOD

The Maastricht Cumulative Needs for Care Monitor (CNCM) involves an interview with all patients with psychotic disorders who are in care in the Maastricht region. The interview takes place at intake and thereafter annually. The main instrument of the CNCM is the CAN, but other instruments are also included. CNCM data are matched with care consumption data extracted from the Psychiatric Case Register South Limburg, including both care consumption in the year before and in the year after the CNCM assessment.

RESULTS

Patients with intermediate or higher levels of need for care were found to use more inpatient care than patients with lower levels of need for care. In addition, the results showed that a high level of need for care was a predictor of shifts from low inpatient care consumption to high inpatient care consumption, although statistically imprecise by conventional alpha.

CONCLUSION

The CAN may well be a valuable instrument for assessing future inpatient care consumption.

[Coping matters in psychosis. Coping and the need for professional care in cases of subclinical psychosis]

BACKGROUND

Changes in the amount of care required in cases of subclinical psychosis are examined in relation to (1) the level of patient distress and (2) the level of dysfunctional coping.

METHOD

The Netherlands Mental Health Survey and Incidence Study (nemesis) is a longitudinal investigation into the occurrence of psychopathology in the general population. In the first two measurements of the nemesis study 4722 individuals had not been diagnosed as having a psychotic disorder according to dsm-iii-r. In the third measurement, 83 of those 4.722 were found to have had at least one subclinical psychotic experience. A panel of experts decided on the level of care that patients required. results Of the various types of psychotic experiences it was only 'passivity phenomena', hearing voices' and 'non-verbal hallucinations' which were associated with the need for care. These associations were largely explained by distress associated with the psychotic experience, with the exception of hearing voices. There were qualitative differences between the various types of coping: in particular, 'symptomatic coping' with psychotic experiences was associated with less perceived control over the psychotic experience (or = 0,79; 95% CI (confidence interval) 0,63-0,98) and an increased probability of the need for care (or = 6,07; 95% CI 1,95-18,95).

CONCLUSION

Various types of psychotic experiences require different levels of care. The need for care can arise when psychotic experiences begin to cause patient distress and/or dysfunctional coping. These factors may well play a role in turning an individual with subclinical psychotic experiences into a psychiatric patient.

Validation of remission criteria for schizophrenia

OBJECTIVE

Remission criteria for schizophrenia have been proposed, consisting of a time criterion and a symptomatic remission criterion. With longitudinal data of a representative patient group (N=317; median follow-up: 1,132 days), validity of the symptomatic remission criterion was investigated.

METHOD

In a group of 145 patients meeting the symptomatic remission criterion at baseline and a group of 172 patients not meeting it at baseline, change over time in remission status was examined in relation to change in various functional outcomes.

RESULTS

In both groups, change over time with the symptomatic remission criterion was associated with substantial changes in unmet needs, Global Assessment of Functioning scale scores, satisfaction with services and, to a lesser extent, quality of life. Changing the symptomatic remission criterion to include depression and suicidality did not affect the results.

CONCLUSIONS

The proposed symptomatic remission criterion has clinical validity and represents the right balance between parsimony and inclusiveness.

Validity and reliability of the CAPE: a self-report instrument for the measurement of psychotic experiences in the general population

OBJECTIVE

General population longitudinal cohort studies have demonstrated the prognostic validity of self-reported psychotic experiences, but data on reliability and cross-validation with interview-based measures of these experiences are sparse. This study tested the reliability and validity of the Community Assessment of Psychic Experiences (CAPE42).

METHOD

At baseline, the CAPE42 was used to measure the subclinical psychosis phenotype in a general population sample (n = 765). At follow-up (mean interval: 7.7 months), the Structured Interview for Schizotypy, Revised (SIS-R), the Brief Psychiatric Rating Scale (BPRS), and the CAPE42 were administered (n = 510).

RESULTS

Baseline self-reported dimensions of psychosis were specifically and independently associated with their equivalent interview-based dimension at follow-up (standardized effect sizes of 0.4-0.5) and with their equivalent self-reported measure (standardized effect sizes of 0.6-0.8).

CONCLUSION

The results indicate that self-reported dimensions of psychotic experiences in general population samples appear to be stable, reliable and valid.

Body posture in women after mastectomy and its changes as a result of rehabilitation

PURPOSE

The aim of the study is: 1) to analyse selected features of body posture in women after mastectomy, 2) to compare them with body posture of healthy women, 3) to determine the effect of rehabilitation physical exercises on the changes in body posture in women after mastectomy.

MATERIAL AND METHODS

The research material consisted of 85 women after mastectomy examined once, including 40 of them who were additionally examined twice at six-monthly intervals. Moreover, a group of 20 women was isolated who regularly attended rehabilitation classes for a period of one year in question. A comparative group was a group of 85 healthy women. The examinations were performed using photogrametric assessment of body posture.

RESULTS

Distinct adverse changes in body posture of women after mastectomy in comparison with healthy women were found, manifested mainly in asymmetry of trunk and shoulder girdle and greater forward leaning of the trunk. Significant relationship was indicated between the operation of mastectomy and the asymmetry of position of scapulas.

CONCLUSIONS

When comparing the changes in the features of body posture in the group of women who exercised regularly with other women for the period of one year it was found that a positive effect of regular rehabilitation was keeping the angle of body inclination on the same level and improvement in trunk symmetry, position of scapulas and shoulder girdle.

Are apparent associations between parental representations and psychosis risk mediated by early trauma?

OBJECTIVE

It was investigated whether the reported association between representations of parental rearing style and psychosis does not represent a main effect, but instead is a proxy indicator of the true underlying risk factor of early trauma.

METHOD

In a general population sample of 4045 individuals aged 18-64 years, first ever onset of positive psychotic symptoms at 3-year follow-up was assessed using the Composite International Diagnostic Interview and clinical interviews if indicated. Representations of parental rearing style were measured with the Parental Bonding Instrument (PBI).

RESULTS

Lower baseline level of PBI parental care predicted onset of psychotic symptoms 2 years later. However, when trauma was included in the equation, a strong main effect of trauma emerged at the expense of the effect size of PBI low care.

CONCLUSION

The results suggest that associations between representations of parental rearing style and psychosis may be an indicator of the effect of earlier exposure to childhood trauma.

Early trauma may increase the risk for psychotic experiences by impacting on emotional response and perception of control

OBJECTIVE

Exposure to early trauma may increase the risk of dysfunctional responses to anomalous psychotic experiences resulting in psychotic symptom formation.

METHOD

In a three-wave longitudinal general population study, 4045 never-psychotic individuals exposed and non-exposed to trauma before the age of 16 years, according to baseline interview were interviewed for the onset of psychotic experiences 3 years later (T2). In 36 individuals with incident psychosis at T2, assessments were made, for each psychotic experience, of i) the amount of distress associated with and ii) the degree of coping and subjective control over the experience.

RESULTS

In the 16 observations of an incident psychotic experience, in the absence of distress, the baseline rate of early trauma was low (6%), whereas it was much higher in the 21 observations of an incident psychotic experience with distress [43%; odds ratio=10.0, 95% confidence interval (CI): 1.04, 96.3; P=0.046]. Similarly, coping attempts in the context of early trauma was associated with less control (reduction of 2 points on a seven-point scale, 95% CI: -4.0, -0.07).

CONCLUSION

Early experience of trauma may create lasting cognitive and affective vulnerabilities to develop clinical symptoms arising out of early, non-clinical psychotic experiences.

Aluminium hydroxide-induced granulomas in pigs

The effect of intramuscular injection of 40 mg/2 ml aluminium hydroxide in the neck of pigs was examined in a number of ways. The investigation followed repeated slaughterhouse reports, according to which 64.8% of pigs from one particular farm were found at slaughter to have one or more nodules in the muscles of the neck (group slaughtered). The pigs had been injected with a vaccine containing 40 mg/2 ml dose of aluminium hydroxide as adjuvant. Research consisted of two phases: first, an epidemiological study was carried out, aimed at determining the risk factors for the granulomas. The results indicated that the vaccine was to be held responsible for the formation of granulomas. A clinical trial was then performed to further substantiate the initial hypothesis, by comparing pigs, which were aseptically inoculated twice with either the original vaccine or the adjuvant alone (groups vaccine and adjuvant) to pigs inoculated twice with apyrogenic bi-distilled water (group water) and to pigs inoculated once with the adjuvant and once with apyrogenic bi-distilled water (group adjuvant/water). Both studies agreed in their conclusions, which indicate that the high amount of aluminium hydroxide was the cause of the granulomas.