Cardiometabolic risk prediction algorithms for young people with psychosis: a systematic review and exploratory analysis

OBJECTIVE

Cardiometabolic risk prediction algorithms are common in clinical practice. Young people with psychosis are at high risk for developing cardiometabolic disorders. We aimed to examine whether existing cardiometabolic risk prediction algorithms are suitable for young people with psychosis.

METHODS

We conducted a systematic review and narrative synthesis of studies reporting the development and validation of cardiometabolic risk prediction algorithms for general or psychiatric populations. Furthermore, we used data from 505 participants with or at risk of psychosis at age 18 years in the ALSPAC birth cohort, to explore the performance of three algorithms (QDiabetes, QRISK3 and PRIMROSE) highlighted as potentially suitable. We repeated analyses after artificially increasing participant age to the mean age of the original algorithm studies to examine the impact of age on predictive performance.

RESULTS

We screened 7820 results, including 110 studies. All algorithms were developed in relatively older participants, and most were at high risk of bias. Three studies (QDiabetes, QRISK3 and PRIMROSE) featured psychiatric predictors. Age was more strongly weighted than other risk factors in each algorithm. In our exploratory analysis, calibration plots for all three algorithms implied a consistent systematic underprediction of cardiometabolic risk in the younger sample. After increasing participant age, calibration plots were markedly improved.

CONCLUSION

Existing cardiometabolic risk prediction algorithms cannot be recommended for young people with or at risk of psychosis. Existing algorithms may underpredict risk in young people, even in the face of other high-risk features. Recalibration of existing algorithms or a new tailored algorithm for the population is required.

Idiopathic interstitial pneumonitis in children: a national survey in the United Kingdom and Ireland

Interstitial lung disease (ILD) of unknown etiology in immunocompetent patients is rare in children. A national survey was carried out in the United Kingdom and Ireland over a 3-year period in order to identify prevalence, age distribution, histopathology, natural history of the illness, and response to current treatment.Forty-six cases were identified, including 29 males and 17 females. Seventy-six percent presented in the first year of life. Nine (16%) occurred within four families. Conventional treatment with pulsed methylprednisolone, prednisolone, or hydroxychloroquine, singly or in combination, resulted in an excellent response in 65% of cases. Seven children died (15%). The recurrence risk for further children within the same family to develop ILD is estimated to be approximately 10%. The prevalence rate of this condition in the United Kingdom and Ireland during the period of study for children aged 0-16 years is estimated to be 3.6 cases/million.

Treatment of pleural empyema

OBJECTIVE

To determine the clinical presentation and treatment strategies for children admitted with pleural empyema.

METHODOLOGY

Retrospective review of medical and radiological records of 54 patients admitted with pleural empyema between January 1989 and April 1997.

RESULTS

Fever (98%), cough (83%), chest pain (38%), clinical cyanosis (17%) and abdominal pain (16%) were common clinical features. The causative organism was identified in 17 patients (31%). Intravenous antibiotics were given for a mean of 18. 2 +/- 7.5 days. Forty-seven (87%) patients had closed chest tube drainage and 21(39%) patients underwent decortication for unsatisfactory response to medical treatment. The chest tube insertion was more likely to be delayed in patients who required decortication, although the difference was not significant (8.1 +/- 5.4 vs 6.3 +/- 5.2 days of illness, P = 0.67). All patients were discharged well, with almost complete resolution of the chest radiograph at 6 months.

CONCLUSIONS

Intensive medical management with adequate chest tube drainage and appropriate antibiotics will result in full resolution for most patients. Surgical intervention is important in patients who fail to receive adequate treatment early in the disease.

Retrospective review of the effects of rhDNase in children with cystic fibrosis

Trials of rhDNase in mixed groups of adults and children with cystic fibrosis (CF) have demonstrated improvements in lung function and well-being. This has led to many pediatric CF patients receiving regular rhDNase therapy although their response to treatment may not be the same as that seen in adults. We have retrospectively reviewed the effects of rhDNase during the first year of therapy in 65 children receiving the drug at two tertiary referral centers. Outcome measures included changes in lung function, oxygen saturation, use of intravenous antibiotics, and subjective improvement. Median baseline lung function (% of predicted) was 45% for forced expiratory volume in 1 second (FEV1) and 58% for forced vital capacity (FVC). At 3-4 months following initiation of therapy the group demonstrated median (95% CI) increases of 14.2% (95% CI 7.3; 21.1%) in FEV1 and 7% (0; 14%) in FVC. Within this wide scatter of responses, one-quarter of children deteriorated, but almost 50% showed significant improvements of > 10%. A similar pattern was seen at 9 months, with median increases for the group of 11.1% (0; 18.8%) in FEV1 and 5.6% (0; 17%) in FVC, again with approximately one-third of the group deteriorating and one-half improving significantly. Intravenous antibiotic use decreased significantly. Almost all the children (89%), including those with a fall in lung function, described subjective improvement. There were no predictive markers at baseline of a good response to the drug. However, there was a good correlation between lung function response at 3 months and that at 6, 9, and 12 months. Thus, children respond to rhDNase at least as well as adults, and a therapeutic trial is justified in those over 5 years with significantly impaired lung function. Response is highly variable, making careful individual assessment mandatory. Baseline characteristics are not useful in predicting those children who will respond well to treatment, but long-term response to the drug can be predicted on the basis of spirometric improvement at 3 months. Therefore, this would be a useful time period for a therapeutic trial.

Effect of human saliva and serum on ion transport by dog tracheal mucosa. Comparison of normal subjects with cystic fibrosis patients

It has been proposed that cystic fibrosis (CF) saliva or serum contains factors that alter ion transport in various tissues. Since CF frequently affects the lungs, and disturbances in epithelial ion transport has been proposed to contribute to the pathophysiology of pulmonary disease in CF, we investigated whether saliva or serum from CF patients could alter ion transport across airways epithelium. Canine tracheal mucosae were mounted in lucite chamber and perfused on both sides with Krebs-Henseleit solution at 37 degrees C and pH 7.4. Unidirectional fluxes of 22Na and 36Cl were measured in pairs of mucosal tissues under short circuit conditions. Saliva from 5 CF patients stimulated short circuit current (SCC) by 33 +/- 8 microA/cm2 and net Cl secretion by 1.10 +/- 0.33 muEq/cm2 X h (mean +/- SE; p less than 0.05). No change occurred in net Na absorption. Saliva from normal subjects raised SCC by 34 +/- 7 microA/cm2 and increased net Cl secretion by 1.29 +/- 0.46 muEq/cm2 X h (n = 9; p less than 0.02). Serum from both CF patients and control subjects briefly stimulated SCC. Exposure of tracheal mucosa to normal as well as CF saliva, such as by aspiration, or to serum, such as by transudation, stimulates Cl secretion, and therefore water secretion into airway lumen. There appears to be no difference in the effect exerted by CF saliva or serum and that of normal subjects. These findings argue against the presence of a specific circulating or secreted CF factor that could alter ion transport across respiratory epithelia in a way that might contribute to lung disease in CF.

Single breath nitrogen washout in pulmonary sarcoidosis

In 35 patients with pulmonary sarcoidosis we explored the utility of single breath nitrogen washout as a means for detecting abnormalities in airway function and intrapulmonary distribution of air. Closing volume/vital capacity ratio (CV/VC) was 21% (predicted 12.5%) in patients with only hilar adenopathy (stage I). CV/VC was 21% (predicted 13%) in patients with hilar adenopathy and parenchymal infiltration (stage II). Abnormalities in CV/VC were less readily detectable in patients with parenchymal infiltrates only (stage III) or those with bullous lesions and lung retraction (stage IV). Closing capacity was abnormally high in 66% of the cases. The slope of the alveolar plateau (delta N2/L) increased with disease progression. Single breath nitrogen test provides useful information concerning the function of small airways and distribution of pulmonary ventilation in all stages of sarcoidosis.