Clinical high risk state of major depressive episodes: Assessment of prodromal phase, its occurrence, duration and symptom patterns by the instrument the DEpression Early Prediction-INventory (DEEP-IN)

BACKGROUND

To decrease the incidence of major depressive episodes, indicated prevention that targets clinical high-risk individuals with first detectable signs that forecast mental disorder is a highly relevant topic of preventive psychiatry. Still little is known about the prodrome of MDE. The aim of the current study was to identify the occurrence of a clinical high-risk state of depression, its duration and symptom constellation.

METHODS

Seventy-three patients with a diagnosed affective disorder in partial remission were assessed with our newly developed semi-structured extensive clinical instrument, the DEpression Early Prediction-INventory (DEEP-IN). Within DEEP-IN the course of prodromal symptoms was explored by using a life-chart method.

RESULTS

The significant majority of patients (93.2 %) reported a prodromal phase. The mean duration was 7.9 months (SD = 12.5). Within the group with an identified prodromal phase, psychopathological (95.6 %) as well as somatic symptoms (88.2 %) were reported. Somatic symptoms showed a moderate-to-strong effect of sex with higher prevalence in females than in males (97.6 % vs 73.1 %; V = 0.370).

LIMITATIONS

This feasibility study had only a small sample size.

CONCLUSIONS

The majority of patients with affective disorders reported a clinical prodromal phase with both psychopathological and somatic symptoms that developed months before the onset of the depressive episode. The development of structured instruments for the assessment of depressive risk states is a promising approach for indicated prevention of depression in the future.

Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department

PURPOSE

Sepsis has a high incidence and a poor prognosis. Early recognition is important to facilitate timely initiation of adequate care. Sepsis screening tools, such as the (quick) Sequential Organ Failure Assessment ((q)SOFA) and National Early Warning Score (NEWS), could help recognize sepsis. These tools have been validated in a general immunocompetent population, while their performance in immunocompromised patients, who are particularly at risk of sepsis development, remains unknown.

METHODS

This study is a post hoc analysis of a prospective observational study performed at the emergency department. Inclusion criteria were age ≥ 18 years with a suspected infection, while ≥ two qSOFA and/or SOFA criteria were used to classify patients as having suspected sepsis. The primary outcome was in-hospital mortality.

RESULTS

1516 patients, of which 40.5% used one or more immunosuppressives, were included. NEWS had a higher prognostic accuracy as compared to qSOFA for predicting poor outcome among immunocompromised sepsis patients. Of all tested immunosuppressives, high-dose glucocorticoid therapy was associated with a threefold increased risk of both in-hospital and 28-day mortality.

CONCLUSION

In contrast to NEWS, qSOFA underestimates the risk of adverse outcome in patients using high-dose glucocorticoids. As a clinical consequence, to adequately assess the severity of illness among immunocompromised patients, health care professionals should best use the NEWS.

[The German Center for Mental Health : Innovative translational research to promote prevention, targeted intervention and resilience]

BACKGROUND

Due to the high disease burden, the early onset and often long-term trajectories mental disorders are among the most widespread diseases with growing significance. The German Center for Mental Health (DZPG) was established to enhance research conditions and expedite the translation of clinically relevant findings into practice.

OBJECTIVE

The aim of the DZPG is to optimize mental healthcare in Germany, influence modifiable social causes and to develop best practice models of care for vulnerable groups. It seeks to promote mental health and resilience, combat the stigmatization associated with mental disorders, and contribute to the enhancement of treatment across all age groups.

MATERIAL AND METHODS

The DZPG employs a translational research program that accelerates the translation of basic research findings into clinical studies and general practice. University hospitals and outpatient departments, other university disciplines, and extramural research institutions are working together to establish a collaboratively coordinated infrastructure for accelerated translation and innovation.

RESEARCH PRIORITIES

The research areas encompass 1) the interaction of somatic and mental risk and resilience factors and disorders across the lifespan, 2) influencing relevant modifiable environmental factors and 3) based on this personalized prevention and intervention.

CONCLUSION

The DZPG aims to develop innovative preventive and therapeutic tools that enable an improvement in care for individuals with mental disorders. It involves a comprehensive integration of experts with experience at all levels of decision-making and employs trilogue and participatory approaches in all research projects.

T5S1607 identified as a antibacterial FtsZ inhibitor：Virtual screening combined with bioactivity evaluation for the drug discovery

Due to antibiotic overuse, many bacteria have developed resistance, creating an urgent need for novel antimicrobial agents. It has been established that the filamentous temperature-sensitive mutant Z (FtsZ) of the bacterial cell division protein is an effective and promising antibacterial target. In this study, the optimal proteins were assessed by early recognition ability and the processed compound libraries were virtually screened using Vina. This effort resulted in the identification of 14 potentially active antimicrobial compounds. Among them, the compound T5S1607 demonstrated remarkable antibacterial efficacy against Bacillus subtilis ATCC9732 (MIC = 1 μg/mL) and Staphylococcus aureus ATC5C6538 (MIC = 4 μg/mL). Furthermore, in vitro experiments demonstrated that the selected compound T5S1607 rapidly killed bacteria and induced FtsZ protein aggregation, preventing bacterial division and leading to bacterial death. Additionally, cell toxicity and hemolysis experiments indicate that compound T5S1607 exhibits minimal toxicity to LO2 cells and shows no significant hemolytic effects on mammalian cells in vitro at the MIC concentration range. All the results indicate that compound T5S1607 is a promising antibacterial agent and a potential FtsZ inhibitor. In conclusion, this work successfully discovered FtsZ inhibitors with good activity through the virtual screening drug discovery process.

Understanding health care pathways of patients with sepsis: protocol of a mixed-methods analysis of health care utilization, experiences, and needs of patients with and after sepsis

BACKGROUND

Sepsis is associated with about 20% of deaths worldwide. It often presents with non-specific initial symptoms, making its emergency treatment an interdisciplinary and cross-sectoral challenge. Three in four sepsis survivors suffers from new cognitive, psychological, or physical sequelae for which specific treatment concepts are scarce. The AVENIR project aims to improve the understanding of patient pathways, and subjective care experiences and needs along the entire healthcare pathway before, with and after sepsis. Based on this, concrete recommendations for the organization of care and patient information materials will be developed with close patient participation.

METHODS

Mixed-methods study including (1) analysis of anonymized nationwide health claims data from Germany, (2) linkage of health claims data with patient care reports (PCR) of emergency medical services from study regions in two federal states within Germany, and (3) qualitative exploration of the patient, relative, and care provider perspective on sepsis care. In (1), we analyze inpatient and outpatient health care utilization until 30 days pre-sepsis; clinical sepsis care including intra- and inter-hospital transfers; and rehabilitation, inpatient and outpatient aftercare of sepsis survivors as well as costs for health care utilization until 24 months post-sepsis. We attempt to identify survivor classes with similar health care utilization by Latent Class Analyses. In (2), PCR are linked with health claims data to establish a comprehensive database outlining care pathways for sepsis patients from pre-hospital to follow-up. We investigate e.g., whether correct initial assessment is associated with acute (e.g., same-day lethality) and long-term (e.g., new need for care, long-term mortality) outcomes of patients. We compare the performance of sepsis-specific screening tools such as qSOFA, NEWS-2 or PRESEP in the pre-clinical setting. In (3), semi-structured interviews as well as synchronous and asynchronous online focus groups are conducted and analyzed using qualitative content analyses techniques.

DISCUSSION

The results of the AVENIR study will contribute to a deeper understanding of sepsis care pathways in Germany. They may serve as a base for improvements and innovations in sepsis care, that in the long-term can contribute to reduce the personal, medical, and societal burden of sepsis and its sepsis sequelae.

TRIAL REGISTRATION

Registered at German Clinical Trial Register (ID: DRKS00031302, date of registration: 5th May 2023).

Structural and Functional Brain Patterns Predict Formal Thought Disorder's Severity and Its Persistence in Recent-Onset Psychosis: Results From the PRONIA Study

BACKGROUND

Formal thought disorder (FThD) is a core feature of psychosis, and its severity and long-term persistence relates to poor clinical outcomes. However, advances in developing early recognition and management tools for FThD are hindered by a lack of insight into the brain-level predictors of FThD states and progression at the individual level.

METHODS

Two hundred thirty-three individuals with recent-onset psychosis were drawn from the multisite European Prognostic Tools for Early Psychosis Management study. Support vector machine classifiers were trained within a cross-validation framework to separate two FThD symptom-based subgroups (high vs. low FThD severity), using cross-sectional whole-brain multiband fractional amplitude of low frequency fluctuations, gray matter volume and white matter volume data. Moreover, we trained machine learning models on these neuroimaging readouts to predict the persistence of high FThD subgroup membership from baseline to 1-year follow-up.

RESULTS

Cross-sectionally, multivariate patterns of gray matter volume within the salience, dorsal attention, visual, and ventral attention networks separated the FThD severity subgroups (balanced accuracy [BAC] = 60.8%). Longitudinally, distributed activations/deactivations within all fractional amplitude of low frequency fluctuation sub-bands (BACslow-5 = 73.2%, BACslow-4 = 72.9%, BACslow-3 = 68.0%), gray matter volume patterns overlapping with the cross-sectional ones (BAC = 62.7%), and smaller frontal white matter volume (BAC = 73.1%) predicted the persistence of high FThD severity from baseline to follow-up, with a combined multimodal balanced accuracy of BAC = 77%.

CONCLUSIONS

We report the first evidence of brain structural and functional patterns predictive of FThD severity and persistence in early psychosis. These findings open up avenues for the development of neuroimaging-based diagnostic, prognostic, and treatment options for the early recognition and management of FThD and associated poor outcomes.

Plasma SARS-CoV-2 N antigen is a powerful molecular marker for early detection of severe COVID-19 in patients and monitoring disease progression

BACKGROUND AND AIMS

Clear and effective indicators for early detection of severe coronavirus disease 2019 (COVID-19) are insufficient. We investigated the clinical value of the plasma SARS-CoV-2 N antigen (plasma N antigen) for severe COVID-19 early identification and disease progression monitoring.

MATERIALS AND METHODS

A cross-sectional study compared the diagnostic value of plasma N antigen levels detected within two days after hospital admission in 957 patients with COVID-19 during the BA2.2 outbreak in Shanghai (April 6-June 15, 2022). A follow-up study analyzed the plasma N antigen prognostic value in 274 non-severe patients, and a longitudinal study evaluated its continuous monitoring value in 16 patients with COVID-19 grade changes.

RESULTS

Plasma N antigen concentrations were significantly higher in severely ill than in non-severely ill patients. The plasma N antigen was superior to nasopharyngeal nucleic acid CT values and established COVID-19 blood biomarkers in identifying severe COVID-19. Patients with high plasma N-antigen concentrations at initial admission were more prone to developing severe COVID-19. The changes in plasma N antigen concentrations were consistent with disease progression. Two logistic regression models, including and excluding plasma N antigen, were established, with model 1 (including plasma N antigen) (AUC = 0.971, 0.958-0.980) yielding a better diagnostic value for severe COVID-19 than Model 2 (plasma N antigen excluded).

CONCLUSION

The plasma N antigen is superior to nasopharyngeal nucleic acids and established COVID-19 blood biomarkers for severe COVID-19 early recognition and progression monitoring, enabling the most accurate patient triaging and efficient utilization of medical resources.

DeepDrRVO: A GAN-auxiliary two-step masked transformer framework benefits early recognition and differential diagnosis of retinal vascular occlusion from color fundus photographs

Retinal vascular occlusion (RVO) are common causes of visual impairment. Accurate recognition and differential diagnosis of RVO are unmet medical needs for determining appropriate treatments and health care to properly manage the ocular condition and minimize the damaging effects. To leverage deep learning as a potential solution to detect RVO reliably, we developed a deep learning model on color fundus photographs (CFPs) using a two-step masked SwinTransformer with a Few-Sample Generator (FSG)-auxiliary training framework (called DeepDrRVO) for early and differential RVO diagnosis. The DeepDrRVO was trained on the training set from the in-house cohort and achieved consistently high performance in early recognition and differential diagnosis of RVO in the validation set from the in-house cohort with an accuracy of 86.3%, and other three independent multi-center cohorts with the accuracy of 92.6%, 90.8%, and 100%. Further comparative analysis showed that the proposed DeepDrRVO outperforms conventional state-of-the-art classification models, such as ResNet18, ResNet50d, MobileNetv3, and EfficientNetb1. These results highlight the potential benefits of the deep learning model in automatic early RVO detection and differential diagnosis for improving clinical outcomes and providing insights into diagnosing other ocular diseases with a few-shot learning challenge. The DeepDrRVO is publicly available on https://github.com/ZhouSunLab-Workshops/DeepDrRVO.

Preservation of Vision after Early Recognition of Anterior Ischemic Optic Neuropathy in a Patient with Sepsis

Non-arteritic ischemic optic neuropathy (NAION) can rarely occur in the setting of sudden vascular compromise, especially in patients with a "disk-at-risk" appearance. Anemia and hypotension are believed to be the main precipitators of shock-induced NAION. Early recognition of this phenomenon can prevent further visual loss and result in partial visual recovery. We here present a 56-year-old patient who developed NAION characterized by optic disc edema in both eyes and visual loss in the left eye secondary to hypotension in the setting of septic shock. He received aggressive blood pressure management (stopping all his anti-hypertensives, hydration, and midrodrine) which resulted in stabilization of vision in the right eye and likely prevented further visual loss in the left eye.

Early Diagnosis of Bipolar Disorder Coming Soon: Application of an Oxidative Stress Injury Biomarker (BIOS) Model

Early distinction of bipolar disorder (BD) from major depressive disorder (MDD) is difficult since no tools are available to estimate the risk of BD. In this study, we aimed to develop and validate a model of oxidative stress injury for predicting BD. Data were collected from 1252 BD and 1359 MDD patients, including 64 MDD patients identified as converting to BD from 2009 through 2018. 30 variables from a randomly-selected subsample of 1827 (70%) patients were used to develop the model, including age, sex, oxidative stress markers (uric acid, bilirubin, albumin, and prealbumin), sex hormones, cytokines, thyroid and liver function, and glycolipid metabolism. Univariate analyses and the Least Absolute Shrinkage and Selection Operator were applied for data dimension reduction and variable selection. Multivariable logistic regression was used to construct a model for predicting bipolar disorder by oxidative stress biomarkers (BIOS) on a nomogram. Internal validation was assessed in the remaining 784 patients (30%), and independent external validation was done with data from 3797 matched patients from five other hospitals in China. 10 predictors, mainly oxidative stress markers, were shown on the nomogram. The BIOS model showed good discrimination in the training sample, with an AUC of 75.1% (95% CI: 72.9%-77.3%), sensitivity of 0.66, and specificity of 0.73. The discrimination was good both in internal validation (AUC 72.1%, 68.6%-75.6%) and external validation (AUC 65.7%, 63.9%-67.5%). In this study, we developed a nomogram centered on oxidative stress injury, which could help in the individualized prediction of BD. For better real-world practice, a set of measurements, especially on oxidative stress markers, should be emphasized using big data in psychiatry.

Multiparametric assessment of sensorimotor abnormalities in vulnerable populations: A window of opportunity

This commentary suggests that neuroscience research on young healthy heavy cannabis users and patients with cannabis-induced psychosis using multimodal assessment of sensorimotor dysfunction (e.g. neuroimaging, clinical rating scales, and instrumental assessments) may help to identify both biological resistance and vulnerability without constraints and confounder factors imposed by antipsychotic treatment or disease chronicity.

The German research consortium for the study of bipolar disorder (BipoLife): a magnetic resonance imaging study protocol

Background

Bipolar disorder is one of the most severe mental disorders. Its chronic course is associated with high rates of morbidity and mortality, a high risk of suicide and poor social and occupational outcomes. Despite the great advances over the last decades in understanding mental disorders, the mechanisms underlying bipolar disorder at the neural network level still remain elusive. This has severe consequences for clinical practice, for instance by inadequate diagnoses or delayed treatments. The German research consortium BipoLife aims to shed light on the mechanisms underlying bipolar disorders. It was established in 2015 and incorporates ten university hospitals across Germany. Its research projects focus in particular on individuals at high risk of bipolar disorder, young patients in the early stages of the disease and patients with an unstable highly relapsing course and/or with acute suicidal ideation.

Methods

Functional and structural magnetic resonance imaging (MRI) data was acquired across nine sites within three different studies. Obtaining neuroimaging data in a multicenter setting requires among others the harmonization of the acquisition protocol, the standardization of paradigms and the implementation of regular quality control procedures. The present article outlines the MRI imaging protocols, the acquisition parameters, the imaging paradigms, the neuroimaging quality assessment procedures and the number of recruited subjects.

Discussion

The careful implementation of a MRI study protocol as well as the adherence to well-defined quality assessment procedures is one key benchmark in the evaluation of the overall quality of large-scale multicenter imaging studies. This article contributes to the BipoLife project by outlining the rationale and the design of the MRI study protocol. It helps to set the necessary standards for follow-up analyses and provides the technical details for an in-depth understanding of follow-up publications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-021-00240-6.

[Rhabdomyolysis induced by paliperidone palmitate]

Rhabdomyolysis is defined by disintegration of skeletal muscle fibres. Clinical presentation varies and is mostly associated with myalgias as well as elevation of creatine kinase in the serum. Mechanical damage, toxic medicinal factors, and predisposing factors such as myopathies may trigger the condition. This report describes a case of rhabdomyolysis uncovered by chance after administration of paliperidonepalmitate as depot medication in a 45 years old schizophrenic male patient after having tolerated oral risperidone without any problems. Routine screening for clinical manifestations and serum-creatin kinase maybe essential in unravelling antipsychotic-induced rhabdomyolysis.

Clinical characteristic of prodromal symptoms between bipolar I and II disorder among Chinese patients: a retrospective study

BACKGROUND

This study aimed to identify the clinical characteristic of prodromal symptoms in Chinese patients with bipolar disorder (BD), prior to the first affective episode. It further aimed to characterize the prodromal traits between bipolar disorder type I (BD-I) and type II (BD-II).

METHODS

120 individuals with BD-I (n = 92) and BD- II (n = 28) were recruited to the study. Semi-structured interviews were then administered to evaluate prodromal symptoms in patients, within 3 years of BD onset, by using the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R).

RESULTS

In the prodromal phase of the first depressive episode, patients with BD-II experienced more prodromal symptoms (p = 0.0028) compared to BD-I. Additionally, more frequent predictors were reported in patients with BD-II than BD-I including educational and occupational dysfunction (p = 0.0023), social isolation (p < 0.001), difficulty making decisions (p = 0.0012), oppositionality (p = 0.012), and suspiciousness/persecutory ideas (p = 0.017). There were also differences in the duration of the precursors. The duration of "weight loss or decrease in appetite" (p = 0.016) lasted longer in patients with BD-I, while "obsessions and compulsions" (p = 0.023) started earlier in patients with BD-II and occurred during the pre-depressive period. The prevalence and duration of each reported prodrome, preceding a first (hypo) manic episode, showed no difference between patients with BD-I and BD-II.

CONCLUSIONS

Specific affective, general, or psychotic symptoms occurred prior to both affective episodes. The characteristic of prodromal symptoms were key predictors for later episodes of BD including attenuated mania-like symptoms, subthreshold depressed mood, mood swings/lability, and anxiety. In the pre-depressive state, when compared to BD-II, BD-I presented with more prodromal symptoms in nonspecific dimensions, which indicated the substantial burden of BD-II. In conclusion, this study extends the understanding of the characteristics of prodromes of BD-I and BD-II.

Challenge in diagnosis of late onset necrotizing enterocolitis in a term infant: a case report

BACKGROUND

Necrotizing enterocolitis (NEC) is a common devastating inflammatory gastrointestinal disease and frequently occurs in premature infants. Here, we reported a case of late-onset NEC in a term neonate with good outcome after surgery for long-term follow-up.

CASE PRESENTATION

Ten-week-old male came to emergency unit due to prolonged diarrhea and abdominal distention. He was born at gestational age of 40 weeks with birth weight and Apgar score of 2800 g and 7/8, respectively. He had no history of formula feeding. Two weeks before admitted to the hospital, the patient had frequent diarrhea with fever. He was found lethargic with abdominal distention, absence of bowel sounds and abdominal tenderness. Plain abdominal x-ray and CT scan showed gastric and intestinal dilatation and gasless colon, suggesting a small bowel obstruction, and bowel wall thickening indicating peritonitis, without any free subdiaphragmatic air (pneumoperitoneum). Moreover, the patient did not have a congenital heart disease. While in intensive medical treatment, he showed a continuous clinical deterioration. All findings were suggestive of intestinal inflammation with clinical deterioration, and we decided to perform an emergency exploratory laparotomy and found an ischemia along the jejunoileal with a perforation at 25 cm above the ileocecal valve. Subsequently, we performed a double-barrel ileostomy through a separate incision from the laparotomy. Histopathological findings confirmed the diagnosis of NEC. We closed the stoma at postoperative day 43. The patient was discharged uneventfully a month after stoma closure.

CONCLUSION

Abdominal CT scan might be useful to establish an early recognition of late-onset NEC; thus, immediate surgical intervention might be performed to decrease its morbidity and mortality. Moreover, late-onset NEC in term neonates might occur without any risk factors or significant co-morbidities.

Early identification of carotid vulnerable plaque in asymptomatic patients

BACKGROUND

This study was to explore the influencing factors of atherosclerotic plaque formation and stability in patients with asymptomatic carotid atherosclerotic plaques, so as to identify the vulnerable plaques at early stage, and then find high-risk group of cardio-cerebrovascular events for early clinical intervention to reduce related mortality and disability.

METHODS

A total of 302 enrolled patients with asymptomatic carotid atherosclerotic plaques were divided into 3 groups based on the results of carotid artery color Doppler ultrasound: atherosclerotic unstable plaque (UP) group, atherosclerotic stable plaque (SP) group, and control group without plaques. Serum markers were measured by ELISA. χ² test, t test, Pearson correlation analysis, and Logistic multivariate regression analysis were used in the analysis, and P < 0.05 was considered statistically significant.

RESULTS

It revealed that high MMP-9, LOX-1and YKL-40 were independent risk factors for unstable plaque formation. The area under the curve (AUC) of serum markers combined with MMP-9, LOX-1 and YKL-40 was 0.850, with sensitivity 87.67%, specificity 81.13%, and diagnostic accuracy 84.92%, which was significantly better than the individual diagnostic efficacy of other three factors. The accuracy rate of Crouse Plaque Score (CPS) in the diagnosis of vulnerable plaques was 61.90%, the 10-year ICVD diagnosis accuracy rate was 56.75%, and the diagnostic accuracy of serum markers was significantly better than CPS and 10-year ICVD.

CONCLUSION

Noninvasive cervical color Doppler ultrasound combined with serum markers MMP-9, LOX-1 and YKL-40 have significant early recognition effect on asymptomatic carotid vulnerable plaque patients.

Improving early recognition and intervention in people at increased risk for the development of bipolar disorder: study protocol of a prospective-longitudinal, naturalistic cohort study (Early-BipoLife)

Background

Bipolar disorders (BD) belong to the most severe mental disorders, characterized by an early onset and recurrent, severe episodes or a chronic course with poor psychosocial functioning in a proportion of patients. Many patients with BD experience substantial symptomatology months or even years before full BD manifestation. Adequate diagnosis and treatment is often delayed, which is associated with a worse outcome. This study aims to prospectively evaluate and improve early recognition and intervention strategies for persons at-risk for BD.

Methods

Early-BipoLife is a prospective-longitudinal cohort study of 1419 participants (aged 15–35 years) with at least five waves of assessment over a period of at least 2 years (baseline, 6, 12, 18 and 24 months). A research consortium of ten university and teaching hospitals across Germany conducts this study. The following risk groups (RGs) were recruited: RG I: help-seeking youth and young adults consulting early recognition centres/facilities presenting ≥ 1 of the proposed risk factors for BD, RG II: in-/outpatients with unipolar depressive syndrome, and RG III: in-/outpatients with attention-deficit/hyperactivity disorder (ADHD). The reference cohort was selected from the German representative IMAGEN cohort. Over the study period, the natural course of risk and resilience factors, early symptoms of BD and changes of symptom severity (including conversion to manifest BD) are observed. Psychometric properties of recently developed, structured instruments on potential risk factors for conversion to BD and subsyndromal symptomatology (Bipolar Prodrome Symptom Scale, Bipolar at-risk criteria, EPIbipolar) and biomarkers that potentially improve prediction are investigated. Moreover, actual treatment recommendations are monitored in the participating specialized services and compared to recently postulated clinical categorization and treatment guidance in the field of early BD.

Discussion

Findings from this study will contribute to an improved knowledge about the natural course of BD, from the onset of first noticeable symptoms (precursors) to fully developed BD, and about mechanisms of conversion from subthreshold to manifest BD. Moreover, these generated data will provide information for the development of evidence-based guidelines for early-targeted detection and preventive intervention for people at risk for BD.

Frontal brain activity in individuals at risk for schizophrenic psychosis and bipolar disorder during the emotional Stroop task - an fNIRS study

OBJECTIVES

The emotional Stroop effect is defined as increased reaction times to emotional stimuli compared to neutral ones. It has been often reported in the literature, on both behavioral and neurophysiological level. The goal of this study was to investigate the frontal brain activation in individuals at risk for schizophrenic psychosis and bipolar disorder during an emotional Stroop task. We expected to observe decreased activation in the at-risk individuals compared to the healthy controls.

METHODS

Individuals at high risk for psychosis (HR), at ultra-high risk for psychosis (UHR), at risk for bipolar disorder (BIP) and healthy controls (HC) performed an emotional Stroop task, which included positively, negatively and neutrally valenced words. Functional near-infrared spectroscopy (fNIRS) was used to measure levels of oxygenated hemoglobin (O2Hb) representing brain activity in the dorsolateral prefrontal and frontotemporal cortex.

RESULTS

Results showed significantly decreased levels of O2Hb in the right dorsolateral prefrontal cortex (DLPFC) in the HR and UHR groups compared to the HC, indicating lower activity. Even though the decrease was independent from the valence of the words, it was the most visible for the negative ones. Moreover, significantly lower O2Hb levels in the frontotemporal cortex (FTC) were observed in all at risk groups compared to the HC.

CONCLUSIONS

Lower activity in the FTC in groups at risk for psychosis and bipolar disorder reflects unspecific dysfunctions. Decreased activity in the DLPFC in the HR and UHR groups indicates that hypofrontality can be found already in individuals at risk for schizophrenic psychosis.

Towards definitions of time-sensitive conditions in prehospital care

Background

Prehospital care has changed in recent decades. Advanced assessments and decisions are made early in the care chain. Patient assessments form the basis of a decision relating to prehospital treatment and the level of care. This development imposes heavy demands on the ability of emergency medical service (EMS) clinicians properly to assess the patient. EMS clinicians have a number of assessment instruments and triage systems available to support their decisions. Many of these instruments are based on vital signs and can sometimes miss time-sensitive conditions. With this commentary, we would like to start a discussion to agree on definitions of temporal states in the prehospital setting and ways of recognising patients with time-sensitive conditions in the most optimal way.

Main body

There are several articles discussing the identification and management of time-sensitive conditions. In these articles, neither definitions nor terminology have been uniform. There are a number of problems associated with the definition of time-sensitive conditions. For example, intoxication can be minor but also life threatening, depending on the type of poison and dose. Similarly, diseases like stroke and myocardial infarction can differ markedly in terms of severity and the risk of life-threatening complications. Another problem is how to support EMS clinicians in the early recognition of these conditions. It is well known that many of them can present without a deviation from normal in vital signs. It will most probably be impossible to introduce specific decision support tools for every individual time-sensitive condition. However, there may be information in the type and intensity of the symptoms patients present. In future, biochemical markers and machine learning support tools may help to identify patients with time-sensitive conditions and predict mortality at an earlier stage.

Conclusion

It may be of great value for prehospital clinicians to be able to describe time-sensitive conditions. Today, neither definitions nor terminology are uniform. Our hope is that this commentary will initiate a discussion on the issue aiming at definitions of time-sensitive conditions in prehospital care and how they should be recognised in the most optimal fashion.

Early Recognition of Pediatric Sepsis Simulation Checklist - An Exploratory Study

PURPOSE

To report on the modification and exploration of a 21-item Early Detection of Pediatric Sepsis Assessment Checklist aimed at improving nursing students' recognition of key factors that contribute to early detection of sepsis in pediatric patients through clinical simulation.

DESIGN AND METHODS

One hundred and thirty-one undergraduate, pre-licensure nursing students were evaluated using the adapted 21-item Early Detection of Pediatric Sepsis Assessment Checklist in simulation using high-fidelity manikins. Categorical Principle Component Analysis was used to evaluate for factor structure, with items accounting for <0.20 of the variance were dropped from the loadings.

RESULTS

Two factors emerged from the analysis: assessment and deterioration, accounting for 68% of the variance. Factor one, assessment, contained nine items (α = 0.77; λ = 3.36). Factor two, deterioration, contained seven items (α = 0.72; λ = 2.85). Five items did not load and were dropped from the factor structure, resulting in a 16-item checklist.

CONCLUSIONS

Two factors emerged from the analysis which is key to improving the early detection of pediatric sepsis. Assessment, factor one, accounted for the nursing students' central skills of recognizing baseline vital signs and timely medication administration. Deterioration, factor two, contained items reflecting the recognition of changes from baseline that require action. Conceptually, these factors reflect the most central points in the early detection of signs in pediatric patients at risk for sepsis.

PRACTICE IMPLICATIONS

This checklist forms a valuable tool to assess the knowledge of pre-licensure students and may possibly be extended as a tool to assess the clinical readiness and performance of new graduates through the safety and supervision allotted by simulation.

[Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 3 : Tardive dyskinesia]

The treatment of schizophrenic psychoses with antipsychotic drugs (AP) is often associated with an increased risk of delayed occurrence of antipsychotic-associated movement disorders. Persistence and chronicity of such symptoms are very frequent. The risk of developing tardive dyskinesia (TD) is associated with the pharmacological effect profile of a particular AP, with treatment duration and age. This systematic review article summarizes the current study situation on prevalence, risk factors, prevention and treatment options and instruments for early prediction of TD in schizophrenic psychoses. The current data situation on treatment strategies for TD is very heterogeneous. For the treatment of TD there is preliminary evidence for reduction or discontinuation of the AP, switching to clozapine, administration of benzodiazepines (clonazepam) and treatment with vesicular monoamine transporter (VMAT2) inhibitors, ginkgo biloba, amantadine or vitamin E. Although TD can be precisely diagnosed it cannot always be effectively treated. Early detection and early treatment of TD can have a favorable influence on the prognosis and the clinical outcome.

[Experiences and results from Rheuma-VOR]

Rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis are the most common chronic autoimmune rheumatic diseases. For all three diseases an early diagnosis and initiation of treatment is crucial. The proof of concept network study "Rheuma-VOR" is a further developed version of the predecessor project ADAPTHERA and was extended to several federal states. The aim of this prospective study is to improve the early diagnosis of rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis and thus positively impact the quality of care for patients with the help of multidisciplinary coordinating centers. To date 3710 disease-specific questionnaires from patients with the suspected diagnosis of rheumatoid arthritis, psoriatic arthritis or axial spondylarthritis from 1298 different primary care providers were registered in the multidisciplinary coordination centers. A total of 1958 appointments were made with 1 of the 53 participating rheumatology specialists. In 876 patients, 1 of the 3 rheumatic diseases was diagnosed in an early stage. The waiting period was on average 42.5 days depending on the federal state, which is well below the nationwide average. It should also be noted that the coordinated cooperation and risk stratification of the Rheuma-VOR coordination centers relieved the capacity of rheumatology specialists by 1281 appointments (34.5%). In addition, the 2‑week Rheuma Bus Tour and the accompanying initiatives in Rhineland-Palatinate (Rheuma-VOR screening app and the triage consultation) are showing first promising positive results.

[Early stage liver cancer : Hepatocellular carcinoma]

Hepatocellular carcinoma (HCC) ranks among the most common primary cancers of the liver. The major risk factor for the formation of HCC is liver cirrhosis. The grade of cirrhosis as well as the extent of the tumor itself, can play an important role in the treatment options and patient prognosis. An operation aimed at an R0 resection is the treatment of choice for patients in an early stage of the disease and is associated with favorable long-term and recurrence-free survival. Liver transplantation offers an even better long-term survival rate after 5 years for selected patients with HCC meeting the Milan criteria as the underlying cirrhosis, the major risk factor for HCC recurrence, is simultaneously treated. Local tumor ablation is the least invasive curative surgical treatment, however, it is associated with an increased local recurrence rate; therefore, the early detection of tumors is of essential importance. As tumor-associated symptoms tend to arise only in advanced tumor stages, it is indispensable to identify patients with typical risk factors and to provide closely monitored screening examinations.

Latent class analysis to evaluate performance of plasma cortisol, plasma catecholamines, and SHSQ-25 for early recognition of suboptimal health status

Background

Chronic stress is associated with suboptimal health status (SHS) which is a new public health challenge in China and worldwide. Plasma stress hormones may act as potential objective biomarkers for SHS measure. This study was aimed to evaluate the diagnostic performance of plasma cortisol, catecholamine adrenaline/noradrenaline, and SHS questionnaires (SHSQ) for SHS using latent class analysis (LCA) in the absence of a gold standard.

Methods

A cross-sectional study was conducted among 868 employees in Beijing. The SHS questionnaires-25 (SHSQ-25) was distributed, and plasma cortisol, adrenaline, and noradrenaline were measured in the survey. LCA was used to assess the performance of both subjective and objective measures for SHS recognition.

Results

Akaike information criterion (AIC) and consistent AIC (CAIC) was 14.11 and 54.48 respectively, indicating that the model was well fitted. The sensitivity and specificity of plasma cortisol were 0.836 (95% CI 0.811-0.861) and 0.840 (95% CI 0.816-0.864), respectively. The area under curve (AUC) of receiver operating characteristic (ROC) of SHSQ-25 was 0.743 (95% CI 0.709-777), while the AUC of plasma adrenaline was 0.688 (95% CI 0.651-0.725). The prevalence of SHS in the investigated population was 34.78%.

Conclusion

Plasma cortisol is a valuable biomarker for SHS detection, whereas SHSQ-25 is more suitable for SHS screening in the population-based health survey. The accuracy and applicability of plasma adrenaline are inferior to cortisol and SHSQ-25, respectively. LCA has merit to evaluate performance of plasma cortisol, catecholamines, and SHSQ-25 for recognition of SHS in the absence of a gold standard test.

At-risk symptoms of bipolar disorder in a university student cohort

To assess the occurrence and frequency of bipolar at-risk symptoms in a large sample of previously undiagnosed students using the new screening tool Bochumer Screeningbogen Bipolar (BSB). 2329 students of the Ruhr-University Bochum, Germany completed online demographic data as well as various self-rating questionnaires (BSB; Hypomania Checklist 32; Altman Self-Rating Mania Scale; Beck Depression Inventory). Within the student cohort (64.4% female, mean age 24.3 years) every fifth student currently suffered from moderate to severe depressive symptoms; every sixth student had already thought about suicide and every other student reported a history of mood swings. The most frequently reported depressive symptoms included physical exhaustion, depressed mood, and tiredness. The most frequently reported (hypo)manic symptoms included physical agitation, feeling extremely energetic, and lack of concentration. The BSB showed good convergent validity with other established questionnaires capturing depressive or (hypo)manic symptoms, as well as a stable administration of underlying constructs. The BSB correlated significantly with the already established applied questionnaires. The predictive power of the BSB regarding the development of bipolar disorder cannot be correctly quantified at present. The further purpose of this exploratory web-based study should be to examine the validity of the presented measures in a longitudinal design.

Using Heuristic Evaluation to Improve Sepsis Alert Usability

Sepsis, life-threatening organ dysfunction in response to infection, is an alarmingly common and aggressive illness in US hospitals, especially for intensive care patients. Preventing sepsis deaths rests on the clinicians' ability to promptly recognize and treat sepsis. To aid early recognition, many organizations have employed clinician-facing electronic sepsis alert systems. However, the effectiveness of the alert relies on heavily on the visual interface, textual information, and overall usability. This article reports a usability inspection of a sepsis alert system. The authors found violations in 12 of the 14 usability principles and promote use of this method in practice to systematically identify usability problems.

Expert consensus to weight an adherence score for audit and feedback of practices that prevent necrotizing enterocolitis in very low birth weight infants

OBJECTIVE

Necrotizing enterocolitis (NEC) is a catastrophic abdominal complication threatening the life of premature infants, but adoption of prevention and early recognition practices differs as do NEC rates in Neonatal Intensive Care Units (NICUs). The purpose of this research was to validate and weight an evidence-based adherence score (aka NEC-Zero Adherence Score) to prevent and foster timely recognition of NEC.

STUDY DESIGN

An electronic Delphi (e-Delphi) approach was used to identify consensus. NEC experts were recruited via the NEC Society and surveyed until consensus and stability criteria for the Delphi were met (≥70% consensus and mean responses changed <15% between rounds).

RESULTS

Expert panelists (n=22) were experienced (M=17.6, SD 11years) and predominately physicians (68%) or neonatal nurse practitioners (18%). Consensus (>70% by item) supported a 10 point score. Points were distributed across 1) an exclusive human milk diet (5 points), 2) standardized feeding protocols (3 points), 3) antibiotic stewardship (1 point), and 4) a unit-specified approach to early recognition (1 point). Withholding feeding during transfusion was controversial (M=0.50, SD 0.73) and met consensus criteria to drop from the score.

CONCLUSIONS

Holding feeding during transfusion was dropped from the score. Relationships between the score and unit NEC rates as well as its utility for use in audit and feedback should be studied in the future.

IV Infiltration and Latex Allergy in an Infant: Early Recognition is Key to Prevent Lasting Disability

Latex allergy confounded by IV infiltration presents a serious problem for pediatric patients. If unrecognized, it can lead to serious neurologic deficits, loss of limb mobility, compartment syndrome, and ultimately lasting disability. Appropriate early recognition can prevent progression to these devastating outcomes. In this case report, we present an infant with IV infiltration and latex allergy. The case is used to highlight important clinical diagnostic criteria, treatment approaches, and how to prevent detrimental outcomes. We provide a detailed review of the literature and highlight the key teaching points in a reader-friendly reference table.

Consensus strategy in genes prioritization and combined bioinformatics analysis for preeclampsia pathogenesis

BACKGROUND

Preeclampsia is a multifactorial disease with unknown pathogenesis. Even when recent studies explored this disease using several bioinformatics tools, the main objective was not directed to pathogenesis. Additionally, consensus prioritization was proved to be highly efficient in the recognition of genes-disease association. However, not information is available about the consensus ability to early recognize genes directly involved in pathogenesis. Therefore our aim in this study is to apply several theoretical approaches to explore preeclampsia; specifically those genes directly involved in the pathogenesis.

METHODS

We firstly evaluated the consensus between 12 prioritization strategies to early recognize pathogenic genes related to preeclampsia. A communality analysis in the protein-protein interaction network of previously selected genes was done including further enrichment analysis. The enrichment analysis includes metabolic pathways as well as gene ontology. Microarray data was also collected and used in order to confirm our results or as a strategy to weight the previously enriched pathways.

RESULTS

The consensus prioritized gene list was rationally filtered to 476 genes using several criteria. The communality analysis showed an enrichment of communities connected with VEGF-signaling pathway. This pathway is also enriched considering the microarray data. Our result point to VEGF, FLT1 and KDR as relevant pathogenic genes, as well as those connected with NO metabolism.

CONCLUSION

Our results revealed that consensus strategy improve the detection and initial enrichment of pathogenic genes, at least in preeclampsia condition. Moreover the combination of the first percent of the prioritized genes with protein-protein interaction network followed by communality analysis reduces the gene space. This approach actually identifies well known genes related with pathogenesis. However, genes like HSP90, PAK2, CD247 and others included in the first 1% of the prioritized list need to be further explored in preeclampsia pathogenesis through experimental approaches.

Dystonic storm: a practical clinical and video review

Dystonic storm is a frightening hyperkinetic movement disorder emergency. Marked, rapid exacerbation of dystonia requires prompt intervention and admission to the intensive care unit. Clinical features of dystonic storm include fever, tachycardia, tachypnea, hypertension, sweating and autonomic instability, often progressing to bulbar dysfunction with dysarthria, dysphagia and respiratory failure. It is critical to recognize early and differentiate dystonic storm from other hyperkinetic movement disorder emergencies. Dystonic storm usually occurs in patients with known dystonia, such as DYT1 dystonia, Wilson’s disease and dystonic cerebral palsy. Triggers such as infection or medication adjustment are present in about one-third of all events. Due to the significant morbidity and mortality of this disorder, we propose a management algorithm that divides decision making into two periods: the first 24 h, and the next 2–4 weeks. During the first 24 h, supportive therapy should be initiated, and appropriate patients should be identified early as candidates for pallidal deep brain stimulation or intrathecal baclofen. Management in the next 2–4 weeks aims at symptomatic dystonia control and supportive therapies.

[Delusions: current psychodynamic and neurocognitive approaches]

BACKGROUND

The symptom "delusions" is a central psychopathological symptom in psychiatric diseases. Since the beginning of psychiatry various disciplines have attempted to explain and understand delusions but even now no generally accepted definition of this phenomenon exists.

AIM

A comprehensive review of current psychopathological and neurobiological theories of delusions is given.

MATERIAL AND METHODS

PubMed and Google scholar searches were performed using the keywords "delusion", "psychodynamic" and "neurobiology", both in English and German. Relevant German textbooks of psychiatry were also included.

DISCUSSION

A differentiated perspective of the phenomenon of delusions appears to be necessary to approach this complex and fascinating symptom. A one-dimensional approach does not do justice to the complexity of delusions. The various explanatory approaches can increasingly be linked to each other and are no longer considered to be mutually exclusive.

Aims and structure of the German Research Consortium BipoLife for the study of bipolar disorder

Background

Bipolar disorder is a severe and heterogeneous mental disorder. Despite great advances in neuroscience over the past decades, the precise causative mechanisms at the transmitter, cellular or network level have so far not been unraveled. As a result, individual treatment decisions cannot be tailor-made and the uncertain prognosis is based on clinical characteristics alone. Although a subpopulation of patients have an excellent response to pharmacological monotherapy, other subpopulations have been less well served by the medical system and therefore require more focused attention. In particular individuals at high risk of bipolar disorder, young patients in the early stages of bipolar disorder, patients with an unstable highly relapsing course and patients with acute suicidal ideation have been identified as those in need.

Structure

A research consortium of ten universities across Germany has therefore implemented a 4 year research agenda including three randomized controlled trials, one epidemiological trial and one cross-sectional trial to address these areas of unmet needs. The topics under investigation will be the improvement of early recognition, specific psychotherapy, and smartphones as an aid for early episode detection and biomarkers of lithium response. A subset of patients will be investigated utilizing neuroimaging (fMRI), neurophysiology (EEG), and biomaterials (genomics, transcriptomics).

Conclusions

This article aims to outline the rationale, design, and methods of these individual studies.

The AngelMed Guardian system: Is there a role for implantable devices for early detection of coronary artery occlusion?

The AngelMed Guardian System is an implantable device similar to a single chamber pacemaker that continuously monitors the intracardiac electrogram for evidence of ST segment shift indicating acute coronary artery occlusion. The system aims to reduce time to presentation by alerting patients to present to a medical facility whether symptoms are present or not. In March 2016, the US Food and Drug Administration (FDA) assembled a meeting of the Circulatory System Devices Panel to review the results of the AngelMed for Early Recognition and Treatment of STEMI (ALERTS) pivotal trial and the accompanying premarket approval (PMA) application for regulatory approval of the AngelMed Guardian System in the US. In this review, we examine the ALERTS trial methodology and results, and describe the FDA panel's deliberations and recommendations.

Congenital Clubfoot: Early Recognition and Conservative Management for Preventing Late Disabilities

Congenital clubfoot is one of the most common musculoskeletal deformities presenting at birth. Many high risk factors have been associated with clubfoot such as male gender, primiparous mothers and maternal smoking. Accurate understanding of clubfoot pathoanatomy is supposed to be the basis for deformity correction. Prenatal ultrasonography is of reference value in recognizing clubfoot during pregnancy. Neglected clubfoot can eventually cause a noticeable disability and severely influence the quality life in adulthood. Early recognition and treatment are presumed to be the key for prevention of late disabilities. Nowadays, Ponseti method, as one of the conservative treatment regimen, has been widely accepted because of the reported good results of long-term follow-up. However, special attention should be paid to the details in clinical practice for achieving even better correction and a lower rate of relapse. After the complete correction, brace wearing is critical for preventing deformity relapse. Non-compliance or non-adherence with the brace protocol has been considered as the predominant risk factor predisposing to the relapse of clubfoot, which is still a challenging problem. This paper was prepared to give a general introduction about clubfoot, in terms of the importance of early recognition and conservative management, especially Ponseti method, for preventing late disabilities.

Triple diagnostics for early detection of ambivalent necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis is an uncommon, rapidly progressive and potential lethal condition. Over the last decade time to surgery decreased and outcome improved, most likely due to increased awareness and more timely referral. Early recognition is key to improve mortality and morbidity. However, early referral frequently makes it a challenge to recognize this heterogeneous disease in its initial stages. Signs and symptoms might be misleading or absent, while the most prominent skin marks might be in discrepancy with the position of the fascial necrosis. Gram staining and especially fresh frozen section histology might be a useful adjunct.

METHODS

Retrospective analysis of 3 year period. Non-transferred patients who presented with suspected necrotizing fasciitis are included. ASA classification was determined. Mortality was documented.

RESULTS

In total, 21 patients are included. Most patients suffered from severe comorbidities. In 11 patients, diagnoses was confirmed based on intra-operative macroscopic findings. Histology and/or microbiotic findings resulted in 6/10 remaining patients in a change in treatment strategy. In total, 17 patients proved to suffer necrotizing fasciitis. In the cohort series 2 patients died due to necrotizing fasciitis.

CONCLUSION

In the early phases of necrotizing fasciitis, clinical presentation can be ambivalent. In the present cohort, triple diagnostics consisting of an incisional biopsy with macroscopic, histologic and microbiotic findings was helpful in timely identification of necrotizing fasciitis.

A two-stage clinical decision support system for early recognition and stratification of patients with sepsis: an observational cohort study

OBJECTIVE

To examine the diagnostic accuracy of a two-stage clinical decision support system for early recognition and stratification of patients with sepsis.

DESIGN

Observational cohort study employing a two-stage sepsis clinical decision support to recognise and stratify patients with sepsis. The stage one component was comprised of a cloud-based clinical decision support with 24/7 surveillance to detect patients at risk of sepsis. The cloud-based clinical decision support delivered notifications to the patients' designated nurse, who then electronically contacted a provider. The second stage component comprised a sepsis screening and stratification form integrated into the patient electronic health record, essentially an evidence-based decision aid, used by providers to assess patients at bedside.

SETTING

Urban, 284 acute bed community hospital in the USA; 16,000 hospitalisations annually.

PARTICIPANTS

Data on 2620 adult patients were collected retrospectively in 2014 after the clinical decision support was implemented.

MAIN OUTCOME MEASURE

'Suspected infection' was the established gold standard to assess clinical decision support clinimetric performance.

RESULTS

A sepsis alert activated on 417 (16%) of 2620 adult patients hospitalised. Applying 'suspected infection' as standard, the patient population characteristics showed 72% sensitivity and 73% positive predictive value. A postalert screening conducted by providers at bedside of 417 patients achieved 81% sensitivity and 94% positive predictive value. Providers documented against 89% patients with an alert activated by clinical decision support and completed 75% of bedside screening and stratification of patients with sepsis within one hour from notification.

CONCLUSION

A clinical decision support binary alarm system with cross-checking functionality improves early recognition and facilitates stratification of patients with sepsis.

Disturbed sleep as risk factor for the subsequent onset of bipolar disorder--Data from a 10-year prospective-longitudinal study among adolescents and young adults

There is ample data suggesting that individuals with bipolar disorder more frequently suffer from disturbed sleep even when euthymic. Since sleep is a process that is crucial for affective homeostasis, disturbed sleep in healthy individuals may be a risk factor for the subsequent onset of bipolar disorder. Utilizing data from a large cohort of adolescents and young adults, this study tests the hypothesis that disturbed sleep constitutes a risk factor for the later onset of bipolar disorder. A representative community sample of N = 3021 adolescents and young adults (baseline age 14-24) was assessed using the standardized Composite International Diagnostic Interview and followed-up prospectively up to 3 times over up to 10 years. Disturbed sleep at baseline was quantified utilizing the corresponding items from the self-report inventory SCL-90-R. The compound value (insomnia-score) as an ordinal parameter for the severity of sleep disturbances was used to assess associations with the incidence of bipolar disorder among participants free of major mental disorder at baseline (N = 1943) using odds ratios (OR) from logistic regressions. Analyses were adjusted for age, gender, parental mood disorder and lifetime alcohol or cannabis dependence. Poor sleep quality significantly increased the risk for the subsequent development of bipolar disorder (OR = 1.75; p = 0.001). Regarding individual sleep items, trouble falling asleep and early morning awakening were predictive for the subsequent onset of bipolar disorder. Disturbed sleep in persons otherwise free of major mental disorders appears to confer an increased risk for the subsequent onset of bipolar disorder.

Recognition and treatment of life-threatening events in the community setting-part 1: the journey

Community-based care provision and the associated workload for health professionals working in the community are on the increase. In recent years, in particular, there has been a greater requirement for the acute aspect of care. It is of the utmost importance that patient deterioration is recognised, and that staff can escalate care in an appropriate and timely way. Of the 576 potentially avoidable deaths reported to the National Patient Safety Agency in 2005, 64 were related to patient deterioration not being recognised or acted upon. The community-specific 'Acute Life-threatening Events Recognition and Treatment' (CSA) course enables practitioners (both registered and non-registered) to identify deteriorating patients and to take appropriate action to ensure that safe, quality care is maintained through early recognition and improved clinical decision-making. North Somerset Community Partnership is the first community area in the UK to facilitate the CSA course. This article is the first of a two-part series on the course. It details the journey from the start, identifying the challenges that were overcome and the success that has followed.

Characteristics, symptomatology and naturalistic treatment in individuals at-risk for bipolar disorders: baseline results in the first 180 help-seeking individuals assessed at the Dresden high-risk project

BACKGROUND

Considering results from the early recognition and intervention in psychosis, identification and treatment of individuals with at-risk states for the development of bipolar disorders (BD) could improve the course and severity of illness and prevent long-term consequences. Different approaches to define risk factors and groups have recently been published, data on treatment options are still missing.

METHODS

Help-seeking persons at the early recognition center in Dresden, Germany, were assessed with a standardized diagnostic procedure including following risk factors for BD: familial risk, increasing mood swings, subsyndromal (hypo)manic symptoms, specific sleep and circadian rhythm disturbances, anxiety/fearfulness, affective disorder, decreased psychosocial functioning, increasing periodic substance use, and attention-deficit/hyperactivity disorder. Based on symptomatology and current and/or life-time psychiatric diagnosis, subjects with an at-risk state were offered individual treatment options.

RESULTS

Out of 180 referred and screened persons, 29 (16%) met criteria for at-risk state for BD. Altogether, 27 (93%) at-risk individuals fulfilled criteria for a current and/or life-time mental illness other than BD; 14 (48%) had received pharmacological and/or psychotherapeutic treatment in the past. Treatments recommended included psychoeducation (100%), psychotherapy alone (62%), pharmacotherapy alone (17%), and psychotherapy+pharmacotherapy (14%).

CONCLUSIONS

To identify at-risk states for BD, a multifactorial approach including all known risk markers should be used. As most at-risk patients meet criteria for other mental disorders, the short- and long-term impact of different treatment strategies on symptomatic, functional and diagnostic outcomes requires detailed investigation.

LIMITATIONS

Small sample size of at-risk individuals, lack of sufficient prospective data and control groups.

The bipolar disorder prodrome revisited: Is there a symptomatic pattern?

OBJECTIVES

To assess the phenomenology and course of pre-(hypo)manic and pre-depressed prodromal symptoms, including mood swings, as precursors of bipolar disorder (BD) in a German multi-center study.

METHODS

Semi-structured interviews [Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R); Semi-structured Interview for Mood Swings] were administered to patients within 8 years of BD (BD I, BD II) onset.

RESULTS

Forty two outpatients were included (40.5% male, mean age 35.1±10.0 years, illness onset at 30.5±9.5 years). Feeling extremely energetic (85.7%), racing thoughts (78.6%), physical agitation (76.2%), overtalkativeness (71.4%), and low sleep requirement (71.4%) occurred most frequently prior to the first (hypo)manic episode, whereas depressed mood (83.0%), reduced vitality (81.0%), physical exhaustion (78.6%), tiredness (76.2%), and insomnia (66.7%) preceded pre-depressively. Mood lability (p=.006), odd ideas (p=.003) and the psychosis index score (p=.003) differed significantly in prevalence depending on the episodes' mood. Extremely energetic (p=.046), overtalkativeness (p<.001), and racing thoughts (p=.013) lasted significantly longer prior to depression. Neither severity nor frequency of prodromal symptoms differed significantly. Most of the symptoms emerged during the proximal prodromal phase. Links between mood swings and subsequent BD were found.

LIMITATIONS

Symptoms were evaluated retrospectively with self-reporting tools in bipolar patients from academic treatment settings without comparison to clinical controls.

CONCLUSIONS

Not only specific depressive or manic but also general symptoms occurred prior to both affective episodes. The pre-depressive prodrome lasted longer than the pre-manic one, but severity and frequency did not differ significantly. Mood swings and disturbed diurnal rhythm occurred prior to both episodes as early signs of BD.

[Predicting bipolar disorder: what can we learn from prospective cohort studies?]

INTRODUCTION

Bipolar disorder (BD) is a life course illness; and there is increasing awareness of the many personal, social and economic consequences of the illness in older adults. However, it is important to emphasize that BD usually begins in late adolescence or early adulthood and 75 % cases have a first episode in this age period. This early onset and the associated level of disability mean that BD is the 4th leading cause of global disease burden in adolescents and young adults. Internationally, mental health services are increasingly striving to diagnose and treat BD as early as possible to try to prevent poor outcomes. In addition, researchers are using methods employed previously in psychosis studies as these may help us to recognise the earliest manifestations of BD. If it is possible to identify sub-threshold and 'ultra high risk' syndromes for BD, this might lead to new interventions that could target the prevention of first episodes of mania. One approach to understanding these risk syndromes is to examine prospective community cohort studies and BD offspring studies.

METHODS

This paper reviews prospective cohort studies that identify robust risk factors in early illness onset, which was defined as age at onset of BD between 15-25 years.

RESULTS

We found that although > 50 % of individuals who developed BD had developed a putative BD prodrome prior to 14 years of age, this usually began with non-specific symptoms that overlap with similar presentations for those who later develop psychosis or severe depression. However, there are some features that seem to better identify groups with a BD "at-risk" syndrome. This syndrome is frequently composed of several factors such as mood lability, depressive episodes, prior anxiety, sleep and/or conduct disorders, attention and concentration impairment, altered energy patterns, and a family history of mania and/or depression. The course of these early predictors suggests the precursor syndromes are composed of mini-clusters of symptoms many of which are episodic and change over time. During the early phases of BD, most of the affective disturbances reported were depressive in polarity and started during adolescence, there were few manic or mixed or psychotic episodes with an onset before puberty. The pathogenesis of BD demonstrates a gradual progression from non-specific to more specific symptoms and then to frank BD features.

CONCLUSION

Prospective community and offspring BD cohort studies are approaches that together can help us understand the evolution of BD and allow us to define the developmental pathways. Further, identifying subjects with BD "at-risk" syndrome using a clinical staging model may allow benign interventions to be used as first-line treatment - such as neuroprotective agents like essential fatty acids; second line treatments, with a less benign risk to benefit ratio should be reserved for severe or resistant cases.