A randomized controlled implementation trial of a multicomponent integrated care program to empower mental health service users and their relatives throughout the recovery process

This study assessed the effectiveness of a psychosocial multicomponent program designed to empower individuals experiencing severe mental distress and their relatives throughout the recovery process. The program consisted of four consecutive interventions, including orientation, psychoeducation, empowerment, and mutual help. A randomized controlled implementation trial was conducted to investigate the program's impact on the recovery of individuals experiencing mental distress, as well as on the caregiving burden and perceived social support experienced by their relatives. Two hundred twenty-two persons in recovery and one of their relatives from 12 different territories within Catalonia, Spain took part in the study. The intervention group exhibited higher recovery scores compared to the control group at 6 months, although this difference was not sustained at the 12-month follow-up. No statistically significant differences were found for burden and social support scores between experimental groups. However, time effects were found for recovery and burden scores regardless of experimental group membership. Dose-effect analyses showed that participation was related to recovery and burden scores, with no time interactions observed. Upon examining the interaction with sociodemographic variables, we discovered statistically significant group-by-time interactions, suggesting a more positive progression of recovery scores among the experimental group when either the person in recovery was younger, their relative was female, or lived outside of the Barcelona Metropolitan Area. These results allow us to conclude that the program has a positive effect on the recovery journey. However, the lack of effectiveness regarding burden and social support in relatives highlights the necessity of reconsidering implementation and evaluation strategies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Interaction between the Participation in and the Impact on Mental Health Service Users and Their Relatives of a Multicomponent Empowerment-Based Psychosocial Intervention

Relatives play an important role in the recovery journey of mental health service users. Interventions directed either at service users or their relatives may influence the other person as well. The project 'Activa't per la salut mental' (Get active for mental health) consisted of a series of four interventions addressed at people diagnosed with mental disorders and their relatives to help them in their recovery process, increasing their agency and quality of life. The main objective of the present study is to evaluate the interaction of the participation of service users on their relatives' outcomes and vice versa. The impact of the project was evaluated within a randomised controlled trial. The treatment group had access to all the circuit interventions, while the control group received treatment as usual and could only access one of the interventions. All participants were evaluated at baseline, six months, and twelve months after the end of the first intervention. Service users were evaluated with the Stages of Recovery Instrument, and relatives with the Family Burden Interview Schedule II and the Duke-UNC-11 questionnaires. The interaction of participation and impact between service users and their relatives was analysed by means of correlational analyses within the intervention group (n = 111, service users mean age = 40.6, 40% women; relatives mean age = 56.7, 72% women). Service users' baseline characteristics (being in a relationship, educational level, employment, and younger age) influenced in the level of participation of relatives and vice versa (lower educational level). The results also indicated correlations between participation and outcomes at various points as well as the evolution of service users' recovery and the care burden of relatives. Service users' participation levels interacted with the decrease of relatives' frequency of burden and the first steps of their own recovery journey (moratorium, awareness, and preparation) while relative's participation just interacted with the evolution of two stages of service users' recovery levels (preparation and growth). These results can be extremely helpful in fostering interactive benefits in future projects addressing the wellbeing of mental health service users and their relatives. Future studies could use specific designs to explore the directionality of the causality of these effects.

An Integrated Account of Expert Perspectives on Functioning in Schizophrenia

An integrated and interdisciplinary care system for individuals with schizophrenia is essential, which implies the need for a tool that assesses the difficulties and contextual factors of relevance to their functioning, and facilitates coordinated working across the different professions involved in their care. The International Classification of Functioning, Disability and Health Core Sets (ICF-CS) cover these requirements. This study aimed to evaluate the content validity of the ICF-CSs for schizophrenia from the perspective of experts. Six three-round Delphi studies were conducted with expert panels from different professional backgrounds which have played a significant role in the treatment of individuals with schizophrenia (psychiatry, psychology, nursing, occupational therapy, social work and physiotherapy). In total, 790 experts from 85 different countries participated in the first round. In total, 90 ICF categories and 28 Personal factors reached expert consensus (reached consensus from four or more professional perspectives). All the categories in the brief version of the ICF-CS for schizophrenia reached consensus from all the professional perspectives considered. As for the comprehensive version, 89.7% of its categories reached expert consensus. The results support the worldwide content validity of the ICF-CSs for schizophrenia from an expert perspective and underline the importance of assessing functioning by considering all the components implied.

Occupational Therapists’ Perspective on the International Classification of Functioning, Disability and Health Core Sets (ICF–CS) for Schizophrenia

Importance: The International Classification of Functioning, Disability and Health (ICF) Core Sets (CSs) for schizophrenia are sets of ICF categories that are relevant specifically to the functioning and disability of people with schizophrenia.

Objective: To identify the problems occupational therapists commonly encounter when treating people with schizophrenia and to validate the ICF–CSs for schizophrenia from their perspective.

Design: Three-round Delphi study using online surveys distributed to occupational therapists worldwide. Participants were asked which problems with functioning they considered most relevant when treating people with schizophrenia.

Participants: Occupational therapists experienced in the treatment of people with schizophrenia.

Measures: Responses were linked to the ICF categories by two trained health professionals, and a statistical measure of agreement and κ coefficient were calculated.

Results: Ninety-two occupational therapists from 29 countries in all six World Health Organization regions named 2,527 meaningful concepts. After the linking process, 121 ICF categories and 31 Personal Factors were presented to the expert panel, who reached consensus (agreement of ≥75%) on 97 ICF categories and 27 Personal Factors. Consensus was reached on the 25 categories in the Brief ICF–CS for schizophrenia and 89 of the 97 categories in the Comprehensive ICF–CS for schizophrenia.

Conclusions and Relevance: The ICF Core Sets for schizophrenia were validated from the perspective of occupational therapists and are potentially useful tools for clinical practice because they cover a wide variety of problems that occupational therapists deal with in interventions with people with schizophrenia.

What This Article Adds: The ICF–CSs for schizophrenia are useful guides for describing and classifying functioning, disability, and health to aid occupational therapy intervention with people with schizophrenia. Occupational therapists are essential in the rehabilitation of this client population, and their perspective has contributed to the development and enrichment of the ICF–CSs for schizophrenia.

[Simulation as a tool to facilitate change in healthcare organisations]

OBJECTIVE

To describe the use of simulation as a tool to support the strategic management of change in the Cantabrian Regional Health Service in Spain.

METHODS

A working group was created to: 1) define the strategic areas of innovation and change; 2) establish criteria for the selection of proposals that can be addressed with simulation; 3) analyse and select the proposals; 4) design and implement the simulation programs, and 5) evaluate results.

RESULTS

The constantly changing needs of the regional health system enabled 6 strategic areas to be identified during 2017-208: 1) efficient use of resources; 2) implementation of health plans of interest in the community; 3) patient safety improvement; 4) management of health personnel; 5) development of new professional skills, and 6) selection and implementation of new technology.

CONCLUSIONS

Clinical simulation is a useful tool to promote innovation strategies in healthcare, facilitating the adaptation of professionals and patients to change.

Functioning in schizophrenia: a Delphi study covering the perspective of physiotherapists

PURPOSE

This qualitative study explores the barriers, personal characteristics/resources, and environmental factors that experienced physiotherapists identify as relevant in the assessment and treatment of persons living with schizophrenia, and whether the identified aspects are represented in the International Classification of Functioning, Disability and Health Core Sets for schizophrenia.

METHODS

A three-round Delphi study with physiotherapists was conducted between April and July 2018. In the first round, participants had to list all the aspects they considered to be relevant when assessing and/or treating individuals with schizophrenia, and they were asked six open-ended questions. Their responses were linked to categories. In the second and third rounds, physiotherapists had to judge whether each category/personal factor was relevant for describing functioning in schizophrenia.

RESULTS

Thirteen of 22 eligible physiotherapists from eight countries responded to the first round, and 10 completed all three rounds. Eighty-two (84.5%) of the 97 categories in the Comprehensive Core Set for schizophrenia and all 25 categories in the Brief Core Set were considered relevant. A total of five categories were additionally identified.

CONCLUSIONS

The barriers, personal characteristics/resources, and environmental factors from the physiotherapists' perspective have been identified. The results largely confirm the content validity of the Core Sets for schizophrenia.Implications for rehabilitationThis study shows which barriers, personal characteristics/resources, and environmental factors in persons with schizophrenia are relevant from physiotherapists' perspective and should be integrated in the rehabilitation process.The content validity of the Comprehensive and Brief Core Sets for schizophrenia is largely supported from the physiotherapists' perspective and therefore could be used in the assessment of functioning in persons with schizophrenia.The Comprehensive and Brief ICF Core Sets for schizophrenia could be used to plan and assess multidisciplinary rehabilitation interventions.

Towards an ICF Core Set for functioning assessment in severe mental disorders: Commonalities in bipolar disorder, depression and schizophrenia

BACKGROUND

The International Classification of Functioning, Disability and Health (ICF) offers an internationally accepted standard for describing and assessing functioning and disability in any health condition. A specific list of ICF categories, an ICF Core Set (CS), has been developed for bipolar disorder, depression and schizophrenia. The aim of this study was to determine commonalities in the ICF-CSs for these three disorders, and to identify relevant categories for the development of tentative ICF-CSs for severe mental disorders in general.

METHODS

The ICF categories of all three mental health conditions were examined and compared.

RESULTS

Comparison of the Comprehensive ICF-CSs for the three mental health conditions revealed a set of 34 common categories (i.e., 10 from the Body functions component, 14 from the Activities and participation component, and 10 Environmental factors ). These categories formed the proposed Comprehensive ICF-CS for severe mental disorders. A total of 11 categories were common to the Brief ICF-CSs of the three mental health conditions, and these formed the Brief ICF-CS for severe mental disorders (i.e., 3 from the Body functions component, 6 from the Activities and participation component, and 2 Environmental factors ). All the categories included refer to key aspects of functioning for severe mental disorders.

CONCLUSIONS

The proposed ICF-CSs for severe mental disorders may be applicable across a number of psychotic and affective disorders and they should prove useful for mental health services whose care remit covers a range of conditions.

An international survey of Psychiatric-Mental-Health Nurses on the content validity of the International Classification of Functioning, Disability and Health Core Sets for Schizophrenia

The International Classification of Functioning, Disability and Health (ICF) Core Sets for schizophrenia describe the key problems in functioning that are experienced by individuals with this disorder. This study examines the content validity of these Core Sets and aims to identify the most frequent problems faced by people with schizophrenia, considering for this analysis the perspective of Psychiatric-Mental-Health Nurses. The study complied with the COREQ checklist for qualitative studies. A total of 101 nurses from 30 countries covering all six World Health Organization regions participated in a Delphi study. Their responses in Round 1 were linked to ICF categories, retaining those reported by at least 5% of participants. In Round 2, they were asked to rate the relevance of each of these categories to the nursing care of patients with schizophrenia. This process was repeated in Round 3. A total of 2327 concepts were extracted in Round 1 and linked to ICF categories. Following the analysis, 125 categories and 31 personal factors were presented to the experts in rounds 2 and 3. Consensus (defined as agreement ≥75%) was reached for 97 of these categories and 29 personal factors. These categories corresponded to all those (N = 25) in the Brief Core Set and 87 of the 97 categories of the Comprehensive Core Set for schizophrenia. Ten new categories emerged. The Delphi process identified the problems in functioning that nurses encounter when treating individuals with schizophrenia, and the results supported the content validity of the Core Sets. We conclude that these Core Sets offer a comprehensive framework for structuring clinical information and guiding the treatment process.

Functioning in schizophrenia from the perspective of psychologists: A worldwide study

Schizophrenia is a severe mental disorder associated with impairment in functioning. A multidisciplinary approach is essential to help individuals with this health condition, and psychological interventions are considered a priority. The International Classification of Functioning, Disability and Health (ICF) offers a theoretical framework for assessing functioning and disability. The ICF Core Sets for schizophrenia are a list of ICF categories describing the most common problems in functioning of persons affected by this health condition. This study aimed to explore the content validity of these ICF Core Sets and to identify the most common problems in people with schizophrenia from the perspective of psychologists. Psychologists with experience of schizophrenia treatment were recruited for a three-round Delphi study in order to gather their views regarding the problems commonly presented by these patients. A total of 175 psychologists from 46 countries covering the six WHO regions answered the first-round questionnaire, and 137 completed all three rounds. The 7,526 concepts extracted from first-round responses were linked to 412 ICF categories and 53 personal factors. Consensus (≥75% agreement) was reached for 76 ICF categories and 28 personal factors. Seventy-three of the 97 ICF categories that form the Comprehensive ICF Core Set for schizophrenia achieved consensus, and only three categories that yielded consensus do not feature in this Core Set. These results support the content validity of these ICF Core Sets from the perspective of psychologists. This provides further evidence of the suitability of the ICF framework for describing functioning and disability in persons with schizophrenia.

Functioning in patients with schizophrenia: A multicentre study evaluating the clinical perspective

Using the WHO International Classification of Functioning, Disability and Health (ICF) as a frame of reference, this study identifies the most common problems of functioning and the environmental factors that are experienced by patients with schizophrenia. An empirical cross-sectional multicentre study was conducted. Data were collected using a case record form, rated by health professionals, that contained 133 ICF categories and which also gathered clinical and sociodemographic information. A total of 127 patients with schizophrenia participated. The categories with a higher prevalence of impairment in the Body functions component were related to mental functions [e.g. b164 Higher-level cognitive functions (97.6%), b152 Emotional functions (88.2%)]. Patients also showed impairment in several categories from the Activities and participation component, reflecting restrictions and limitations in several challenging everyday activities such as solving problems (77.2%), handling stress (87.4%), looking after one's health (63.8%), informal social relationships (70.9%), economic self-sufficiency (68.5%), and leisure (79.5%). Environmental factors were most frequently scored as facilitators. Support from family (94.5%) and health professionals (99.2%), together with antipsychotic medication (96.9%) and social (85.0%) and health services (95.3%), were the most common factors for people with schizophrenia. Our study identified the most common problems in functioning and the environmental factors that are experienced by persons with schizophrenia. This kind of comprehensive approach to the assessment of functioning in schizophrenia could help to shape interventions for improving functioning in this population.

The Screen for Cognitive Impairment in Psychiatry: Proposal for a polytomous scoring system

The Screen for Cognitive Impairment in Psychiatry is a simple, fast, and easy to administer scale that has been validated in clinical and community samples. The aim of this study was to propose a polytomous scoring system for the Screen for Cognitive Impairment in Psychiatry and to demonstrate its functioning, thus providing new and complementary information regarding the utility and precision of this screening tool. Three hundred seventy-six Spanish patients diagnosed with schizophrenia spectrum disorder were evaluated. A polytomous scoring system was generated and analyzed by means of the partial credit model. Category assessment revealed optimal functioning after collapsing the 7-category system to 1 with either 5 or 4 categories, depending on the item. The proposed polytomous scoring system shows good psychometric properties and an adequate fit to the partial credit model. These results provide further confirmation of the test's utility in clinical settings and of its suitability for detecting cognitive impairment.

Beyond diagnosis: the Core Sets for persons with schizophrenia based on the World Health Organization's International Classification of Functioning, Disability, and Health

PURPOSE

Based on the International Classification of Functioning, Disability and Health (ICF), this paper presents the results of the process to develop the Comprehensive and Brief Core Sets for schizophrenia that allow to comprehensively describe functioning in persons with schizophrenia.

METHODS

Twenty health professionals from diverse backgrounds participated in a formal and iterative decision-making process during an international consensus conference to develop these Core Sets. The conference was carried out based on evidence gathered from four preparatory studies (systematic literature review, qualitative study, expert survey, and empirical study). The first step of this decision-making and consensus process comprised of discussions and voting in working groups and plenary sessions to develop the comprehensive version. The categories of the Comprehensive ICF Core Set for schizophrenia served as the basis for the second step -a ranking and cutoff procedure to decide on the brief version.

RESULTS

Of the 184 candidate categories identified in the preparatory studies, 97 categories were included in the Comprehensive Core Set for schizophrenia. A total of 25 categories were selected to constitute the Brief Core Set.

CONCLUSIONS

The formal decision-making and consensus process integrating evidence from four preparatory studies and expert opinion led to the first version of the Core Sets for schizophrenia. Comprehensive and Brief Core Sets for schizophrenia may provide a common language among different health professionals and researchers, and a basic international standard of what to measure, report, and assess the functioning of persons with schizophrenia. Implications for rehabilitation Schizophrenia is a chronic mental disorder that has a tremendous impact on functioning and daily life of persons living with the disorder. The International Classification of Functioning, Disability and Health (ICF) offers an internationally recognized standard for describing the functioning status of these individuals. The Core Sets for schizophrenia have potential use in supporting rehabilitation practice such as for planning mental health services and other interventions or defining rehabilitation goals, and documenting patient care. The Core Sets for schizophrenia may also be used to promote interdisciplinary coordination and facilitate communication between members of a multidisciplinary rehabilitation team. Rehabilitation research is another potential area of application of the Core Sets for schizophrenia. This is valuable, since rehabilitation research provides crucial evidence for optimizing rehabilitation practice.

Functioning in Schizophrenia: Similarities and Differences Between Clinical, Patient and Expert Perspectives

Introduction

In 2001, the World Health Organization (WHO) created the International Classification of Functioning, Disability and Health (ICF) to offer a comprehensive and universally accepted framework to describe functioning, disability and health. The ICF Core Sets (ICF-CS) are a selection of categories that serve as a minimal standard for the assessment of functioning and disability in a specific health condition. The ICF-CS for schizophrenia was created in 2015 based on four preliminary studies that intend to capture different perspectives.

Objectives

The aim of this study is to describe the similarities (i.e. overlap) and discrepancies (i.e. unique contribution) between the clinical, patient and expert perspectives on the most relevant problems in functioning of individuals with schizophrenia, being focused on the European WHO region.

Methods

Forty-four experts from 14 European countries participated in an expert survey, patients with schizophrenia were involved in four focus groups, and health professionals assessed 127 patients in relation to daily life functioning. Information gathered from these three preliminary studies was linked to the ICF.

Results

Data showed that although a considerable number of second-level ICF categories agreed on the three preparatory studies (n = 54, 27.7%), each perspective provided a unique set of ICF categories. Specifically, experts reported 65 unique ICF categories, patients 23 and health professionals 11.

Conclusions

Even though there were similarities between perspectives, each one underlined different areas of functioning, showing the importance of including different perspectives in order to get a complete view of functioning and disability in individuals with schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The comprehensive Icf core set for schizophrenia from the perspective of psychiatrists: A content-validity study using the Delphi technique

Introduction

Schizophrenia is a chronic mental illness associated with several functional impairments. There has been an increasing interest in the impact of schizophrenia on functioning. The development of the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for schizophrenia, a shortlist of 97 ICF categories that are relevant for describing functioning and disability of people living with schizophrenia, has derived from this interest.

Objectives

This study aims to explore the content validity of this core set from the perspective of psychiatrists.

Methods

In a 3-round Delphi survey, psychiatrists experienced in schizophrenia treatment were asked about patients’ problems, resources and environmental factors they treat in patients with schizophrenia.

Results

A total of 352 psychiatrists from 65 countries representing all six World Health Organization regions completed the first round questionnaire. The response rate at the third round was 86%. Answers were linked to 422 ICF categories. Of all these, 109 ICF categories reached consensus (≥ 75% agreement) at the third round. Eighty-seven out of the 97 ICF categories that form the comprehensive ICF core set for schizophrenia were represented in this list. All the comprehensive ICF core set for schizophrenia categories reached consensus except five categories.

Conclusions

The content validity of the comprehensive ICF core set for schizophrenia from the perspective of psychiatrists was largely supported. However, further research is needed including other health professionals (e.g., psychologists, nurses and occupational therapists) to further obtain new content validity evidences.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Presentation of the Comprehensive and Brief International Classification of Functioning, Disability and Health Core Sets (ICF-CS) for schizophrenia

Objective

The aim this presentation is present the results of the preparatory studies were presented at an international consensus conference, a multi-stage, iterative, decision-making and consensus process that took place 12–14 May 2015 in Barcelona, Spain. At this consensus conference, schizophrenia experts from different countries worldwide and working in a broad range of professions decided which ICF categories should be included in the first version of the ICF Core Sets for schizophrenia.

Method

Four preliminary studies intend to capture the researcher's perspective, the patient's perspective, the expert's perspective and the clinician's perspective, respectively, on the most relevant aspects of functioning of persons living with schizophrenia. The final definition of ICF Core Sets for schizophrenia have been determined by integrating the results of preliminary studies in a consensus conference with international expert.

Result

The experts included 97 categories in the Comprehensive ICF Core Set and 25 categories in the Brief ICF-CS. The specific categories of each ICF-CS are shown in this presentation. The Comprehensive ICF-CS can guide multidisciplinary assessments of functioning in persons with schizophrenia, and the brief version is ideal for use in both clinical and epidemiological research, since it includes a small and practical number of categories, but sufficiently wide for finding utility in clinical assessments.

Conclusion

ICF-CS are being designed with the goal of providing useful standards for research, clinical practice and teaching, and it will stimulate research and will improve understanding of functioning, health and environmental factors in schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Disability in bipolar I disorder: the 36-item World Health Organization Disability Assessment Schedule 2.0

BACKGROUND

The WHODAS 2.0 is an ICF-based multidimensional instrument developed for measuring disability. The present study analyzes the utility of the 36-item interviewer-administered version in a sample of patients with bipolar disorder. There is no study to date that analyses how the scale works in a sample that only comprises such patients.

METHODS

A total of 291 patients with bipolar disorder (42.6% males) according to DSM-IV-TR criteria from a cross-sectional study conducted in outpatient psychiatric clinics were enrolled. In addition to the WHODAS 2.0, patients completed a comprehensive assessment battery including measures on psychopathology, functionality and quality of life. Analyses were centered on providing evidence on the validity and utility of the Spanish version of the WHODAS 2.0 in bipolar patients.

RESULTS

Participation domain had the highest percentage of missing data (2.7%). Confirmatory factorial analysis was used to test three models formulated in the literature: six primary correlated factors, six primary factors with a single second-order factor, and six primary factors with two second-order factors. The three models were plausible, although the one formed by six correlated factors produced the best fit. Cronbach's alpha values ranged between .73 for the Self-care domain and .92 for Life activities, and the internal consistency of the total score was .96. Relationships between the WHODAS 2.0 and measures of psychopathology, functionality and quality of life were in the expected direction, and the scale was found to be able to differentiate among patients with different intensity of clinical symptoms and work situation.

LIMITATIONS

The percentage of euthymic patients was considerable. However, the assessment of euthymic patients is less influenced by mood. Some psychometric properties have not been studied, such as score stability and sensitivity to change.

CONCLUSIONS

The Spanish version of the 36-item WHODAS 2.0 has suitable psychometric properties in terms of reliability and validity when applied to patients with bipolar disorder. Disability in bipolar patients is especially prominent in Cognition, Getting along, Life activities, and Participation domains, so functional remediation interventions should emphasize these areas in order to improve the daily living activities of these patients.

Neurodevelopment or neurodegeneration: review of theories of schizophrenia

Many hypothesis have tried to explain the aetiology of schizophrenia, the abnormal neurodevelopmental hypothesis is one of the most widely acknowledged and is based on the presence of both prenatal and perinatal disorders, differences in IQ or the existence of genetic abnormalities, which, with the interaction of certain environmental factors, schizophrenia could occur at some point in the development. This hypothesis provides a good account of how these factors result in an alteration in the normal development and how they can lead to a disorder of schizophrenia. On the other hand, a smaller but not insignificant number of studies based on variables such as the presence of neurotoxicity in the brains of individuals with schizophrenia, alterations at the structural and brain connectivity, suggest the existence of a degenerative process in the course of this disease. In this work, we review the different factors underlying both hypotheses, some of which are difficult to categorize in either approach given the controversy and lack of consensus in their interpretation of the available data. Finally, we discuss the need for a non-exclusive alternative model to help understand the available evidence on the origin, course and consequences of the disease.

Efficacy of second-generation-antipsychotics in the treatment of negative symptoms of schizophrenia: a meta-analysis of randomized clinical trials

OBJECTIVES

To determine whether second-generation-antipsychotics (SGAs) are effective for negative symptoms treatment in schizophrenia.

METHODS

Two meta-analyses were carried out using placebo or haloperidol as comparators. The search included the following databases: Pubmed, The Cochrane Central Register of Controlled Trials, Proquest Health and Medical Complete, Science Citation Index Expanded, and Current Contents Connect. The outcome measure used was the change in negative symptoms, choosing a standardized statistic (Cohen's d) to synthesize the data.

RESULTS

In the placebo-controlled meta-analysis, the effect sizes (Cohen's d) obtained for amisulpride, haloperidol, olanzapine, quetiapine, risperidone and ziprasidone were 0.52, 0.34, 0.43, 0.36, 0.40 and 0.46, respectively, favoring active treatment against placebo (P<0.001 in all cases). The haloperidol-controlled meta-analysis only showed a statistically significant trend favoring antipsychotics over haloperidol (Cohen's d=0.15).

CONCLUSIONS

Most antipsychotics (amisulpride, haloperidol, olanzapine, quetiapine, risperidone and ziprasidone) are effective in the treatment of negative symptoms. Amisulpride and ziprasidone showed higher effect sizes.

Incidence and influence on referral of primary stabbing headache in an outpatient headache clinic

Primary stabbing headache (PSH) is a pain, as brief, sharp, jabbing stabs, predominantly felt in the first division of trigeminal nerve. Population studies have shown that PSH is a common headache. However, most people suffer attacks of low frequency or intensity and seldom seek for medical assistance. There are few clinic-based studies of PSH, and its real influence as a primary cause for referral to neurology outpatient offices is to be determined. We aim to investigate the burden of PSH as main complaint in an outpatient headache clinic. We reviewed all patients with PSH (ICHD-II criteria), attended in an outpatient headache clinic in a tertiary hospital during a 2.5-year period (January 2008–June 2010). We considered demographic and nosological characteristics and if PSH was main cause of submission. 36 patients (26 females, 10 males) out of 725 (5%) were diagnosed of PSH. Mean age at onset 34.1 ± 2.9 years (range 10–72). Mean time from onset to diagnosis 68.8 ± 18.3 months. Twenty-four patients fulfilled ICHD-II criteria for other headaches (14 migraine, 6 tension-type headache, 2 hemicrania continua, 1 primary cough headache and 1 primary exertional headache). 77.7% of patients were submitted from primary care. In 14 patients (39%), PSH was main reason for submission, its intensity or frequency in 5 (35.7%) and fear of malignancy in 9 (74.3%). Only two patients of those who associated other headaches were submitted due to PSH. In conclusion, PSH is not an uncommon diagnosis in an outpatient headache office. However, and according to our data, it is not usually the main cause of submission to a headache clinic.

Neurocognitive diagnosis and cut-off scores of the Screen for Cognitive Impairment in Psychiatry (SCIP-S)

OBJECTIVES

To demonstrate the ability of the Screen for Cognitive Impairment in Psychiatry (SCIP-S) to discriminate between cognitively-impaired individuals and those with adequate functioning in a sample of schizophrenic and bipolar patients, as well as in a control group.

METHODS

The SCIP-S, together with a full neuropsychological battery, was administered to three groups: patients with schizophrenia, patients diagnosed with bipolar disorder I, and controls. The battery scores were used to perform a standardization with respect to the control group and this served to determine the comparison groups (cognitively impaired versus unimpaired) for each of the subtests of the SCIP-S. A full analysis of decision validity was conducted on the basis of receiver operating characteristic curves (sensitivity and specificity, +LR and -LR, PPV and NPV).

RESULTS

All the subtests yielded adequate values for sensitivity and specificity with the proposed cut-off points, while the total score of the SCIP (<70) was associated with a sensitivity of 87.9 and specificity of 80.6.

CONCLUSIONS

The SCIP-S shows adequate decision validity as a screening tool for cognitive deficit in patients diagnosed with schizophrenia or bipolar disorder.

Antipsychotics Efficacy in Treatment of Schizophrenia Negative Symptoms: Meta-analysis of Randomized Clinical Trials

Purpose:

To examine the efficacy of second-generation-antipsychotics (SGAs) in the treatment of negative symptoms in Schizophrenia.

Methods:

Two meta-analyses were carried out using placebo or haloperidol as comparators. Studies were identified by searching for randomized, double-blind, placebo and/or haloperidol -controlled trials reporting data on efficacy of SGAs. Search was extended to the following databases: Pubmed, the Cochrane Central Register of Controlled Trials, Proquest Health and Medical Complete, Science Citation Index Expanded, and Current Contents Connect. the outcome measure used was the change in negative symptoms, choosing a standardized statistic (Cohen's d) to synthesize data.

Results:

A total of 46 homogeneous trials (Q=45.18, df=50, p=0.667, I2=0%) were included. in the placebo-controlled meta-analysis, the effect sizes (Cohen's d) obtained for amisulpride, haloperidol, olanzapine, quetiapine, risperidone and ziprasidone were 0.52, 0.34, 0.43, 0.36, 0.40 and 0.46, respectively, favoring active treatment against placebo (p< 0.001 in all cases). Comparing SGAs against haloperidol, showed just a statistically significant trend favoring SGA's in treatment of negative symptoms (Cohen's d = 0.15, p=0.008). Comparisons by drug showed a significant low and low-to-moderate standardized mean favoring SGA: Cohen's d = 0.34, p< 0.001; Cohen's d = 0.27, p< 0.001 and Cohen's d = 0.19, p=0.030, respectively for ziprasidone, risperidone and olanzapine.

Conclusion:

Most antipsychotics (aminosulpride, haloperidol, olanzapine. quetiapine, risperidone, ziprasidone) are effective in treatment of negative symptoms, showing moderate effect sizes. Amisulpride and ziprasidone were slightly better than the rest of drugs when compared with placebo. Compared with haloperidol, SGA showed controversial results.

Augmentation of electroconvulsive therapy seizures with sleep deprivation

Electroconvulsive therapy (ECT) is the fastest and most effective treatment for severe or treatment-resistant affective and psychotic disorders. Its therapeutic effect is obtained through a generalized tonic-clonic seizure of adequate duration. Several factors (older age, male gender, and the sessions of ECT themselves) increase seizure threshold and reduce seizure time. In our work, sleep deprivation was used as a strategy to enhance the ECT seizure. A matched sample design was conducted on the basis of the following variables: gender, age range, and seizure threshold. After the first ECT, when the initial seizure threshold was measured, subjects were assigned to ECT (electroconvulsive therapy) or SD+ECT (sleep deprivation + electroconvulsive therapy). Changes in the variable of seizure threshold were studied in both groups during the treatment course. A nonparametric analysis was implemented for 2 independent groups. During the treatment course, the SD+ECT group showed a decreased seizure threshold, from 190.4 mC in the first ECT session to 176.4 mC in the last ECT session, whereas the ECT group showed an increased seizure threshold, increasing from 190.4 mC to 321.91 mC. Sleep deprivation is an effective and safe technique used to lower the seizure threshold of ECT and to obtain an adequate seizure time without increasing the energy applied.

Abdominal vascular injuries: injuries to the aorta

This article discusses injuries to the abdominal aorta at its supra- and infrarenal positions, focusing on the surgical approaches to abdominal aorta injuries and renal vascular pedicles. The controversy regarding the use of bioprosthetic materials and the coLlective experience with these injuries as reported in the literature are reviewed. Primary renal artery repair versus nephrectomy also is examined.

Renal vascular injuries

Even today, most renal vascular injuries result in loss of renal function. Kidney salvage is not possible because of late diagnosis and the presence of severe associated injuries. Physical exam and basic laboratory tests are not sensitive; thus, a high index of suspicion is required. Repair should be attempted for all solitary kidneys and for patients sustaining bilateral injuries. All viable kidneys should be revascularized in order to increase the chances of obtaining adequate functional renal tissue. In the event that revascularization is not feasible, nephrectomy can be performed at a later time, if hypertension develops. In some cases, delayed return of function is possible, but in most cases the kidney will atrophy without producing hypertension. Most importantly, maintaining a high index of suspicion, prompt diagnostic evaluation, and judicious treatment can optimize outcome lowering the significant morbidity and mortality of renal vascular injuries.

Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma

Extrahepatic bile duct traumatic injuries are extremely rare and their treatment is difficult and with several controversies. The aim of this study was to offer some more clinical information on their surgical repair and outcome. We present seven patients with extrahepatic biliary tract lesions after blunt abdominal trauma, (isolated gallbladder lesions were excluded) four males and three females from 23 to 51 years of age (mean age 35.1 years). All patients had suffered high-energy blunt abdominal trauma and presented associated injuries, mostly liver trauma and lung contusions. Six gallbladder lesions and six common bile duct injures were identified; a right hepatic duct laceration and a left hepatic duct transection were also present. Injuries were treated either with primary repair or with duct-jejunal anastomoses with Roux-en-Y reconstruction. Principal complications were postoperative anastomotic leakage (1 case) and recurrent cholangitis (3 cases) with or without stricture. Not-diagnosed injuries caused substantial morbidity. We prefer and recommend the use of primary repair in partial ruptures with no significant tissue loss and biliary-enteric anastomoses in large injuries and complete transections because they offer the best long-term drainage with less risk of stricture formation than end-to-end anastomoses. We defend the use of long duration (6 to 9 months) transanastomotic stents.

VACUOLELESS1 is an essential gene required for vacuole formation and morphogenesis in Arabidopsis

Most plant cells are characterized by the presence of a large central vacuole that in differentiated cells accounts for more than 90% of the total volume. We have undertaken a genetic screen to look for mutants that are affected in the formation of vacuoles in plants. In this study, we report that inactivation of the Arabidopsis gene VACUOLELESS1 (VCL1) blocks vacuole formation and alters the pattern of cell division orientation and cell elongation in the embryo. Consistent with a role in vacuole biogenesis, we show that VCL1 encodes the Arabidopsis ortholog of yeast Vps16p. In contrast to yeast mutants that lack a vacuolar compartment but are viable and morphologically normal, loss of the plant vacuole leads to aberrant morphogenesis and embryonic lethality.

Wound signalling in plants

Plants undergoing the onslaught of wound-causing agents activate mechanisms directed to healing and further defence. Responses to mechanical damage are either local or systemic or both and hence involve the generation, translocation, perception, and transduction of wound signals to activate the expression of wound-inducible genes. Although the central role for jasmonic acid in plant responses to wounding is well established, other compounds, including the oligopeptide systemin, oligosaccharides, and other phytohormones such as abscisic acid and ethylene, as well as physical factors such as hydraulic pressure or electrical pulses, have also been proposed to play a role in wound signalling. Different jasmonic acid-dependent and -independent wound signal transduction pathways have been identified recently and partially characterized. Components of these signalling pathways are mostly similar to those implicated in other signalling cascades in eukaryotes, and include reversible protein phosphorylation steps, calcium/calmodulin-regulated events, and production of active oxygen species. Indeed, some of these components involved in transducing wound signals also function in signalling other plant defence responses, suggesting that cross-talk events may regulate temporal and spatial activation of different defences.

Wound signalling in plants

Plants undergoing the onslaught of wound-causing agents activate mechanisms directed to healing and further defence. Responses to mechanical damage are either local or systemic or both and hence involve the generation, translocation, perception, and transduction of wound signals to activate the expression of wound-inducible genes. Although the central role for jasmonic acid in plant responses to wounding is well established, other compounds, including the oligopeptide systemin, oligosaccharides, and other phytohormones such as abscisic acid and ethylene, as well as physical factors such as hydraulic pressure or electrical pulses, have also been proposed to play a role in wound signalling. Different jasmonic acid-dependent and -independent wound signal transduction pathways have been identified recently and partially characterized. Components of these signalling pathways are mostly similar to those implicated in other signalling cascades in eukaryotes, and include reversible protein phosphorylation steps, calcium/calmodulin-regulated events, and production of active oxygen species. Indeed, some of these components involved in transducing wound signals also function in signalling other plant defence responses, suggesting that cross-talk events may regulate temporal and spatial activation of different defences.

European Society of Gene Therapy (ESGT) Seventh Meeting. 26-28 November 1999, Munich, Germany

This meeting gave an excellent overview of the recent developments in gene therapy. Much research effort has focused on the improvement and de novo construction of gene vectors, on characterizing their mechanisms of action and on their interactions with, and in, living organisms. The continual improvements in understanding disease at a molecular level and the progress in cell biology, immunology and related fields have opened the way for novel gene therapy approaches. The gene therapeutic strategy has proven to be feasible and efficient in numerous preclinical (animal) models of a variety of diseases. On the other hand, applying this experience to humans has turned out to be difficult. Currently, the field is rapidly moving into clinical applications. No major limiting side effects have been observed in patients in the phase I and later stage trials presented. Nonetheless, years of preclinical and clinical research will be required before gene therapy can be considered a reliable and efficient therapeutic approach with broad applicability.

Cross-talk between wound signalling pathways determines local versus systemic gene expression in Arabidopsis thaliana

Plants react to mechanical damage by activating a set of genes, the products of which are thought to serve defensive functions. In solanaceous plants, cell wall-derived oligosaccharides and the plant hormones jasmonic acid and ethylene participate in the signalling network for wound-induced expression of proteinase inhibitors and other defence-related genes, both in the locally damaged and in the systemic non-damaged leaves. Here we show that in Arabidopsis thaliana, these signalling components interact in novel ways to activate distinct responses. In damaged tissues, oligosaccharides induce the expression of a specific set of wound-responsive genes while repressing jasmonic acid-responsive genes that are activated in the systemic tissues. The oligosaccharide-mediated repression of the jasmonic acid-dependent signalling pathway is exerted through the production and perception of ethylene in the locally damaged tissue. This cross-talk between separate wound signalling pathways thus allows the set up of different responses in the damaged and the systemic tissues of plants reacting to injury.

Jasmonic acid-dependent and -independent wound signal transduction pathways are differentially regulated by Ca2+/calmodulin in Arabidopsis thaliana

We have used wound- and jasmonic acid (JA)-responsive genes as molecular markers to elucidate the pathway(s) of wound signal transduction in Arabidopsis thaliana. The JA-responsive (JR) genes JR1, JR2, and JR3 are strongly induced by wounding and by JA, while the wound-responsive (WR) genes WR3 and acyl CoA oxidase (ACO) are induced by wounding only. Accumulation of JR transcripts upon wounding was blocked by indomethacin. However, indomethacin did not affect either induction of these genes by JA or wound-induced expression of WR genes, suggesting that JA synthesis is only needed for wound-dependent induction of JR genes, and also that separate JA-dependent and -independent wound signal transduction pathways exist in Arabidopsis. The two pathways are differentially regulated by Ca2+ and calmodulin. Mobilization of intracellular Ca2+ pools blocked induction of JR genes by both wounding and JA, but not the induction of WR genes by wounding, but this effect could not be reproduced by increasing intracellular Ca2+ levels using ionophores. In addition, calmodulin antagonists blocked the expression of JR genes and up-regulated WR gene expression. Ca2+ and calmodulin seem to act downstream of both JA and the COI1 gene in the JA-dependent pathway, and downstream of reversible phosphorylation events that differentially regulate JA-dependent and JA-independent wound signal transduction pathways.

Reversible protein phosphorylation regulates jasmonic acid-dependent and -independent wound signal transduction pathways in Arabidopsis thaliana

Plants responses to mechanical injury are complex and include the induced expression of defence-related genes. The phytohormone JA has been reported to mediate some of these responses. To elucidate further the signal transduction processes involved, the action of specific agonists and antagonists of known signalling effectors on the response of Arabidopsis thaliana plantlets to JA and wounding was investigated. The identification and characterization of a reversible protein phosphorylation step in a transduction pathway leading to JA-induced gene transcription is reported. This phosphorylation event involved the opposing activities of a staurosporine-sensitive protein kinase, negatively regulating the pathway, and a protein phosphatase, most probably of type 2 A, which activated JA-responsive gene expression. JA activation via this pathway was blocked in the A. thaliana JA-insensitive mutants jin1, jin4 and coi1, and by exogenous application of cycloheximide or auxins. Wound-induced activation of JA-responsive genes was also regulated by this protein phosphorylation step. An alternative wound signalling pathway, independent of JA, was also identified, leading to the transcriptional activation of a different set of genes. This JA-independent pathway was also regulated by a protein phosphorylation switch, in which the protein kinase positively regulated the pathway while the protein phosphatase negatively regulated it. Moreover, a labile protein apparently repressed the expression of these genes. One of the genes analysed, JR3, had a complex pattern of expression, possibly because it was regulated via both of the wound signalling pathways identified. According to the function of an homologous gene, JR3 may be involved in feedback inhibition of the JA response.

Jasmonic acid-dependent and -independent signaling pathways control wound-induced gene activation in Arabidopsis thaliana

Plant response to mechanical injury includes gene activation both at the wound site and systemically in nondamaged tissues. The model developed for the wound-induced activation of the proteinase inhibitor II (Pin2) gene in potato (Solanum tuberosum) and tomato (Lycopersicon esculentum) establishes the involvement of the plant hormones abscisic acid and jasmonic acid (JA) as key components of the wound signal transduction pathway. To assess in Arabidopsis thaliana the role of these plant hormones in regulating wound-induced gene expression, we isolated wound- and JA-inducible genes by the differential mRNA display technique. Their patterns of expression upon mechanical wounding and hormonal treatments revealed differences in the spatial distribution of the transcripts and in the responsiveness of the analyzed genes to abscisic acid and JA. A correlation can be established between sensitivity to JA and the accumulation of the transcripts in systemic tissues upon wounding. A comparative study of the wound response in wild-type and JA-insensitive coi1 mutant plants indicated that in A. thaliana wound signals are transmitted via at least two different pathways. One of them does not involve JA as a mediator and is preferentially responsible for gene activation in the vicinity of the wound site, whereas the other requires JA perception and activates gene expression throughout the aerial part of the plant.

Abscisic acid and jasmonic acid activate wound-inducible genes in potato through separate, organ-specific signal transduction pathways

Mechanical damage to leaf tissue causes an increase in abscisic acid (ABA) which in turn activates the biosynthesis of jasmonic acid (JA). The resulting higher endogenous JA levels subsequently activate the expression of wound-inducible genes. This study shows that JA induces the expression of different sets of genes in roots and leaves of potato plants. When roots of intact plants were treated with JA, high levels of proteinase inhibitor II (pin2), cathepsin D inhibitor, leucine aminopeptidase and threonine deaminase mRNAs accumulated in the systemic leaves. However, in the treated roots, very low, if any, expression of these genes could be detected. In contrast, a novel, root-specific pin2 homologue accumulated in the JA-treated root tissue which could not be detected in leaves, either systemic or those directly treated with JA. Application of okadaic acid and staurosporine revealed that a protein phosphorylation step is involved in the regulation of this differential response. In leaves, a protein phosphatase is required for the JA-induced expression of pin2 and the other genes analysed. This phosphatase activity is not necessary for the JA-induced expression of a pin2 homologue in roots, suggesting the existence of different transduction pathways for the JA signal in these organs. The requirement of a protein phosphatase activity for JA-mediated gene induction has enabled identification of a JA-independent pathway for ABA induction of pin2 and the other wound-inducible genes. This alternative pathway involves a protein kinase, and appears to be selective for wound-inducible genes. Our data suggest the presence of a complex, organ-specific transduction network for regulating the effects of the plant hormones ABA and JA on gene expression upon wounding.

Epidemic outbreak of Serratia marcescens infection in a cardiac surgery unit

Between 2 February and 16 April 1985, an outbreak of Serratia marcescens infection involving 10 male patients occurred in a cardiac surgery unit. All the patients had surgical wound infection, five also had osteomyelitis (four sternal, one costal), and another had peritonitis secondary to peritoneal dialysis. Three patients had concomitant bacteremia. All Serratia strains isolated produced a cherry-red pigment, and all had the same biochemical and antibiotic susceptibility pattern. An intensive search for the origin of the outbreak was initially unsuccessful, and it proved impossible to isolate S. marcescens from cultures of numerous samples taken from hospital personnel and from the environment. The fact that all patients were male and had been shaved for surgery by the same team of barbers led us to investigate the shaving procedures. We finally isolated a strain of pigmented S. marcescens, corresponding to that involved in the outbreak, from samples taken from the hands and equipment of the barbers. After suitable action had been taken, the epidemic terminated.